Medical Oncologist
CION Cancer Clinics
Upper GI surveillance in FAP: watching the stomach and duodenum | CION Cancer Clinics
People with FAP need regular camera checks of the stomach and duodenum as well as the bowel. The same gene fault causes polyps there, and they rarely cause symptoms until late. This page explains what the endoscopy looks for, how the Spigelman stage sets the timing of your next check, and why the checks continue after bowel surgery. At CION Cancer Clinics, our oncologists plan screening and care for families with an inherited cancer syndrome, explained in plain words.
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Medically reviewed by Dr. Naresh GunduConsultant Medical Oncologist · MBBS, DNB (Internal Medicine), DM (Medical Oncology, AIIMS) · last reviewed September 2026, next review due September 2027
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On this page
- Why does FAP need a camera test of the stomach too?
- What is the doctor looking for during the endoscopy?
- How does upper GI surveillance run over a lifetime?
- What do the words on an upper endoscopy report mean?
- What this page cannot tell you
- Four things people with FAP tell us, and what is actually true
- Common questions about upper GI checks in FAP
The short answer
Why does FAP need a camera test of the stomach too?
Because the APC fault behind FAP is in every cell, not only in the large bowel. Most people with FAP also grow polyps in the stomach and in the first part of the small bowel, called the duodenum. A regular upper endoscopy watches these, and it carries on for life, even after the large bowel has been removed.
Why the duodenum matters most
Once the large bowel has been dealt with, the duodenum becomes the main place where cancer can still start in FAP. The area around the papilla, the small opening where bile and pancreatic juice drain into the gut, needs particular attention. Polyps there are easy to miss with an ordinary camera, which is why a special side-viewing scope is used.
Why most people feel nothing
Duodenal polyps almost never cause symptoms while they are small. By the time they cause bleeding or a blocked bile duct, they are usually advanced. That is the whole reason for checking on a schedule rather than waiting to feel unwell.
What the stomach polyps usually are
Most stomach polyps in FAP are a harmless type called fundic gland polyps. They can be numerous and still need no treatment. A smaller number are the adenoma type, which are watched or removed like bowel polyps.
Upper GI checks are part of FAP care for life. They do not stop after bowel surgery.Inside the upper gut
What is the doctor looking for during the endoscopy?
Each area of the upper gut behaves differently in FAP, so each gets its own look.
The stomach
Many small, smooth polyps are common and usually harmless. The doctor looks for any polyp that looks different, is larger, or sits in the lower part of the stomach, and takes samples from those.
The duodenum
This is the main focus. The doctor counts the polyps, measures the largest and takes samples to see how abnormal the cells look. Those findings are combined into a stage.
What goes into the stage
- How many polyps there are
- How big the largest one is
- The type of polyp under the microscope
- How abnormal the cells look
The papilla
The drainage point for bile and pancreatic juice can grow its own polyp. It is seen properly only with a side-viewing scope, the kind also used for ERCP. Ask whether this was checked.
After surgery
Someone who has had an ileal pouch or an ileostomy also has the remaining bowel checked. That is usually a separate test on a different day, arranged by the bowel team.
Not sure whether this applies to you?
Ask an oncologistOver the years
How does upper GI surveillance run over a lifetime?
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The first upper endoscopy
International guidelines usually start it in the early to mid twenties, or sooner if bowel surgery is being planned. It gives a baseline picture to compare against.
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A stage is given
The findings are graded on a scale, often called the Spigelman stage, from zero to four. A low stage means few, small, mild polyps. A high stage means many, large or more abnormal ones.
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The gap to the next check is set
A low stage means a longer gap, sometimes several years. A higher stage means checks within a year or sooner. The stage decides the timing, not the calendar.
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Larger polyps are removed
Polyps that are growing or look more abnormal can often be removed through the scope. This is more delicate in the duodenum than in the large bowel, and is done by an experienced endoscopist.
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Surgery is discussed if the stage stays high
When polyps cannot be controlled through the scope, an operation on the duodenum may be discussed. It is a major operation, and the choice is made with a specialist surgical team.
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Signs that cannot wait for the next check
If you have FAP and pass black, tarry stools, vomit blood, notice yellowing of your skin or eyes, or have severe upper tummy pain in the days after a polyp was removed, go to the nearest emergency department the same day. Tell them you have FAP and when your last endoscopy was done. Do not wait for your planned appointment.
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On your report
What do the words on an upper endoscopy report mean?
- Duodenum
- The first part of the small bowel, just after the stomach. It is the main area watched in upper GI surveillance for FAP.
- Papilla or ampulla
- The small opening in the duodenum where bile and pancreatic juice enter the gut. Polyps here need special attention.
- Fundic gland polyps
- Small, smooth stomach polyps that are common in FAP and are usually harmless.
- Adenoma
- The type of polyp that can slowly turn into cancer if left alone. This is what the doctor is counting.
- Dysplasia
- How abnormal the cells look under the microscope. Low grade is milder. High grade is closer to cancer and is acted on sooner.
- Spigelman stage
- A score from zero to four built from the number, size, type and dysplasia of duodenal polyps. It sets how often you are checked.
Being straight with you
What this page cannot tell you
It cannot tell you what your own stage means for you, or how long you can safely wait before the next endoscopy. That depends on your report, your biopsy results and what your endoscopist saw. What your specific findings mean is a question for the gastroenterologist and genetic counsellor looking after you.
It cannot choose a treatment for you
Removing a duodenal polyp through the scope, watching it, or planning surgery are all reasonable in different situations. The evidence on the best timing is limited, and experienced teams sometimes weigh it differently. A second opinion is sensible before any operation on the duodenum.
Who this does not apply to
Most people who have a stomach polyp found on a routine endoscopy do not have FAP. A single fundic gland polyp in an adult with acid symptoms, and no family history of bowel polyps, is common and is not a sign of an inherited condition. This page is for people with a confirmed or strongly suspected FAP diagnosis.
Families travelling from the districts can ask for the upper and lower checks to be booked close together, to cut the number of trips to Hyderabad.Commonly believed
Four things people with FAP tell us, and what is actually true
"My bowel has been removed, so I am done with FAP checks."
Bowel surgery removes the biggest risk. The duodenum still carries the same gene fault, and it becomes the main place to watch. Upper GI checks continue for life.
"I have lots of stomach polyps, so my cancer risk is very high."
Most stomach polyps in FAP are the harmless fundic gland type. Their number alone says little. The doctor is more interested in the type, the size and what the duodenum shows.
"An ordinary endoscopy is enough."
A standard forward-viewing scope can miss the papilla. FAP surveillance should include a side-viewing look at that area, or a clear note from your doctor about how it was checked.
"No symptoms means the duodenum is fine."
Duodenal polyps are silent until they are advanced. Feeling well tells you nothing about what the camera would see. That is why checks run on a schedule.
Questions we are asked
Common questions about upper GI checks in FAP
Is the upper endoscopy painful?
Most people are given sedation and remember little of it. The throat may feel sore for a day. The side-viewing scope takes a little longer than an ordinary endoscopy, so allow for a few hours at the unit, including recovery, and bring someone to take you home.
How often will I need it?
It depends on your stage. People with few, small, mild polyps may go several years between checks. People with a higher stage are checked within a year or sooner. Your endoscopist sets the gap after each test, so it can change over time.
Can the duodenal polyps be removed through the scope?
Often, yes, especially larger or more abnormal ones. It is more delicate than removing bowel polyps, with a higher chance of bleeding afterwards. Some people need a short hospital stay. Your team will explain the risks for your specific polyps before going ahead.
Will I need surgery on my duodenum?
Most people with FAP do not. Surgery is considered when polyps stay at a high stage despite treatment through the scope, or when cancer is suspected. It is a major operation, and the decision is made with an experienced surgical team.
Is there a tablet that shrinks the polyps?
Some anti-inflammatory medicines have been studied and reduced polyps in some people. None of them replaces the endoscopy, and the studies are small. Some carry real side effects, so please do not start one on your own.
Do children with FAP need upper endoscopy?
Usually not in early childhood. Upper checks generally start in early adult life, or before bowel surgery. Your child's team may bring it forward if there are symptoms or unusual findings. The bowel checks are the priority in the teenage years.
Does the milder attenuated form need upper checks too?
Yes. People with attenuated FAP can still grow duodenal polyps, sometimes many. The upper GI schedule is often similar to classic FAP, and is set by what the first endoscopy shows rather than by the label.
Where do I start if my upper checks have lapsed?
Find your last endoscopy report and any biopsy results, and take them to a gastroenterologist who sees FAP. Call the CION helpline if you are not sure who to see, and someone will point you to the right clinic.
Your Specialists
Meet CION's oncologists. Bring your family history or genetic report to them.
Our medical oncologists see people with a strong family history of cancer, arrange genetic counselling and testing where it fits, and plan the checks that follow.
Medical Oncologist
Dr. C. Raghavendra Reddy
MBBS(Gold Medal), DNB(General Medicine), DM(Medical Oncology)(Gold Medal)
Medical Oncologist
Dr. Bharati Devi Gorantla
MBBS, MD(General Medicine), DM(Medical Oncology)(Adyar,Chennai), ECMO, MRCP SCE(UK)
Medical Oncologist
Dr. Owais Mohammed
MBBS, MD (General Medicine), DrNB (Medical Oncology), ECMO, MRCP SCE (Medical Oncology) (UK)
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Sources
- GeneReviews (NCBI) — APC-Associated Polyposis Conditions
- NCCN — Genetic/Familial High-Risk Assessment: Colorectal, Endometrial, and Gastric
- National Cancer Institute — Genetics of Colorectal Cancer (PDQ) - Health Professional Version
- MedlinePlus Genetics — Familial adenomatous polyposis
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Familial adenomatous polyposis explainedThe whole condition, in plain wordsLife after preventive bowel surgery in FAPWhat checks continue once the bowel is removedThyroid screening in FAPThe other check that runs alongside endoscopyWhen screening should start in an FAP familyThe full timeline, from childhood onwards
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