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Checklist for endoscopic evaluation

► Location: duodenal bulb, postbulbar duodenum, papilla

► Morphology: pedunculated or sessile, mucosal surface

Endoscopic diagnostic criteria for individual polypoid lesions

► Inflammatory hyperplastic polyps (Figs. 3.148, 3.149)

- Most common polypoid lesions in the duodenum

- Occur in the bulbar and postbulbar duodenum

- Rarely solitary, usually multiple

- Mucosa: unchanged or may be erythematous, eroded, or ulcerated

- Histology: often shows normal duodenal mucosa

► Heterotopic gastric mucosa (Fig. 3.148a-c)

- Found mainly in the postpyloric or postbulbar duodenum

- Usually multiple, arranged in clusters, or sheetlike

- Raised, poorly demarcated from surroundings

- Mucosa: nodular, erythematous

- Histology: gastric mucosa, often positive for H. pylori

Brunner gland hyperplasia (Fig. 3.148d)

- Occurs throughout the proximal duodenum, includ-

ing the bulb

- Usually multiple

- Small (2-6 mm)

- Mucosa may be erythematous

Lymphatic hyperplasia

- Found in the second part of the duodenum

- Usually multiple, arranged in clusters

- Small (several millimeters)

Adenomas

- Rare

- Occur in the first and second parts of the duodenum

- Papilla

- Solitary or multiple

- Usually relatively large (> 1 cm)

- Pedunculated or sessile

- Mucosa: nodular, eroded, ulcerated

Leiomyoma

- Found mainly between the first and second parts of

the duodenum

- Usually relatively large (> 1 cm)

Mucosa: may show erosion, ulceration

b Villous adenoma c Multiple villous adenomas

Fig. 3.149 Villous adenomas and polypoid lesions in bulbitis a Small villous adenoma

Fig. 3.149 Villous adenomas and polypoid lesions in bulbitis a Small villous adenoma

b Villous adenoma

e, f Erosions in the duodenal bulb c Multiple villous adenomas

e, f Erosions in the duodenal bulb

Sprue is an immune-mediated condition in which the mucosa of the small bowel becomes damaged due to the ingestion of gluten-containing foods. The disease is characterized by the loss of mucosal villi, resulting in malabsorption and diarrhea. Involvement of the duodenum is almost always present.

Endoscopic diagnostic criteria (Figs. 3.150, 3.151)

► Mucosa appears grossly unchanged in some cases

► Abnormally smooth mucosa

► Loss of mucosal granularity

► Effacement of valvulae conniventes

► Mucosal atrophy

Differential diagnosis

Tropical sprue Eosinophilic gastroenteritis Lymphoma Viral gastroenteritis

Checklist for endoscopic evaluation

Deep duodenoscopy

Evaluate mucosa and valvulae conniventes

Villous atrophy in

Duodenum in

Fig. 3.1SC sprue

Villous atrophy in

Fig. 3.1S1 a-c sprue

Duodenum in

Fig. 3.1S1 a-c sprue

Additional Studies

Biopsy distal to the papilla Gliadin antibodies

Small bowel function studies (D-xylose test, lactose H2 breath test)

Fig.3.1S2a-c Crohn disease of the duodenum b a

Comments

The macroscopic and histological findings are very typical. The diagnosis is considered established if the complaints subside after gluten is eliminated from the diet. The risk of developing an intestinal lymphoma or carcinoma is high in untreated cases of sprue.

Fig.3.1S2a-c Crohn disease of the duodenum

■ Crohn Disease

The lesions of Crohn disease can also involve the duodenum, but this occurs in fewer than 5% of patients (Fig. 3.152).

Endoscopy reveals small, aphthoid erosions and ulcerations.

villi, thickened bowel wall, and edema are found in affected segments of the duodenum and jejunum. The histological findings are diagnostic.

■ Whipple Disease

Whipple disease is a very rare, bacterial systemic disease that is len. characterized by joint pain, weight loss, and diarrhea. Swollen

At endoscopy, the mucosa is fragile with a whitish speckled pattern. The villi appear blunted and swol-

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