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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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=Getting started=
=Getting started=
===Normal duodenum===
==Normal duodenum==
*Abbreviated ''ND''.
===General===
*Very common.
 
===Microscopic===
*Three tall villi.
*Three tall villi.
*Few intraepithelial lymphocytes; < 1 lymphocyte / 4 epithelial cells.
*Few intraepithelial lymphocytes; < 1 lymphocyte / 4 epithelial cells.
*No (pink) subepithelial collagen band.
*No (pink) subepithelial collagen band.
*Predominant lamina propria cell: plasma cells.
*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>
**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.
*No organisms in lumen.


===Basic DDx===
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.
*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.
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**Too much blue and epithelium in the wrong place.
**Too much blue and epithelium in the wrong place.
====More====
====More====
*H. pylori only in areas of gastric metaplasia.<ref>El-Zimaity. 18 October 2010.</ref>
*[[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===
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{{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}}


===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>===
===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>===
Common:
Common:
*Giardia
*[[Giardia]].
Rare:
Rare:
*Cryptosporidia.
*[[Cryptosporidia]].
*Microsporidia.
*[[Microsporidia]].
*Isospora belli.
*Isospora belli.
*Cyclospora.  
*Cyclospora.  
*MAI (Mycobacterium avium intracellulare).
*MAC ([[Mycobacterium avium complex]]).
*CMV (cytomegalovirus).
*CMV ([[cytomegalovirus]]).
*Cryptococcus neoformans.
*[[Cryptococcus neoformans]].


=Common stuffs=
=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}}
{{main|Celiac sprue}}
===General===
*Etiology: autoimmune.


====Epidemiology====
==Giardiasis==
*Associated with:
{{Main|Giardiasis}}
**The skin condition ''[[dermatitis herpetiformis]]''.<ref>TN 2007 D22</ref>
**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).


====Clinical====
==Acute duodenitis==
Treatment:
*Abbreviated ''AD''.
*Gluten free diet.
{{Main|Acute duodenitis}}
**''Mnemonic'': BROW = barley, rye, oats, wheat.


Serologic testing:
==Chronic duodenitis==
*Anti-transglutaminase antibody.
===General===
**Alternative test: anti-endomysial antibody.
*This is not very well defined as [[plasma cell]]s are present in a normal duodenum.
*IgA -- assoc. with celiac sprue.
 
===Gross===
*Duodenal erythema.


===Microscopic===
===Microscopic===
Features:<ref name=Ref_PBoD843>{{Ref PBoD|843}}</ref>
Features:
*Intraepithelial lymphocytes (IELs) - '''key feature'''.
*"Abundant" lamina propria plasma cells.
**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>
*Villous blunting.
**Criteria for number varies:
*[[Brunner's gland hyperplasia]].
*** > 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>
*** > 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>
*Loss of villi - '''important feature'''.
**Normal duodenal biopsy should have 3 good villi.
*Plasma cells - abundant (weak feature).
*Macrophages.
*Mitosis increased (in the crypts).
*+/-Collagen band (pink material in mucosa) - "Collagenous sprue"; must encompass ~25% of mucosa.


Image:
DDx:
*[http://commons.wikimedia.org/wiki/File:Coeliac_path.jpg Celiac sprue (WC)].
*[[Normal duodenum]].


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:
*Flat lesions without IELs are unlikely to be celiac sprue.
- MODERATE NON-SPECIFIC CHRONIC DUODENTIS (SMALL BOWEL MUCOSA WITH VILLOUS
*Mucosa erosions are rare in celiac sprue; should prompt consideration of an alternate diagnosis (infection, medications, Crohn's disease).
  BLUNTING, PROMINENT BRUNNER'S GLANDS, ABUNDANT LAMINA PROPRIA PLASMA CELLS
  AND OCCASIONAL INTRAEPITHELIAL LYMPHOCYTES, WITHOUT FOVEOLAR METAPLASIA).
- NEGATIVE FOR DYSPLASIA.
</pre>


===Grading===
==Peptic duodenitis==
Rarely done - see ''[[celiac sprue]]'' article.
{{Main|Peptic duodenitis}}


==Giardiasis==
==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===
===General===
*Etiology:
*Benign.
**Flagellate protozoan ''Giardia lamblia''.
*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>


*Treatment
Note:
**Antibiotics, e.g. metronidazole (Flagyl).
*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:
Features:
*+/-Loss of villi.
*Prominent Brunner's gland.
*Intraepithelial lymphocytes.  
**Tubular structures - formed by cells abundant cytoplasm that is clear with eosinophilic "cobwebs" and a round, small basal nucleus without a nucleolus.
**+Other inflammatory cells, especially PMNs, close to the luminal surface.
**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>
*Flagellate protozoa -- '''diagnostic feature'''.
*+/-Pancreatic acini and ducts.<ref name=pmid16928936/>
**Organisms often at site of bad inflammation.
 
**Pale/translucent on H&E.
DDx:
**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>
*Foveolar metaplasia (isolated) - see [[peptic duodenitis]].
***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.
*[[Peptic duodenitis]].


Notes:  
Image:
*Giardiasis can look (histologically) a lot like celiac disease.
*[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/>


Images:
===Sign out===
*[http://commons.wikimedia.org/wiki/File:Giardiasis_duodenum_high.jpg Giardiasis - high mag. (WC)].
<pre>
*[http://commons.wikimedia.org/wiki/File:Giardiasis_duodenum_low.jpg Giardiasis - low mag. (WC)].
DUODENUM, BIOPSY:
- CONSISTENT WITH BRUNNER'S GLAND HYPERPLASIA.
- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.
</pre>


==Acute duodenitis==
<pre>
===Etiology (DDx)===
DUODENUM, BIOPSY:
*Infection.
- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.
**Helicobactor organisms in the [[stomach]].
- PROMINENT BRUNNER'S GLANDS WITH EXTENSION INTO THE LAMINA PROPRIA.
*Medications (NSAIDs).
</pre>
*Crohn's disease (usually focal/patchy).
 
*Celiac sprue.
====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.


===Microscopic===
==Helicobacter duodenitis==
Features:
*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>
*Intraepithelial lymphocytes.
*Overall, Helicobacter is rare in the duodenum.
*Neutrophils - "found without searching" - '''key feature'''.
**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>
*Eosinophils - "found without searching" - '''key feature'''.
*Plasma cells (increased).


Notes:
===Sign out===
*One needs stomach concurrent biopsies to r/o Helicobactor.
<pre>
*Erosions make celiac sprue much less likely.
A. Duodenum, Biopsy:
*Presence of chronic inflammation useful for NSAIDS vs. Helicobacter organisms:
- Active duodenitis associated with foveolar epithelium and HELICOBACTER-LIKE ORGANISMS.
**NSAIDs not commonly assoc. with acute inflammation;<ref name=pmid8406146>{{cite journal |author=Taha AS, Dahill S, Nakshabendi I, Lee FD, Sturrock RD, Russell RI |title=Duodenal histology, ulceration, and Helicobacter pylori in the presence or absence of non-steroidal anti-inflammatory drugs |journal=Gut |volume=34 |issue=9 |pages=1162–6 |year=1993 |month=September |pmid=8406146 |pmc=1375446 |doi= |url=}}</ref> thus, without chronic inflammation NSAIDs are unlikely.
- NEGATIVE for dysplasia.
***Acute NSAID-related duodenitis reported.<ref name=pmid18158085>{{cite journal |author=Hashash JG, Atweh LA, Saliba T, ''et al.'' |title=Acute NSAID-related transmural duodenitis and extensive duodenal ulceration |journal=Clin Ther |volume=29 |issue=11 |pages=2448–52 |year=2007 |month=November |pmid=18158085 |doi=10.1016/j.clinthera.2007.11.012 |url=}}</ref>
</pre>


=Weird stuff=
=Weird stuff=
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==Whipple disease==
==Whipple disease==
===General===
{{Main|Whipple's disease}}
Etiology:
*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>
 
Epidemiology:
*Very rare.
*Classically middle aged men.
 
====Clinical====
*Malabsorption (diarrhea), arthritis + others.
**Symptoms are non-specific.
 
Treatment:
*Antibiotics - for months and months.
 
===Microscopic===
Features:<ref name=pmid15476147>{{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.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Whipple_disease_-_intermed_mag.jpg Whipple disease - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Whipple_disease_-a-_high_mag.jpg Whipple disease - high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Whipple2.jpg Whipple disease - poor quality - low mag. (WC)].
 
DDx:
*Mycobacterium avium intracellulare (MAI).
 
===Stains===
*PAS +ve organisms.
*AFB stain -ve -- to r/o MAI.
 
Image:
*[http://www.biomedcentral.com/content/figures/1472-6823-6-3-2-l.jpg Whipple disease - PAS stain (biomedcentral.com)].


==Microvillous inclusion disease==
==Microvillous inclusion disease==
Line 205: Line 243:


==Tufting enteropathy==
==Tufting enteropathy==
*[[AKA]] ''intestinal epithelial dysplasia''.
===General===
===General===
*[[AKA]] intestinal epithelial dysplasia.
*Genetic disease<ref name=omim613217>{{OMIM|613217}}</ref> - related to abnormal enterocytes (development and/or differentiation).
*Genetic disease<ref>URL: [http://www.ncbi.nlm.nih.gov/omim/185535 http://www.ncbi.nlm.nih.gov/omim/185535]. Accessed on: 21 September 2010.</ref> - related to abnormal enterocytes (development and/or differentiation).
**Gene implicated: ''EPCAM''.<ref name=omim185535>{{OMIM|185535}}</ref>


===Microscopic===
===Microscopic===
Line 215: Line 254:
*Abnormal surface enterocytes:  
*Abnormal surface enterocytes:  
**Focal crowding -- resembling tufts.
**Focal crowding -- resembling tufts.
==Gangliocytic paraganglioma==
*Abbreviated ''GP''.
{{Main|Gangliocytic paraganglioma}}
==Pseudomelanosis duodeni==
{{Main|Pseudomelanosis duodeni}}


=Tumours=
=Tumours=
Line 220: Line 267:
{{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 229: 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:
*[[Crohn's disease]].
*[[Celiac sprue]].
*[[Familial adenomatous polyposis]] (FAP).
*[[HNPCC]].
*[[Peutz-Jeghers syndrome]].


==Neuroendocrine tumours==
==Duodenal neuroendocrine tumour==
{{Main|Neuroendocrine tumours}}
:''Duodenal NET'' redirects here.
===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.
 
==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=
=See also=
Michael
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