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| | [[Image:Duodenumanatomy.jpg|thumb|Schematic of the duodenum. (WC/Luke Guthmann)]] |
| The '''duodenum''' is the first part of the [[small bowel]] and receives food from the [[stomach]]. It is accessible by EGD (esophagogastroduodenoscopy) and frequently biopsied. | | The '''duodenum''' is the first part of the [[small bowel]] and receives food from the [[stomach]]. It is accessible by EGD (esophagogastroduodenoscopy) and frequently biopsied. |
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| ===Sign out=== | | ===Sign out=== |
| | <pre> |
| | Duodenum, Biopsy: |
| | - Small bowel mucosa and Brunner's glands within normal limits.</pre> |
| | |
| | <pre> |
| | Duodenum, Biopsy: |
| | - Small bowel mucosa within normal limits. |
| | </pre> |
| | |
| | <pre> |
| | Duodenum, Biopsy: |
| | - Small bowel mucosa within normal limits. |
| | - NEGATIVE for findings suggestive of celiac disease. |
| | </pre> |
| | |
| | <pre> |
| | Small Bowel (Duodenum), Biopsy: |
| | - Small bowel mucosa within normal limits. |
| | - NEGATIVE for findings suggestive of celiac disease. |
| | </pre> |
| | |
| | ====Block letters==== |
| <pre> | | <pre> |
| DUODENUM, BIOPSY: | | DUODENUM, BIOPSY: |
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| ==Gastric heterotopia of the duodenum== | | ==Gastric heterotopia of the duodenum== |
| *[[AKA]] ''heterotopic gastric mucosa''. | | *[[AKA]] ''heterotopic gastric mucosa''. |
| ===General===
| | {{Main|Gastric heterotopia of the duodenum}} |
| *Common ~15% of cases in one series.<ref name=pmid22295146>{{Cite journal | last1 = Terada | first1 = T. | title = Pathologic observations of the duodenum in 615 consecutive duodenal specimens: I. benign lesions. | journal = Int J Clin Exp Pathol | volume = 5 | issue = 1 | pages = 46-51 | month = | year = 2012 | doi = | PMID = 22295146 }}</ref>
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| *Probably not related to [[Helicobacter pylori]].<ref name=pmid20656325>{{Cite journal | last1 = Genta | first1 = RM. | last2 = Kinsey | first2 = RS. | last3 = Singhal | first3 = A. | last4 = Suterwala | first4 = S. | title = Gastric foveolar metaplasia and gastric heterotopia in the duodenum: no evidence of an etiologic role for Helicobacter pylori. | journal = Hum Pathol | volume = 41 | issue = 11 | pages = 1593-600 | month = Nov | year = 2010 | doi = 10.1016/j.humpath.2010.04.010 | PMID = 20656325 }}</ref>
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| ===Gross===
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| *Typically nodules/polyps.<ref name=pmid6840712>{{Cite journal | last1 = Shousha | first1 = S. | last2 = Spiller | first2 = RC. | last3 = Parkins | first3 = RA. | title = The endoscopically abnormal duodenum in patients with dyspepsia: biopsy findings in 60 cases. | journal = Histopathology | volume = 7 | issue = 1 | pages = 23-34 | month = Jan | year = 1983 | doi = | PMID = 6840712 }}</ref>
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| ===Microscopic===
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| Features:
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| #Foveolar epithelium.
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| #Gastric glands - body-type or antral-type.
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| DDx:
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| *Foveolar metaplasia (isolated) - see [[chronic duodenitis]].
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| *Foveolar gastric-type dysplasia.<ref>{{Cite journal | last1 = Park | first1 = do Y. | last2 = Srivastava | first2 = A. | last3 = Kim | first3 = GH. | last4 = Mino-Kenudson | first4 = M. | last5 = Deshpande | first5 = V. | last6 = Zukerberg | first6 = LR. | last7 = Song | first7 = GA. | last8 = Lauwers | first8 = GY. | title = Adenomatous and foveolar gastric dysplasia: distinct patterns of mucin expression and background intestinal metaplasia. | journal = Am J Surg Pathol | volume = 32 | issue = 4 | pages = 524-33 | month = Apr | year = 2008 | doi = 10.1097/PAS.0b013e31815b890e | PMID = 18300795 }}</ref>
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| ====Images====
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| <gallery>
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| Image: Gastric heterotopia in the duodenum -- low mag.jpg | GH - low mag. (WC)
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| Image: Gastric heterotopia in the duodenum -- intermed mag.jpg | GH - intermed. mag. (WC)
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| Image: Gastric heterotopia in the duodenum -- high mag.jpg | GH - high mag. (WC)
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| </gallery>
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| www:
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| *[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3267485/figure/fig03/ Gastric heterotopia (nih.gov)].<ref name=pmid22295146>{{Cite journal | last1 = Terada | first1 = T. | title = Pathologic observations of the duodenum in 615 consecutive duodenal specimens: I. benign lesions. | journal = Int J Clin Exp Pathol | volume = 5 | issue = 1 | pages = 46-51 | month = | year = 2012 | doi = | PMID = 22295146 }}</ref>
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| ===Sign out===
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA WITH GASTRIC (BODY-TYPE) HETEROTOPIA.
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| - NEGATIVE FOR SIGNIFICANT PATHOLOGY.
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| </pre>
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| | |
| ====Alternate====
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA AND BRUNNER'S GLANDS WITHIN NORMAL LIMITS.
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| - GASTRIC HETEROTOPIA, BODY-TYPE MUCOSA.
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| </pre>
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| ==Celiac sprue== | | ==Celiac sprue== |
| | *[[AKA]] ''celiac disease''. |
| {{main|Celiac sprue}} | | {{main|Celiac sprue}} |
| ===General===
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| *Etiology: autoimmune.
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| ====Epidemiology====
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| *Associated with:
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| **The skin condition ''[[dermatitis herpetiformis]]''.<ref>TN 2007 D22</ref>
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| **IgA deficiency - 10-15X more common in celiac disease vs. healthy controls.<ref name=pmid12414763>{{Cite journal | last1 = Kumar | first1 = V. | last2 = Jarzabek-Chorzelska | first2 = M. | last3 = Sulej | first3 = J. | last4 = Karnewska | first4 = K. | last5 = Farrell | first5 = T. | last6 = Jablonska | first6 = S. | title = Celiac disease and immunoglobulin a deficiency: how effective are the serological methods of diagnosis? | journal = Clin Diagn Lab Immunol | volume = 9 | issue = 6 | pages = 1295-300 | month = Nov | year = 2002 | doi = | PMID = 12414763 }}</ref>
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| **Risk factor for ''gastrointestinal T cell lymphoma'' - known as: ''enteropathy-associated T cell lymphoma'' (EATL).
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| ====Clinical====
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| Treatment:
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| *Gluten free diet.
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| **''Mnemonic'': BROW = barley, rye, oats, wheat.
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| Serologic testing:
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| *Anti-transglutaminase antibody.
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| **Alternative test: anti-endomysial antibody.
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| *IgA -- assoc. with celiac sprue.
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| ===Microscopic===
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| Features:<ref name=Ref_PBoD843>{{Ref PBoD|843}}</ref>
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| *Intraepithelial lymphocytes (IELs) - '''key feature'''.
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| **Should be more pronounced at tips of villi.<ref name=pmid15280404>{{cite journal |author=Biagi F, Luinetti O, Campanella J, ''et al.'' |title=Intraepithelial lymphocytes in the villous tip: do they indicate potential coeliac disease? |journal=J. Clin. Pathol. |volume=57 |issue=8 |pages=835–9 |year=2004 |month=August |pmid=15280404 |pmc=1770380 |doi=10.1136/jcp.2003.013607 |url=}}</ref>
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| **Criteria for number varies:
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| *** > 40 IELs / 100 enterocytes (epithelial cells).<ref name=pmid10524652>{{cite journal |author=Oberhuber G, Granditsch G, Vogelsang H |title=The histopathology of coeliac disease: time for a standardized report scheme for pathologists |journal=Eur J Gastroenterol Hepatol |volume=11 |issue=10 |pages=1185–94 |year=1999 |month=October |pmid=10524652 |doi= |url=}}</ref>
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| *** > 25 IELs / 100 enterocytes (epithelial cells).<ref name=pmid17544877>{{cite journal |author=Corazza GR, Villanacci V, Zambelli C, ''et al.'' |title=Comparison of the interobserver reproducibility with different histologic criteria used in celiac disease |journal=Clin. Gastroenterol. Hepatol. |volume=5 |issue=7 |pages=838–43 |year=2007 |month=July |pmid=17544877 |doi=10.1016/j.cgh.2007.03.019 |url=}}</ref>
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| *Loss of villi - '''important feature'''.
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| **Normal duodenal biopsy should have 3 good villi.
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| *Plasma cells - abundant (weak feature).
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| *Macrophages.
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| *Mitosis increased (in the crypts).
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| *+/-Collagen band (pink material in mucosa) - "Collagenous sprue"; must encompass ~25% of mucosa.
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| Image:
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| *[http://commons.wikimedia.org/wiki/File:Coeliac_path.jpg Celiac sprue (WC)].
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| Notes:
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| *If you see acute inflammatory cells, i.e. neutrophils, consider Giardiasis and other infectious etiologies.
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| *Biopsy should consist of 2-3 sites. In children it is important to sample the duodenal cap, as it is the only affected site in ~10% of cases.
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| *Flat lesions without IELs are unlikely to be celiac sprue.
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| *Mucosa erosions are rare in celiac sprue; should prompt consideration of an alternate diagnosis (infection, medications, Crohn's disease).
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| ===Grading===
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| Rarely done - see ''[[celiac sprue]]'' article.
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| ==Giardiasis== | | ==Giardiasis== |
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| ==Peptic duodenitis== | | ==Peptic duodenitis== |
| ===General===
| | {{Main|Peptic duodenitis}} |
| *A somewhat controversial type of [[chronic duodenitis]].
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| *Considered to be a consequence of [[peptic ulcer disease]] ([[Helicobacter gastritis]]).
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| *One of the key components of the diagnosis is foveolar metaplasia and it is disputed that this is really due to Helicobacter.
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| **Genta ''et al.'' consider gastric foveolar metaplasia a congenital lesion.<ref name=pmid20656325>{{Cite journal | last1 = Genta | first1 = RM. | last2 = Kinsey | first2 = RS. | last3 = Singhal | first3 = A. | last4 = Suterwala | first4 = S. | title = Gastric foveolar metaplasia and gastric heterotopia in the duodenum: no evidence of an etiologic role for Helicobacter pylori. | journal = Hum Pathol | volume = 41 | issue = 11 | pages = 1593-600 | month = Nov | year = 2010 | doi = 10.1016/j.humpath.2010.04.010 | PMID = 20656325 }}</ref>
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| ===Microscopic===
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| Features:<ref name=Ref_GLP145>{{Ref GLP|145}}</ref>
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| *Gastric foveolar metaplasia - '''key feature'''.
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| *[[Brunner's gland hyperplasia]].
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| *+/-Inflammation - neutrophils.{{fact}}
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| *Ulceration.{{fact}}
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| DDx:
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| *[[Chronic duodenitis]] not otherwise specified - no foveolar metaplasia, abundant plasma cells.
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| *[[Acute duodenitis]].
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| *[[Brunner's gland hyperplasia]].
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| *[[Gastric heterotopia of the duodenum]].
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| ====Images====
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| <gallery>
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| Image:Duodenum_with_foveolar_metaplasia_-_low_mag.jpg | Duodenum with foveolar metaplasia - low mag. (WC/Nephron)
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| Image:Duodenum_with_foveolar_metaplasia_-_intermed_mag.jpg | Duodenum with foveolar metaplasia - intermed. mag. (WC/Nephron)
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| Image:Duodenum_with_foveolar_metaplasia_-_alt_-_very_high_mag.jpg | Duodenum with foveolar metaplasia - very high mag. (WC/Nephron)
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| </gallery>
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| ===Stains===
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| Foveolar metaplasia:
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| *[[PAS stain]] +ve.<ref name=Ref_GLP145>{{Ref GLP|145}}</ref>
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| *[[Mucicarmine stain]] +ve.
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| ===Sign out===
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| ====Foveolar metaplasia only====
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA WITH FOCAL GASTRIC FOVEOLAR METAPLASIA.
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| - BRUNNER'S GLANDS NOT IDENTIFIED.
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| - VILLI AND INTRAEPITHELIAL LYMPHOCYTES WITHIN NORMAL LIMITS (NEGATIVE FOR CELIAC DISEASE).
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| - NEGATIVE FOR ACUTE DUODENITIS.
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| - NEGATIVE FOR DYSPLASIA.
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| </pre>
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA WITH FOCAL GASTRIC FOVEOLAR METAPLASIA.
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| - BRUNNER'S GLANDS NOT IDENTIFIED.
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| - NEGATIVE FOR ACUTE DUODENITIS.
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| - NEGATIVE FOR DYSPLASIA.
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| </pre>
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| ====Chronic duodenitis====
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA WITH BRUNNER'S GLAND IN THE LAMINA PROPRIA AND
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| GASTRIC FOVEOLAR METAPLASIA -- CONSISTENT WITH CHRONIC DUODENITIS.
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| - NEGATIVE FOR ACUTE DUODENITIS.
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| - NEGATIVE FOR MALIGNANCY.
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| </pre>
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA WITH PROMINENT BRUNNER'S GLANDS AND FOCAL GASTRIC
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| FOVEOLAR METAPLASIA.
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| - NEGATIVE FOR ACUTE INFLAMMATION.
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| - NEGATIVE FOR DYSPLASIA.
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| </pre>
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| =====Micro=====
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| The sections show small bowel mucosa and a small amount of submucosa. Brunner's glands are abundant and found focally in the lamina propria. Gastric foveolar-type epithelium is identified. Intraepithelial neutrophils are not identified.
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| The epithelium matures appropriately. There is no increase in intraepithelial lymphocytes.
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| ==Brunner's gland hyperplasia== | | ==Brunner's gland hyperplasia== |
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| ==Pseudomelanosis duodeni== | | ==Pseudomelanosis duodeni== |
| ===General===
| | {{Main|Pseudomelanosis duodeni}} |
| *Rare.
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| *Consists of iron and lipofuscin.<ref name=pmid2458404>{{Cite journal | last1 = Lin | first1 = HJ. | last2 = Tsay | first2 = SH. | last3 = Chiang | first3 = H. | last4 = Tsai | first4 = YT. | last5 = Lee | first5 = SD. | last6 = Yeh | first6 = YS. | last7 = Lo | first7 = GH. | title = Pseudomelanosis duodeni. Case report and review of literature. | journal = J Clin Gastroenterol | volume = 10 | issue = 2 | pages = 155-9 | month = Apr | year = 1988 | doi = | PMID = 2458404 }}
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| </ref>
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| Associations:<ref name=pmid18253910/>
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| *[[Hypertension]] ~90% of cases.
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| *Iron supplementation ~75% of cases.
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| *End-stage renal disease ~60% of cases.
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| Note:
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| *The associations are different than for ''[[melanosis coli]]''.
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| ===Gross/endoscopic===
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| *Dark spots ~35% of cases.<ref name=pmid18253910>{{Cite journal | last1 = Giusto | first1 = D. | last2 = Jakate | first2 = S. | title = Pseudomelanosis duodeni: associated with multiple clinical conditions and unpredictable iron stainability - a case series. | journal = Endoscopy | volume = 40 | issue = 2 | pages = 165-7 | month = Feb | year = 2008 | doi = 10.1055/s-2007-995472 | PMID = 18253910 }}</ref>
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| ===Microscopic===
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| Features:
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| *Dark pigment in the lamina propria macrophages.
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| Images:
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| *[http://path.upmc.edu/cases/case616.html Pseudomelanosis duodeni - several images (upmc.edu)].
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| ===Stains===
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| *Prussian blue +ve ~80% of cases.<ref name=pmid18253910/>
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| =Tumours= | | =Tumours= |
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| ==Duodenal neuroendocrine tumour== | | ==Duodenal neuroendocrine tumour== |
| {{Main|Neuroendocrine tumours}} | | {{Main|Neuroendocrine tumours}} |
| | :''Duodenal NET'' redirects here. |
| ===General=== | | ===General=== |
| *Like [[neuroendocrine tumours]] elsewhere. | | *Like [[neuroendocrine tumours]] elsewhere. |
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| Image:Small_intestine_neuroendocrine_tumour_high_mag.jpg | Neuroendocrine tumour - high mag. (WC) | | Image:Small_intestine_neuroendocrine_tumour_high_mag.jpg | Neuroendocrine tumour - high mag. (WC) |
| </gallery> | | </gallery> |
| | |
| | ===Sign out=== |
| | <pre> |
| | Duodenum, Biopsy: |
| | - Incidental neuroendocrine tumour, grade 1, see comment. |
| | - Background small bowel mucosa with Brunner's glands within normal limits. |
| | |
| | Comment: |
| | The tumour stains as follows: |
| | POSITIVE: AE1/AE3, CD56, synaptophysin. |
| | NEGATIVE: S-100, CD68. |
| | PROLIFERATION (Ki-67): <2%. |
| | </pre> |
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| ==Ampullary tumours== | | ==Ampullary tumours== |
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| *Commonly found in association foveolar metaplasia - especially in sporadic cases ~60% of cases. | | *Commonly found in association foveolar metaplasia - especially in sporadic cases ~60% of cases. |
| **In FAP ~30% of cases have foveolar metaplasia.<ref name=pmid16837629>{{Cite journal | last1 = Rubio | first1 = CA. | title = Gastric duodenal metaplasia in duodenal adenomas. | journal = J Clin Pathol | volume = 60 | issue = 6 | pages = 661-3 | month = Jun | year = 2007 | doi = 10.1136/jcp.2006.039388 | PMID = 16837629 | PMC = 1955048}}</ref> | | **In FAP ~30% of cases have foveolar metaplasia.<ref name=pmid16837629>{{Cite journal | last1 = Rubio | first1 = CA. | title = Gastric duodenal metaplasia in duodenal adenomas. | journal = J Clin Pathol | volume = 60 | issue = 6 | pages = 661-3 | month = Jun | year = 2007 | doi = 10.1136/jcp.2006.039388 | PMID = 16837629 | PMC = 1955048}}</ref> |
| | *A colonscopy is recommended in individuals with nonampullary duodenal adenomas, as they are likely at increased risk of large bowel adenomas.<ref name=pmid26811631>{{Cite journal | last1 = Lim | first1 = CH. | last2 = Cho | first2 = YS. | title = Nonampullary duodenal adenoma: Current understanding of its diagnosis, pathogenesis, and clinical management. | journal = World J Gastroenterol | volume = 22 | issue = 2 | pages = 853-61 | month = Jan | year = 2016 | doi = 10.3748/wjg.v22.i2.853 | PMID = 26811631 }}</ref> |
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| ===Sign out=== | | ===Sign out=== |
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| - TUBULAR ADENOMA. | | - TUBULAR ADENOMA. |
| -- NEGATIVE FOR HIGH-GRADE DYSPLASIA. | | -- NEGATIVE FOR HIGH-GRADE DYSPLASIA. |
| | </pre> |
| | |
| | ====Alternate==== |
| | <pre> |
| | Polyp (Nonampullary), Duodenum, Polypectomy: |
| | - Tubular adenoma, NEGATIVE for high-grade dysplasia. |
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| | Comment: |
| | A colonscopy is recommended if not done recently, as individual with nonampullary duodenal adenomas are likely at increased risk of large bowel adenomas.[1] |
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| | 1. Therap Adv Gastroenterol. 2012 Mar; 5(2): 127138. doi: 10.1177/1756283X11429590 |
| </pre> | | </pre> |
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