Overview of Pathological Findings in the Duodenum

Table 2.26 Pathological findings in the duodenum

TO u

CT O

Table 2.26 Pathological findings in the duodenum

Duodenal ulcer

Bulbitis

Polypoid lesions

Sprue

Crohn disease

Whipple disease

Diverticula

Changes associated with diseases

in adjacent organs

Fig. 3.134 Duodenal ulcer

Bulbitis Duodenum

Fig. 3.136 Polypoid lesions in the duodenal bulb

Bulbitis Duodeni
Fig. 3.135 Bulbitis

Fig. 3.136 Polypoid lesions in the duodenal bulb

Fig. 3.137 Sprue

Fig. 3.138 Bulbar diverticulum

Inflammation The Duodenum
Fig. 3.139 Inflammation and necrosis in the duodenum of a patient with pancreatitis

■ Definition and Causes

Duodenal ulcer is an epithelial defect in the bulbar or descending duodenum that penetrates the muscularis mucosae and extends into the submucosa (Fig. 3.141 ). The precipitating causes include Helicobacter pylori infection (detectable in more than 90% of cases) and the ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs). Additional risk factors include nicotine abuse, alcohol abuse, and stress.

■ Clinical Aspects

A duodenal ulcer cannot be diagnosed from the clinical presentation alone. The symptoms range from typical nocturnal pain and vague or crampy abdominal discomfort to an almost complete absence of complaints, particularly with NSAID-in-duced ulcers.

Ninety percent of duodenal ulcers occur in the duodenal bulb. Ulcers are usually located on the anterior wall of the bulb, less commonly on the posterior wall and lesser curvature. Ulcers on the greater curvature are rare (Fig. 3.140). Multiple "kissing" ulcers are found on the anterior and posterior walls in 10-20% of cases. Ulcers located distal to the bulb should raise suspicion of Zollinger-Ellison syndrome.

Fig. 3.141 a-d Duodenal ulcer

Fig. 3.141 a-d Duodenal ulcer

Hematin Ulcer

Lesser curvature

Pool of secretions

Anterior wall

Lesser curvature

Pool of secretions

Anterior wall

Endoscopic Topography Stomach

25% \ Posterior wall

Greater curvature

Fig. 3.140 Frequency distribution of duodenal ulcers

25% \ Posterior wall

Greater curvature

Posterior Wall Duodenal Bulb

Fig. 3.140 Frequency distribution of duodenal ulcers

Duodenal Ulcer With Giant Visible Vessel

Endoscopic diagnostic criteria (Figs. 3.141, 3.142)

► The endoscopic appearance depends on the ulcer stage. Three stages are distinguished: the active stage, healing stage, and scar stage.

- Usually round or oval

- Oblong, streaklike, linear, irregular

- Multiple lesions, stippled pattern

- Inflamed ulcer margin

- Ulcer base: fibrin-coated, greenish

- Hematin

- Visible vessel

► Healing stage

- Flatter ulcer margin

- Hyperemic mucosa growing from edges to center

- Reddish mucosa covering the ulcer base

- Healed epithelial defect

- Occasional deep niche, deformity due to scarring

Differential diagnosis

► Very typical appearance

► Very rare: penetrating pancreatic carcinoma

► Crohn disease

► Malignant lymphoma

► Duodenal carcinoma

Checklist for endoscopic evaluation

- Duodenal bulb, postbulbar duodenum, anterior or posterior wall of bulb, lesser or greater curvature

- Caution: The posterior wall of the bulb is difficult to inspect. Posterior wall ulcers are easily missed on cursory inspection because they are located on the right, convex side of the curved duodenal bulb in the endoscopic image, and it is easy to look past them.

► Shape: round, oval, oblong, linear, bizarre

► Ulcer base: fresh blood, hematin, fibrin, visible vessel

► Assess need for endoscopic treatment.

- Caution: A bleeding posterior wall ulcer (that has eroded the pancreaticoduodenal artery) requires immediate operative treatment!

Additional Studies

► Always biopsy the gastric antrum and body (H. pylori?) for histology, rapid urease testing, or both.

► Biopsy the ulcer only if it does not heal or in order to exclude a particular diagnosis (Crohn disease).

■ Treatment and Follow-Up

The patient is treated with proton pump inhibitors (PPI). If H. pylori is detected, eradication therapy is indicated (see p. 103).

An uncomplicated duodenal ulcer that shows good clinical response does not require endoscopic follow-up. If complaints persist, the patient should undergo repeat endoscopy with biopsy (Crohn disease?), and further tests should be performed to exclude Zollinger-Ellison syndrome.

Zollinger Ellison Syndrome

Fig. 3.142 Duodenal ulcer b Traces of hematin c Rounded ulcer with fibrin coating a Fibrin-coated duodenal ulcer with traces of hematin in an aspirin user

Fig. 3.142 Duodenal ulcer b Traces of hematin c Rounded ulcer with fibrin coating a Fibrin-coated duodenal ulcer with traces of hematin in an aspirin user

■ Bleeding, Penetration, and Perforation

Posterior wall ulcers can result in massive bleeding due to erosion of the adjacent pancreaticoduodenal artery (Figs. 3.143, 3.144). They may also penetrate into the pancreas. The main complication of anterior wall ulcers is perforation.

Duodenal ulcers are more likely than gastric ulcers to cause wall deformity due to scarring. This can lead to pseudodivertic-ula and strictures, especially with recurrent ulcers.

Fig.3.143 Risk of bleeding from a posterior wall ulcer

Fig.3.143 Risk of bleeding from a posterior wall ulcer

Anatomy Posterior Duodenal Bulb

a Anatomical diagram shows the b The duodenal bulb viewed with the looped related to the large-caliber gastroduodenal relation of the gastroduodenal and endoscope, shown with adjacent structures. artery, which is continuous with the pancrea-

pancreaticoduodenal arteries to the The posterior wall of the bulb is closely ticoduodenal artery posterior wall of the duodenal bulb a Anatomical diagram shows the b The duodenal bulb viewed with the looped related to the large-caliber gastroduodenal relation of the gastroduodenal and endoscope, shown with adjacent structures. artery, which is continuous with the pancrea-

pancreaticoduodenal arteries to the The posterior wall of the bulb is closely ticoduodenal artery posterior wall of the duodenal bulb

Peptic Duodenitis

TO u

CT O

Peptic duodenitis is believed to result from gastric metaplasia of the duodenal mucosa with subsequent H. pylori infection.

Endoscopic diagnostic criteria (Fig. 3.146)

► Boggy swelling

► Lesions: stippled, spotty, diffuse, patchy, ubiquitous

Granular Mucosa Duodenum

Fig. 3.146 Bulbitis a Erythematous mucosa

Differential diagnosis

► Granular mucosa as a normal variant (Fig. 3.147)

► Heterotopic gastric mucosa

► Infection (Salmonella, Shigella)

► Crohn disease

► Whipple disease

Checklist for endoscopic evaluation

► Morphology of the lesions

► Extent of the lesions

Additional Studies

Erythematous Duodemum

b Erosive bulbitis

Gastric Metaplasia Duodenum

c Edematous bulb

Fig. 3.146 Bulbitis a Erythematous mucosa b Erosive bulbitis c Edematous bulb

Erythematous And Edematous Tissue

d, e Stippled to spotty lesions

Granular Duodenum EndoscopyDuodenitis With Patchy Erythema

f Ulcerative bulbitis d, e Stippled to spotty lesions f Ulcerative bulbitis

Granular Duodenum Endoscopy
Fig. 3.147 Granular mucosa in the duodenal bulb

Polypoid lesions in the duodenum are rare. Their endoscopic appearance may be quite typical (e.g., adenomas), but in doubtful cases the diagnosis is established histologically.

■ Classification

Polypoid lesions can result from inflammatory hyperplasia (most frequent cause), heterotopic tissues (gastric, occasionally pancreatic), lymphofollicular hyperplasia, and Brunner gland hyperplasia. Malignant polyps are very rare. The various types, including rare causes, are summarized in Table 3.27.

Table 3.27 Polypoid lesions in the duodenum Benign polypoid lesions in the duodenum

► Inflammatory hyperplastic polyps

► Heterotopic gastric mucosa

► Heterotopic pancreatic tissue

► Lymphatic hyperplasia

► Brunner gland hyperplasia

► Mesenchymal tumors (leiomyoma, lipoma)

Malignant polypoid lesions in the duodenum

► Adenocarcinoma

► Metastases

Duodenal Ectopic Gastric Mucosa

Fig. 3.148 Polypoid lesions in the duodenum a Heterotopic gastric mucosa

Fig. 3.148 Polypoid lesions in the duodenum a Heterotopic gastric mucosa

Grade Oesophgitis Pic
b Heterotopic gastric epithelium
Ectopic Lymph Tissue
c Ectopic gastric tissue
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Responses

  • franziska
    Where is the duodenum located in the human body?
    5 years ago
  • Chantelle
    What causes duodenum bulbitis?
    4 years ago

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