Difference between revisions of "Duodenum"

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The '''duodenum''' is the first part of the small bowel.  It is accessible by EGD (esophagogastroduodenoscopy) and frequently biopsied.   
[[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.   


An introduction to gastrointestinal pathology is in the ''[[gastrointestinal pathology]]'' article.
An introduction to gastrointestinal pathology is in the ''[[gastrointestinal pathology]]'' article.
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The clinical history is often: ''r/o celiac'' or ''r/o giardia''.
The clinical history is often: ''r/o celiac'' or ''r/o giardia''.


==Getting started==
=Getting started=
===PGY-2 DDx===
==Normal duodenum==
*Celiac.
*Abbreviated ''ND''.
===General===
*Very common.
 
===Microscopic===
*Three tall villi.
*Few intraepithelial lymphocytes; < 1 lymphocyte / 4 epithelial cells.
*No (pink) subepithelial collagen band.
*Predominant lamina propria cell: [[plasma cells]].
**Lack of plasma cells suggests ''[[common variable immunodeficiency]]'' (CVID).<ref name=pmid20629103>{{cite journal |author=Agarwal S, Smereka P, Harpaz N, Cunningham-Rundles C, Mayer L |title=Characterization of immunologic defects in patients with common variable immunodeficiency (CVID) with intestinal disease |journal=Inflamm Bowel Dis |volume= |issue= |pages= |year=2010 |month=July |pmid=20629103 |doi=10.1002/ibd.21376 |url=}}</ref>
*No organisms in lumen.
 
DDx:
*[[Intestinal metaplasia of the stomach]] - foveolar epithelium + other histologic components of the stomach.
*[[Chronic duodenitis]] - foveolar epithelium, [[Brunner's gland hyperplasia]].
 
===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>
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>
 
==Basic DDx==
*Celiac sprue.
**Intraepithelial lymphocytes - '''key feature'''.
**Intraepithelial lymphocytes - '''key feature'''.
**Loss of villi.
**Loss of villi.
*Giarrdia.
*Giardia.
**Like celiac... but giarrdia organisms.
**Like celiac... but giardia organisms.
*Adenomas.
*Adenomas.
**Too much blue - similar to colonic adenomas.
**Too much blue - similar to colonic adenomas.
*Cancer.
*[[Cancer]].
**Too much blue and epithelium in the wrong place.
**Too much blue and epithelium in the wrong place.
====More====
*[[Helicobacter duodenitis|H. pylori]] only in areas of [[Gastric heterotopia of the duodenum|gastric metaplasia]].<ref>El-Zimaity. 18 October 2010.</ref>


===Duodenal nodules DDX===
===Duodenal nodules DDX===
Line 23: Line 88:
{{familytree | | | | | B01 | | | | | | | | | | | | | | B02 | | | | | | | | | | | | |B01=Benign<br>(common)| B02=Neoplastic}}
{{familytree | | | | | B01 | | | | | | | | | | | | | | B02 | | | | | | | | | | | | |B01=Benign<br>(common)| B02=Neoplastic}}
{{familytree | |,|-|-|-|+|-|-|-|.| | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | | | |}}
{{familytree | |,|-|-|-|+|-|-|-|.| | | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | | | |}}
{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C06 | | C07 | | C08 | | | | |C01=Brunner's<br>gland|C02=Heterotopic<br>gastric mucosa|C03=Lymphoid<br>nodule|C04=Adenoma|C05=NET|C06=Paraganglioma|C07=Prolapsed<br>gastric polyp|C08=Metastasis}}
{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C06 | | C07 | | C08 | | | | |C01=Brunner's<br>gland|C02=[[Gastric heterotopia of the duodenum|Heterotopic<br>gastric mucosa]]|C03=Lymphoid<br>nodule|C04=Adenoma|C05=[[Neuroendocrine tumour|NET]]|C06=[[Paraganglioma]]|C07=Prolapsed<br>gastric polyp|C08=[[Metastasis]]}}
{{familytree/end}}
{{familytree/end}}


===Normal duodenum===
===Infections of the duodenum<ref>{{cite journal |author=Serra S, Jani PA |title=An approach to duodenal biopsies |journal=J. Clin. Pathol. |volume=59 |issue=11 |pages=1133–50 |year=2006 |month=November |pmid=16679353 |pmc=1860495 |doi=10.1136/jcp.2005.031260 |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860495/?tool=pubmed}}</ref>===
*Three tall villi.
Common:
*Few intraepithelial lymphocytes; < 1 lymphocyte / 4 epithelial cells.
*[[Giardia]].
*No (pink) subepithelial collagen band.
Rare:
*Predominant lamina propria cell: plasma cells.
*[[Cryptosporidia]].
**Lack of plasma cells suggests ''common variable immunodeficiency'' (CVID).<ref name=pmid20629103>{{cite journal |author=Agarwal S, Smereka P, Harpaz N, Cunningham-Rundles C, Mayer L |title=Characterization of immunologic defects in patients with common variable immunodeficiency (CVID) with intestinal disease |journal=Inflamm Bowel Dis |volume= |issue= |pages= |year=2010 |month=July |pmid=20629103 |doi=10.1002/ibd.21376 |url=}}</ref>
*[[Microsporidia]].
*No organisms in lumen.
*Isospora belli.
*Cyclospora.
*MAC ([[Mycobacterium avium complex]]).
*CMV ([[cytomegalovirus]]).
*[[Cryptococcus neoformans]].
 
=Common stuffs=
==Gastric heterotopia of the duodenum==
*[[AKA]] ''heterotopic gastric mucosa''.
{{Main|Gastric heterotopia of the duodenum}}


==Celiac sprue==
==Celiac sprue==
*[[AKA]] ''celiac disease''.
{{main|Celiac sprue}}
==Giardiasis==
{{Main|Giardiasis}}
==Acute duodenitis==
*Abbreviated ''AD''.
{{Main|Acute duodenitis}}
==Chronic duodenitis==
===General===
===General===
====Etiology====
*This is not very well defined as [[plasma cell]]s are present in a normal duodenum.
*Autoimmune.


====Epidemiology====
===Gross===
*Associated with:
*Duodenal erythema.
**The skin condition ''[[dermatitis herpetiformis]]''.<ref>TN 2007 D22</ref>
***Tx: dapsone.
**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>
**Risk factor for ''gastrointestinal T cell lymphoma'' - known as: ''enteropathy-associated T cell lymphoma'' (EATL).


====Treatment====
===Microscopic===
*Gluten free diet.
Features:
**''Mnemonic'': BROW = barley, rye, oats, wheat.
*"Abundant" lamina propria plasma cells.
*Villous blunting.
*[[Brunner's gland hyperplasia]].


====Serologic testing====
DDx:
*Anti-transglutaminase antibody.
*[[Normal duodenum]].
**Alternative test: anti-endomysial antibody.
 
*IgA -- assoc. with celiac sprue.
===Sign out===
<pre>
DUODENUM, BIOPSY:
- MODERATE NON-SPECIFIC CHRONIC DUODENTIS (SMALL BOWEL MUCOSA WITH VILLOUS
  BLUNTING, PROMINENT BRUNNER'S GLANDS, ABUNDANT LAMINA PROPRIA PLASMA CELLS
  AND OCCASIONAL INTRAEPITHELIAL LYMPHOCYTES, WITHOUT FOVEOLAR METAPLASIA).
- NEGATIVE FOR DYSPLASIA.
</pre>
 
==Peptic duodenitis==
{{Main|Peptic duodenitis}}
 
==Brunner's gland hyperplasia==
:''Brunner's gland hamartoma'' redirects here.
*Abbreviated ''BGH''.
*[[AKA]] ''Brunneroma''.<ref name=pmid12376792>{{Cite journal  | last1 = Tan | first1 = YM. | last2 = Wong | first2 = WK. | title = Giant Brunneroma as an unusual cause of upper gastrointestinal hemorrhage: report of a case. | journal = Surg Today | volume = 32 | issue = 10 | pages = 910-2 | month =  | year = 2002 | doi = 10.1007/s005950200179 | PMID = 12376792 }}</ref>
===General===
*Benign.
*Usually asymptomatic.<ref name=pmid18583897>{{Cite journal  | last1 = Lee | first1 = WC. | last2 = Yang | first2 = HW. | last3 = Lee | first3 = YJ. | last4 = Jung | first4 = SH. | last5 = Choi | first5 = GY. | last6 = Go | first6 = H. | last7 = Kim | first7 = A. | last8 = Cha | first8 = SW. | title = Brunner's gland hyperplasia: treatment of severe diffuse nodular hyperplasia mimicking a malignancy on pancreatic-duodenal area. | journal = J Korean Med Sci | volume = 23 | issue = 3 | pages = 540-3 | month = Jun | year = 2008 | doi = 10.3346/jkms.2008.23.3.540 | PMID = 18583897 }}</ref>
 
Note:
*The AFIP uses the term ''Brunner's gland hamartoma'' for lesions > 5 mm.<ref name=pmid16928936>{{Cite journal  | last1 = Patel | first1 = ND. | last2 = Levy | first2 = AD. | last3 = Mehrotra | first3 = AK. | last4 = Sobin | first4 = LH. | title = Brunner's gland hyperplasia and hamartoma: imaging features with clinicopathologic correlation. | journal = AJR Am J Roentgenol | volume = 187 | issue = 3 | pages = 715-22 | month = Sep | year = 2006 | doi = 10.2214/AJR.05.0564 | PMID = 16928936 }}</ref>
**Multiple lesions less than 5 mm are ''hyperplasia''.
 
===Gross===
*Nodularity of the duodenum.


===Microscopic===
===Microscopic===
Features:<ref name=Ref_PBoD843>{{Ref PBoD|843}}</ref>
Features:
*Enteritis.  
*Prominent Brunner's gland.
**Intraepithelial lymphocytes - '''key feature'''.
**Tubular structures - formed by cells abundant cytoplasm that is clear with eosinophilic "cobwebs" and a round, small basal nucleus without a nucleolus.
**Plasma cells.
**Brunner's glands close to the surface epithelium - '''key feature'''.<ref name=pmid4076734>{{Cite journal  | last1 = Franzin | first1 = G. | last2 = Musola | first2 = R. | last3 = Ghidini | first3 = O. | last4 = Manfrini | first4 = C. | last5 = Fratton | first5 = A. | title = Nodular hyperplasia of Brunner's glands. | journal = Gastrointest Endosc | volume = 31 | issue = 6 | pages = 374-8 | month = Dec | year = 1985 | doi =  | PMID = 4076734 }}</ref>
**Macrophages.  
*+/-Pancreatic acini and ducts.<ref name=pmid16928936/>
*Loss of villi - '''important feature'''.
 
**Normal duodenal biopsy should have 3 good villi.
DDx:
*Mitosis increased (in the crypts).
*Foveolar metaplasia (isolated) - see [[peptic duodenitis]].
*[[Peptic duodenitis]].


Image:
Image:
*[http://commons.wikimedia.org/wiki/File:Coeliac_path.jpg Celiac sprue (WC)].
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526515/figure/F3/ BGH (nih.gov)].<ref name=pmid18583897/>
*[http://www.ajronline.org/content/187/3/715.full BGH (ajronline.org)].<ref name=pmid16928936/>


Notes:  
===Sign out===
*If you see acute inflammatory cells, i.e. neutrophils, consider Giardiasis and other infectious etiologies.
<pre>
*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.
DUODENUM, BIOPSY:
- CONSISTENT WITH BRUNNER'S GLAND HYPERPLASIA.
- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.
</pre>


DDx:
<pre>
*Giardiasis.
DUODENUM, BIOPSY:
**Have giarrdia organisms.
- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.
**Always consider ''Giardiasis'' and especially on exams.
- PROMINENT BRUNNER'S GLANDS WITH EXTENSION INTO THE LAMINA PROPRIA.
*Whipple's disease (very rare).
</pre>
**Abundant macrophages should make one suspicious.
 
====Superficial Brunner's glands====
<pre>
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA WITH BRUNNER'S GLANDS THAT ARE FOCALLY SUPERFICIAL.
- NO FINDINGS SUGGESTIVE OF CELIAC DISEASE.
- NEGATIVE FOR ACTIVE INFLAMMATION.
- NEGATIVE FOR DYSPLASIA.
</pre>
 
====Micro====
The sections show small bowel mucosa and a small amount of submucosa. Brunner's glands are abundant and found focally in the lamina propria.
 
The epithelium matures appropriately.  There is no increase in intraepithelial lymphocytes.  No foveolar metaplasia of the epithelium is identified.


===Grading===
==Helicobacter duodenitis==
Most pathologists do not grade celiac sprue.
*Helicobacter is the most common cause of duodenitis.<ref>URL: [https://www.saintlukeskc.org/health-library/duodenitis https://www.saintlukeskc.org/health-library/duodenitis]. Accessed on: 2024 Feb 5.</ref><ref>URL: [https://www.webmd.com/digestive-disorders/what-is-duodenitis https://www.webmd.com/digestive-disorders/what-is-duodenitis]. Accessed on: 2024 Feb 5.</ref>
*Overall, Helicobacter is rare in the duodenum.
**Infection associated with [[Gastric heterotopia of the duodenum|gastric metaplasia]].<ref name=pmid7769188>{{cite journal |authors=Yang H, Dixon MF, Zuo J, Fong F, Zhou D, Corthésy I, Blum A |title=Helicobacter pylori infection and gastric metaplasia in the duodenum in China |journal=J Clin Gastroenterol |volume=20 |issue=2 |pages=110–2 |date=March 1995 |pmid=7769188 |doi=10.1097/00004836-199503000-00007 |url=}}</ref>


The most common system is the ''modified Marsh system'':<ref name=pmid12145668>{{cite journal |author=Wahab PJ, Meijer JW, Dumitra D, Goerres MS, Mulder CJ |title=Coeliac disease: more than villous atrophy |journal=Rom J Gastroenterol |volume=11 |issue=2 |pages=121–7 |year=2002 |month=June |pmid=12145668 |doi= |url=}}</ref><ref name=pmid20844959>{{cite journal |author=Ciaccio EJ, Bhagat G, Tennyson CA, Lewis SK, Hernandez L, Green PH |title=Quantitative Assessment of Endoscopic Images for Degree of Villous Atrophy in Celiac Disease |journal=Dig Dis Sci |volume= |issue= |pages= |year=2010 |month=September |pmid=20844959 |doi=10.1007/s10620-010-1371-6 |url=}}</ref>
===Sign out===
{| class="wikitable"
<pre>
|
A. Duodenum, Biopsy:
| '''Marsh 1'''
- Active duodenitis associated with foveolar epithelium and HELICOBACTER-LIKE ORGANISMS.
| '''Marsh 3A'''
- NEGATIVE for dysplasia.
| '''Marsh 3C'''
</pre>
|-
| Descriptors
| Well-formed villi
| Partial villous atrophy
| Total villous atrophy
|-
| Alternate descriptors
| Normal villous arch.
| Blunted villi
| Flattened mucosa
|}


==Giardiasis==
=Weird stuff=
===Etiology===
==Disaccharidases deficiency==
*Flagellate protozoan ''Giardia lamblia''.
===General===
*Common among asians.
*Includes: lactase, sucrase, and maltase.
**Lactase changes seen with mild histomorphologic changes.<ref name=pmid2116456>{{cite journal |author=Langman JM, Rowland R |title=Activity of duodenal disaccharidases in relation to normal and abnormal mucosal morphology |journal=J. Clin. Pathol. |volume=43 |issue=7 |pages=537–40 |year=1990 |month=July |pmid=2116456 |pmc=502575 |doi= |url=}}</ref>
**Maltase and sucrase only affected in moderate and severe lesions.


===Histology===
===Microscopic===
*Loss of villi.
Features:<ref name=pmid2116456>{{cite journal |author=Langman JM, Rowland R |title=Activity of duodenal disaccharidases in relation to normal and abnormal mucosal morphology |journal=J. Clin. Pathol. |volume=43 |issue=7 |pages=537–40 |year=1990 |month=July |pmid=2116456 |pmc=502575 |doi= |url=}}</ref>
*Intraepithelial lymphocytes.
*Decreased villous-crypt ratio (mild to severe).
**+Other inflammatory cells, especially PMNs, close to the luminal surface.
*+/-Inflammation (only in moderate and severe).
*Flagellate protozoa -- '''diagnostic feature'''.
**Organisms often at site of bad inflammation.
**Pale/translucent on H&E.
**Size: 12-15 micrometers (long axis) x 6-10 micrometers (short axis) -- if seen completely.<ref>[http://www.water-research.net/Giardia.htm http://www.water-research.net/Giardia.htm]</ref>
***Often look like a crescent moon ([http://en.wikipedia.org/wiki/File:Crescent_Moon.JPG image of crescent moon]) or semicircular<ref>[http://en.wikipedia.org/wiki/Semicircle http://en.wikipedia.org/wiki/Semicircle]</ref> -- as the long axis of the organism is rarely in the plane of the (histologic) section.


Notes:  
DDx:
*Giardiasis can look (histologically) a lot like celiac disease.
*Celiac disease.<ref name=pmid11252408>{{cite journal |author=Murray IA, Smith JA, Coupland K, Ansell ID, Long RG |title=Intestinal disaccharidase deficiency without villous atrophy may represent early celiac disease |journal=Scand. J. Gastroenterol. |volume=36 |issue=2 |pages=163–8 |year=2001 |month=February |pmid=11252408 |doi= |url=}}</ref>


Images:
Notes:
*[http://commons.wikimedia.org/wiki/File:Giardiasis_duodenum_high.jpg Giardiasis - high mag. (WC)].
*May have normal histomorphology.<ref name=pmid2116456>{{cite journal |author=Langman JM, Rowland R |title=Activity of duodenal disaccharidases in relation to normal and abnormal mucosal morphology |journal=J. Clin. Pathol. |volume=43 |issue=7 |pages=537–40 |year=1990 |month=July |pmid=2116456 |pmc=502575 |doi= |url=}}</ref>
*[http://commons.wikimedia.org/wiki/File:Giardiasis_duodenum_low.jpg Giardiasis - low mag. (WC)].


===Treatment===
==Whipple disease==
*Antibiotics, e.g. metronidazole (Flagyl).
{{Main|Whipple's disease}}


==Whipple's disease==
==Microvillous inclusion disease==
===Epidemiology===
{{Main|Microvillous inclusion disease}}
*Very rare.
This rare disease presents very shortly after birth.  
*Classically middle aged men.


===Clinical===
==Tufting enteropathy==
*Malabsorption (diarrhea), arthritis + others.  
*[[AKA]] ''intestinal epithelial dysplasia''.
**Symptoms are non-specific.
===General===
*Genetic disease<ref name=omim613217>{{OMIM|613217}}</ref> - related to abnormal enterocytes (development and/or differentiation).
**Gene implicated: ''EPCAM''.<ref name=omim185535>{{OMIM|185535}}</ref>


===Etiology===
===Microscopic===
*Infection - caused by ''Tropheryma whipplei''.<ref>{{cite journal |author=Liang Z, La Scola B, Raoult D |title=Monoclonal antibodies to immunodominant epitope of Tropheryma whipplei |journal=Clin. Diagn. Lab. Immunol. |volume=9 |issue=1 |pages=156?9 |year=2002 |month=January |pmid=11777846 |pmc=119894 |doi= |url=http://cvi.asm.org/cgi/pmidlookup?view=long&pmid=11777846}}</ref>
Features:<ref name=pmid17448233>{{cite journal |author=Goulet O, Salomon J, Ruemmele F, de Serres NP, Brousse N |title=Intestinal epithelial dysplasia (tufting enteropathy) |journal=Orphanet J Rare Dis |volume=2 |issue= |pages=20 |year=2007 |pmid=17448233 |pmc=1878471 |doi=10.1186/1750-1172-2-20 |url=}}</ref>
*Villous atrophy
*Mononuclear cell infiltration of the lamina propria
*Abnormal surface enterocytes:
**Focal crowding -- resembling tufts.


===Histology===
Features:<ref>{{cite journal | author=Bai J, Mazure R, Vazquez H, Niveloni S, Smecuol E, Pedreira S, Mauriño E | title=Whipple's disease | journal=Clin Gastroenterol Hepatol | volume=2 | issue=10 | pages=849?60 | year=2004 | pmid=15476147  | doi=10.1016/S1542-3565(04)00387-8}}</ref>
*Infectious microorganism typically found in macrophages.
**Macrophages usually abundant - '''key feature''' that should raise Dx in DDx.
**Organisms periodic acid-Schiff (PAS) positive.


===Treatment===  
==Gangliocytic paraganglioma==
*Antibiotics - for months and months.
*Abbreviated ''GP''.
{{Main|Gangliocytic paraganglioma}}


Micrograph: [http://en.wikipedia.org/wiki/File:Whipple2.jpg Whipple's disease] - wikipedia.org.
==Pseudomelanosis duodeni==
{{Main|Pseudomelanosis duodeni}}


==Tumours==
=Tumours=
==Lymphoma==
==Lymphoma==
{{main|Lymphoma}}
{{main|Lymphoma}}
*Non-Hodgkin's lymphoma.
*Non-Hodgkin's lymphoma.
**Enteropathy-associated T-cell lymphoma (EATL) - due to ''celiac sprue''.
**[[Enteropathy-associated T-cell lymphoma]] (EATL) - due to ''[[celiac sprue]]''.
***Image: [http://commons.wikimedia.org/wiki/File:Enteropathy-associated_T_cell_lymphoma_-_low_mag.jpg EATL - low mag. (WC)].
**[[MALT lymphoma]] - common GI tract lymphoma.
**[[MALT lymphoma]] - common GI tract lymphoma.
**[[Mantle cell lymphoma]].
**[[Mantle cell lymphoma]].
Line 160: Line 275:
*[[Hodgkin's lymphoma]] does not arise in the GI tract.
*[[Hodgkin's lymphoma]] does not arise in the GI tract.


==Adenocarcinoma==
==Adenocarcinoma of the duodenum==
*Similar to large bowel adenocarcinomas (see ''[[colorectal tumours]]'' article).
*[[AKA]] ''duodenal adenocarcinoma''.
*Duodenum - most common site in small bowel.
*[[AKA]] ''duodenal carcinoma''.
{{Main|Adenocarcinoma of the duodenum}}


Risk factors:
==Duodenal neuroendocrine tumour==
*[[Crohn's disease]]
{{Main|Neuroendocrine tumours}}
*[[Celiac disease]]
:''Duodenal NET'' redirects here.
*[[FAP]]
*[[HNPCC]]
*[[Peutz-Jeghers syndrome]]
 
==Neuroendocrine tumours==
===General===
===General===
*Like neuroendocrine tumours elsewhere.
*Like [[neuroendocrine tumours]] elsewhere.
*Use of the term ''carcinoid'' is discouraged.<ref name=pmid18414708>{{Cite journal  | last1 = Chetty | first1 = R. | title = Requiem for the term 'carcinoid tumour' in the gastrointestinal tract? | journal = Can J Gastroenterol | volume = 22 | issue = 4 | pages = 357-8 | month = Apr | year = 2008 | doi =  | PMID = 18414708 }}
*Use of the term ''carcinoid'' is discouraged.<ref name=pmid18414708>{{Cite journal  | last1 = Chetty | first1 = R. | title = Requiem for the term 'carcinoid tumour' in the gastrointestinal tract? | journal = Can J Gastroenterol | volume = 22 | issue = 4 | pages = 357-8 | month = Apr | year = 2008 | doi =  | PMID = 18414708 }}
</ref><ref name=pmid15153416>{{Cite journal  | last1 = Klöppel | first1 = G. | last2 = Perren | first2 = A. | last3 = Heitz | first3 = PU. | title = The gastroenteropancreatic neuroendocrine cell system and its tumors: the WHO classification. | journal = Ann N Y Acad Sci | volume = 1014 | issue =  | pages = 13-27 | month = Apr | year = 2004 | doi =  | PMID = 15153416 }}
</ref><ref name=pmid15153416>{{Cite journal  | last1 = Klöppel | first1 = G. | last2 = Perren | first2 = A. | last3 = Heitz | first3 = PU. | title = The gastroenteropancreatic neuroendocrine cell system and its tumors: the WHO classification. | journal = Ann N Y Acad Sci | volume = 1014 | issue =  | pages = 13-27 | month = Apr | year = 2004 | doi =  | PMID = 15153416 }}
</ref><ref name=pmid14513276>{{cite journal |author=Klöppel G |title=[Neuroendocrine tumors of the gastrointestinal tract] |language=German |journal=Pathologe |volume=24 |issue=4 |pages=287–96 |year=2003 |month=July |pmid=14513276 |doi=10.1007/s00292-003-0636-7 |url=}}</ref>
</ref><ref name=pmid14513276>{{cite journal |author=Klöppel G |title=[Neuroendocrine tumors of the gastrointestinal tract] |language=German |journal=Pathologe |volume=24 |issue=4 |pages=287–96 |year=2003 |month=July |pmid=14513276 |doi=10.1007/s00292-003-0636-7 |url=}}</ref>
Associations:
*[[Neurofibromatosis type 1]].
*[[MEN I]].


===Microscopic===
===Microscopic===
Features:
Features:<ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/SmallbowelNET_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/SmallbowelNET_11protocol.pdf]. Accessed on: 29 March 2012.</ref>
*Nests of cells.
*Usu. nests of cells - may be:
*Stippled chromatin - AKA: salt-and-pepper chromatin, coarse chromatin.
**[[Trabecular]].
**Glandular - common in stomatostatin producing tumours.
*Stippled chromatin - ([[AKA]] salt-and-pepper chromatin, coarse chromatin).
*Classically subepithelial/mural.
*Classically subepithelial/mural.
*+/-[[Psammoma bodies]] - suggestive of [[somatostatinoma]] and [[NF1]].<ref name=pmid21437171>{{Cite journal  | last1 = Kim | first1 = JA. | last2 = Choi | first2 = WH. | last3 = Kim | first3 = CN. | last4 = Moon | first4 = YS. | last5 = Chang | first5 = SH. | last6 = Lee | first6 = HR. | title = Duodenal somatostatinoma: a case report and review. | journal = Korean J Intern Med | volume = 26 | issue = 1 | pages = 103-7 | month = Mar | year = 2011 | doi = 10.3904/kjim.2011.26.1.103 | PMID = 21437171 }}</ref>


Images:
DDx:
*[http://commons.wikimedia.org/wiki/File:Small_intestine_neuroendocrine_tumour_low_mag.jpg Neuroendocrine tumour - low mag. (WC)].
*[[Adenocarcinoma of the duodenum]].
*[http://commons.wikimedia.org/wiki/File:Small_intestine_neuroendocrine_tumour_intermed_mag.jpg Neuroendocrine tumour - intermed. mag. (WC)].
 
*[http://commons.wikimedia.org/wiki/File:Small_intestine_neuroendocrine_tumour_high_mag.jpg Neuroendocrine tumour - high mag. (WC)].
====Images====
<gallery>
Image:Small_intestine_neuroendocrine_tumour_low_mag.jpg | Neuroendocrine tumour - low mag. (WC)
Image:Small_intestine_neuroendocrine_tumour_intermed_mag.jpg | Neuroendocrine tumour - intermed. mag. (WC)
Image:Small_intestine_neuroendocrine_tumour_high_mag.jpg | Neuroendocrine tumour - high mag. (WC)
</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>


==Ampullary tumours==
==Ampullary tumours==
{{Main|Ampullary tumours}}
===General===
*Individuals with high-grade dysplasia (on biopsy) are usually treated with a pancreaticoduodenectomy (Whipple procedure), as local resections have a very high recurrence rate.<ref name=pmid16332486>{{Cite journal  | last1 = Meneghetti | first1 = AT. | last2 = Safadi | first2 = B. | last3 = Stewart | first3 = L. | last4 = Way | first4 = LW. | title = Local resection of ampullary tumors. | journal = J Gastrointest Surg | volume = 9 | issue = 9 | pages = 1300-6 | month = Dec | year = 2005 | doi = 10.1016/j.gassur.2005.08.031 | PMID = 16332486 }}</ref>
===Microscopic===
Features:
*''See [[ampullary tumours]]''.
DDx:
*[[Intraductal papillary mucinous tumour]] (IPMT) - a pancreatic tumour, see ''[[pancreas]]'' article.
*[[Invasive ductal carcinoma of the pancreas]].
===Sign out===
*Ampullary carcinoma - has separate staging.
*Ampullary carcinoma - has separate staging.
*Intraductal papillary mucinous tumour (IPMT) - a pancreatic tumour, see ''[[pancreas]]'' article.


==See also==
==Traditional adenoma==
:''Duodenal adenoma'' redirects here.
{{Main|Traditional adenoma}}
===General===
*Strong association of [[familial adenomatous polyposis]].
**In one series of 208 adenomas, almost 70% were from FAP patients.<ref name=pmid16837629/>
*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>
*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>
 
===Sign out===
<pre>
POLYP, DUODENUM, EXCISION:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
 
====Alternate====
<pre>
Polyp (Nonampullary), Duodenum, Polypectomy:
    - Tubular adenoma, NEGATIVE for high-grade dysplasia.
 
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]
 
1. Therap Adv Gastroenterol. 2012 Mar; 5(2): 127138. doi: 10.1177/1756283X11429590
</pre>
 
=See also=
*[[Gastrointestinal pathology]].
*[[Gastrointestinal pathology]].
*[[Intestinal polyps]].
*[[Intestinal polyps]].
*[[Small bowel]].
*[[Small bowel]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


[[Category:Gastrointestinal pathology]]
[[Category:Gastrointestinal pathology]]
=External links=
===Review article(s)===
*{{cite journal |author=Serra S, Jani PA |title=An approach to duodenal biopsies |journal=J. Clin. Pathol. |volume=59 |issue=11 |pages=1133–50 |year=2006 |month=November |pmid=16679353 |pmc=1860495 |doi=10.1136/jcp.2005.031260 |url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860495/?tool=pubmed}}
Michael
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