Foveolar Gland Metaplasia of the Duodenal Bulb on Retrograde View of the Pylorus

CASE REPORT A 69-year-old woman with a medical history of Roux-en-Y gastric bypass presented with iron deficiency anemia. An upper endoscopy and colonoscopy were normal. A capsule endoscopy found erosions in the jejunum. To exclude other intraluminal causes, an antegrade double-balloon enteroscopy was performed to go down the roux limb and reach the enteroenterostomy anastomosis, after which the scope was advanced into the biliopancreatic limb, eventually reaching the duodenum and excluded portion of the stomach. A large circumferential nodular/mass-like lesion was found in the duodenal bulb (Figure 1). Biopsies showed foveolar gland metaplasia without dysplasia (Figure 2).Figure 1.: (A and B) A large circumferential nodular/mass-like lesion was found in the duodenal bulb on antegrade double-balloon examination of the excluded stomach.Figure 2.: The small intestine mucosa lacks its goblet cells as it was replaced by gastric-type epithelium (foveolar metaplasia). It accompanies chronic inflammation of lamina propria and reparative changes (Stain hematoxylin and eosin, magnification 100×).Foveolar gland metaplasia is a common benign finding seen in response to chronic inflammation.1 In patients with a Roux-en-Y gastric bypass studies have shown remodeling of gastric mucosa toward a foveolar cell phenotype and premalignant conditions such as intestinal metaplasia.2,3 In conclusion, foveolar gland metaplasia should be considered in the differential for mass-like lesions that can mimic malignancy. DISCLOSURES Author contributions: Z. Ansari edited images, drafted manuscript and is the article guarantor; P. Bejarano provided and interpreted path images, reviewed manuscript; A. Rahman obtained images, revised manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.