Views Descending Duodenum and Superior Duodenal Angle

Fig. 2.70 Descending duodenum

Fig. 2.70 Descending duodenum

Superior Duodenal Angle

View 9

Bile Yellow

View 9

The complex maneuver described above usually advances the endoscope tip quickly down the descending duodenum. When the instrument is now pulled back, the redundant loop of shaft within the stomach straightens out, causing the endoscope tip to advance again by several centimeters. The lumen is centered in the image, and the duodenum is evaluated while the endoscope is withdrawn. The papillary region is easily recognized but cannot be adequately evaluated with a forward-viewing instrument.

The descending duodenum in view 9 has been distended with air. The valvulae conniventes are clearly visible, and the papilla of Vater can be seen at the 10-o'clock position. Further withdrawal should be done carefully, as the endoscope can easily slip out of the duodenum and fall back into the stomach.

- Fig. 2.71 Junction of the bulbar and descending duodenum

- Fig. 2.71 Junction of the bulbar and descending duodenum

Descending Duodenum
View 10

View 10 shows the typical appearance of the junction of the bulbar and descending duodenum. With the instrument straightened, the view is directed almost at right angles toward the duodenal wall. This view is proximal to view 9 anatomically, but comes after it in the examination sequence. Additional withdrawal will return to the position at view 8.

Inspection of the duodenal bulb requires patience and "feel." The endoscope tip is very unstable when just distal to the pylorus and can easily fall back into the antrum. Lesions in the posterior wall of the bulb are easily missed in this situation, since the straightened endoscope tip extending through the pylorus is aimed at the anterior wall of the bulb.

The following structural details are noted during endoscopy: Shape

- With air insufflation: rounded, bulbous, occasionally oblong (Fig. 2.72)

Topography in the endoscopic image (Fig. 2.76)

- Above: lesser curvature

- Below: greater curvature

- Right: posterior wall

- With air insufflation: almost without folds

- Distant view: relatively smooth

- Color: yellowish-gray

- Frequent: contact bleeding from the instrument tip on the anterior bulb wall (Fig. 2.75)

Fig. 2.72 Normal duodenal bulb. Notice the rounded, oblong shape
Normal Pylorus Endoscopy
Fig. 2.73 Normal duodenal bulb. Notice the granular mucosal surface
Reflux Esophagitis

Fig. 2.74 Normal duodenal bulb. The relatively coarse granular pattern of the mucosa is a normal variant

Fig. 2.74 Normal duodenal bulb. The relatively coarse granular pattern of the mucosa is a normal variant

Penis Inside Rectum
Fig. 2.75 Typical contact bleeding. This occurred when the instrument tip was initially propelled into the duodenal bulb. It is generally located on the anterior wall of the bulb

s = stomach p = pancreas a = aorta d = duodenum l = liver ga = gastroduodenal artery ha = hepatic artery ga

Fig. 2.76 Topography in the duodenal bulb. The lesser curve of the bulb is above, the greater curve below. The anterior wall is on the left, the posterior wall on the right

Fig. 2.76 Topography in the duodenal bulb. The lesser curve of the bulb is above, the greater curve below. The anterior wall is on the left, the posterior wall on the right

Descending Duodenum

The details of the descending duodenum are as follows:

- Curved tunnel

- Typical: valvulae conniventes

► Topography

- Difficult to appreciate spatial orientation

- Aid orientation by identifying the Vater papilla at approximately the 9-o'clock position (Fig. 2.80)

- Valvulae conniventes

- Finely granular mucosal pattern (Figs. 2.78, 2.79)

Mastdarmspiegelung Rektoskopie
Fig. 2.77 Normal descending duodenum

Fig. 2.80 Topography of the proximal duodenum. Orientation is aided by identifying the Vater papilla, which is often visible even with a forward-viewing scope.

Fig. 2.80 Topography of the proximal duodenum. Orientation is aided by identifying the Vater papilla, which is often visible even with a forward-viewing scope.

Superior Duodenal AngleDuodenum Fine Granular

Fig. 2.78 Normal descending duodenum. Notice the fine granularity of the mucosal surface

Fig. 2.78 Normal descending duodenum. Notice the fine granularity of the mucosal surface

Mucosa With Reflux Esophagitis
Fig. 2.79 Normal descending duodenum. Relatively coarse granular pattern of the mucosa
Hazy Sun Flare Overlays Transparent

Overview of Pathological Findings in the Esophagus - 60

Cardial Incompetence - 61

Hernia Duodeno

Hiatal Hernia:

Axial Sliding Hernia - 62

Hiatal Hernia: Paraesophageal Hernia - 63

Hiatal Hernia:

Upside-Down Stomach - 64

Gastroesophageal Prolapse - 65

Mallory-Weiss Lesion and Boerhaave Syndrome - 66

Gastroesophageal Reflux and Reflux Esophagitis: Clinical Aspects - 67

Reflux Esophagitis: Diagnosis and Treatment - 68

Reflux Esophagitis: Grading - 69

Complications of Reflux Esophagitis: Barrett Esophagus - 70

Complications of Reflux Esophagitis: Management of Barrett Esophagus - 71

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    How to tell posterior duodenum on endoscopy?
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