S5316 Endoscopic Management of Synchronous Major and Minor Papillary Adenomas in Familial Adenomatous Polyposis With Incomplete Pancreas Divisum

Introduction: Familial adenomatous polyposis (FAP) is an inherited disorder characterized by the development of numerous adenomatous polyps in the gastrointestinal tract, with a significant risk of progression to malignancy. While duodenal and ampullary adenomas are recognized as extracolonic manifestations of FAP, concurrent involvement of both major and minor papillae is rare. This case highlights the endoscopic management of synchronous major and minor papillary adenomas in a patient with FAP and incomplete pancreas divisum. Case Description: A 47-year-old man with a history of FAP and prior total colectomy underwent routine surveillance esophagogastroduodenoscopy (EGD). Findings included a 20 mm × 15 mm mass at the major papilla and more than ten sessile polyps (<5 mm) throughout the duodenum, consistent with Spigelman stage I duodenal polyposis. Biopsies from the ampullary mass and duodenal polyps revealed low-grade adenomas without high-grade dysplasia. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) involved papillectomy of the major papillary lesion. A pancreatogram revealed incomplete pancreas divisum. The minor papilla appeared adenomatous; biopsies confirmed a low-grade adenoma. The patient subsequently underwent minor papillectomy. Follow-up endoscopy showed no evidence of residual or recurrent adenomatous tissue which was confirmed by biopsy of the major and minor papillae. Discussion: This case underscores the feasibility of endoscopic management for synchronous major and minor papillary adenomas in FAP, even in the presence of anatomical variations such as incomplete pancreas divisum. The multidisciplinary approach, incorporating EGD, EUS, and ERCP with therapeutic interventions, facilitated organ-preserving treatment and obviated the need for surgical resection. Importantly, while major papillary adenomas are well recognized in FAP, involvement of the minor papilla is rare and underreported. This case highlights the need for careful inspection and biopsy of the minor papilla during endoscopic surveillance—particularly in the setting of pancreas divisum, where functional significance of the minor papilla increases. Our findings expand the clinical spectrum of FAP-related upper GI neoplasia and support the role of advanced endoscopic techniques in achieving safe and effective local control.