Duodenum

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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.

The clinical history is often: r/o celiac or r/o giardia.

Getting started

Normal duodenum

  • 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.
  • No organisms in lumen.

DDx:

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Duodenum, Biopsy:
- Small bowel mucosa and Brunner's glands within normal limits.
Duodenum, Biopsy:
- Small bowel mucosa within normal limits.

Duodenum, Biopsy:
- Small bowel mucosa within normal limits.
- NEGATIVE for findings suggestive of celiac disease.

Small Bowel (Duodenum), Biopsy:
- Small bowel mucosa within normal limits.
- NEGATIVE for findings suggestive of celiac disease.

Block letters

DUODENUM, BIOPSY: 
- SMALL BOWEL MUCOSA AND BRUNNER'S GLANDS WITHIN NORMAL LIMITS.

DUODENUM, BIOPSY: 
- SMALL BOWEL MUCOSA WITHIN NORMAL LIMITS.

DUODENUM, BIOPSY: 
- SMALL BOWEL MUCOSA WITHIN NORMAL LIMITS.
- NEGATIVE FOR FINDINGS SUGGESTIVE OF CELIAC DISEASE.

SMALL BOWEL (DUODENUM), BIOPSY: 
- SMALL BOWEL MUCOSA WITHIN NORMAL LIMITS.
- NEGATIVE FOR FINDINGS SUGGESTIVE OF CELIAC DISEASE.

Basic DDx

  • Celiac sprue.
    • Intraepithelial lymphocytes - key feature.
    • Loss of villi.
  • Giardia.
    • Like celiac... but giardia organisms.
  • Adenomas.
    • Too much blue - similar to colonic adenomas.
  • Cancer.
    • Too much blue and epithelium in the wrong place.

More

  • H. pylori only in areas of gastric metaplasia.[2]

Duodenal nodules DDX

 
 
 
 
 
 
 
 
 
 
 
 
Duodenal
nodule
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Benign
(common)
 
 
 
 
 
 
 
 
 
 
 
 
 
Neoplastic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Brunner's
gland
 
Heterotopic
gastric mucosa
 
Lymphoid
nodule
 
Adenoma
 
NET
 
Paraganglioma
 
Prolapsed
gastric polyp
 
Metastasis
 
 
 
 

Infections of the duodenum[3]

Common:

Rare:

Common stuffs

Gastric heterotopia of the duodenum

  • AKA heterotopic gastric mucosa.
Main article: Gastric heterotopia of the duodenum

Celiac sprue

  • AKA celiac disease.
Main article: Celiac sprue

Giardiasis

Main article: Giardiasis

Acute duodenitis

  • Abbreviated AD.
Main article: Acute duodenitis

Chronic duodenitis

General

  • This is not very well defined as plasma cells are present in a normal duodenum.

Gross

  • Duodenal erythema.

Microscopic

Features:

DDx:

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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.

Peptic duodenitis

Main article: Peptic duodenitis

Brunner's gland hyperplasia

Brunner's gland hamartoma redirects here.
  • Abbreviated BGH.
  • AKA Brunneroma.[4]

General

  • Benign.
  • Usually asymptomatic.[5]

Note:

  • The AFIP uses the term Brunner's gland hamartoma for lesions > 5 mm.[6]
    • Multiple lesions less than 5 mm are hyperplasia.

Gross

  • Nodularity of the duodenum.

Microscopic

Features:

  • Prominent Brunner's gland.
    • Tubular structures - formed by cells abundant cytoplasm that is clear with eosinophilic "cobwebs" and a round, small basal nucleus without a nucleolus.
    • Brunner's glands close to the surface epithelium - key feature.[7]
  • +/-Pancreatic acini and ducts.[6]

DDx:

Image:

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DUODENUM, BIOPSY:
- CONSISTENT WITH BRUNNER'S GLAND HYPERPLASIA.
- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.

 DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.
- PROMINENT BRUNNER'S GLANDS WITH EXTENSION INTO THE LAMINA PROPRIA.

Superficial Brunner's glands

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.

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.

Weird stuff

Helicobacter duodenitis

  • Helicobacter is rare in the duodenum.
    • Infection associated with gastric metaplasia.[8]

Disaccharidases deficiency

General

  • Common among asians.
  • Includes: lactase, sucrase, and maltase.
    • Lactase changes seen with mild histomorphologic changes.[9]
    • Maltase and sucrase only affected in moderate and severe lesions.

Microscopic

Features:[9]

  • Decreased villous-crypt ratio (mild to severe).
  • +/-Inflammation (only in moderate and severe).

DDx:

Notes:

  • May have normal histomorphology.[9]

Whipple disease

Main article: Whipple's disease

Microvillous inclusion disease

Main article: Microvillous inclusion disease

This rare disease presents very shortly after birth.

Tufting enteropathy

  • AKA intestinal epithelial dysplasia.

General

  • Genetic disease[11] - related to abnormal enterocytes (development and/or differentiation).
    • Gene implicated: EPCAM.[12]

Microscopic

Features:[13]

  • Villous atrophy
  • Mononuclear cell infiltration of the lamina propria
  • Abnormal surface enterocytes:
    • Focal crowding -- resembling tufts.


Gangliocytic paraganglioma

  • Abbreviated GP.
Main article: Gangliocytic paraganglioma

Pseudomelanosis duodeni

Main article: Pseudomelanosis duodeni

Tumours

Lymphoma

Main article: Lymphoma

Note:

Adenocarcinoma of the duodenum

  • AKA duodenal adenocarcinoma.
  • AKA duodenal carcinoma.
Main article: Adenocarcinoma of the duodenum

Duodenal neuroendocrine tumour

Main article: Neuroendocrine tumours
Duodenal NET redirects here.

General

Associations:

Microscopic

Features:[17]

  • Usu. nests of cells - may be:
    • Trabecular.
    • Glandular - common in stomatostatin producing tumours.
  • Stippled chromatin - (AKA salt-and-pepper chromatin, coarse chromatin).
  • Classically subepithelial/mural.
  • +/-Psammoma bodies - suggestive of somatostatinoma and NF1.[18]

DDx:

Images

  • Neuroendocrine tumour - low mag. (WC)

  • Neuroendocrine tumour - intermed. mag. (WC)

  • Neuroendocrine tumour - high mag. (WC)

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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%.

Ampullary tumours

Main article: 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.[19]

Microscopic

Features:

DDx:

Sign out

  • Ampullary carcinoma - has separate staging.

Traditional adenoma

Duodenal adenoma redirects here.
Main article: Traditional adenoma

General

  • Strong association of familial adenomatous polyposis.
    • In one series of 208 adenomas, almost 70% were from FAP patients.[20]
  • Commonly found in association foveolar metaplasia - especially in sporadic cases ~60% of cases.
    • In FAP ~30% of cases have foveolar metaplasia.[20]
  • A colonscopy is recommended in individuals with nonampullary duodenal adenomas, as they are likely at increased risk of large bowel adenomas.[21]

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POLYP, DUODENUM, EXCISION:
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.

Alternate

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

See also

References

  1. ↑ Agarwal S, Smereka P, Harpaz N, Cunningham-Rundles C, Mayer L (July 2010). "Characterization of immunologic defects in patients with common variable immunodeficiency (CVID) with intestinal disease". Inflamm Bowel Dis. doi:10.1002/ibd.21376. PMID 20629103.
  2. ↑ El-Zimaity. 18 October 2010.
  3. ↑ Serra S, Jani PA (November 2006). "An approach to duodenal biopsies". J. Clin. Pathol. 59 (11): 1133–50. doi:10.1136/jcp.2005.031260. PMC 1860495. PMID 16679353. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860495/?tool=pubmed.
  4. ↑ Tan, YM.; Wong, WK. (2002). "Giant Brunneroma as an unusual cause of upper gastrointestinal hemorrhage: report of a case.". Surg Today 32 (10): 910-2. doi:10.1007/s005950200179. PMID 12376792.
  5. ↑ 5.0 5.1 Lee, WC.; Yang, HW.; Lee, YJ.; Jung, SH.; Choi, GY.; Go, H.; Kim, A.; Cha, SW. (Jun 2008). "Brunner's gland hyperplasia: treatment of severe diffuse nodular hyperplasia mimicking a malignancy on pancreatic-duodenal area.". J Korean Med Sci 23 (3): 540-3. doi:10.3346/jkms.2008.23.3.540. PMID 18583897.
  6. ↑ 6.0 6.1 6.2 Patel, ND.; Levy, AD.; Mehrotra, AK.; Sobin, LH. (Sep 2006). "Brunner's gland hyperplasia and hamartoma: imaging features with clinicopathologic correlation.". AJR Am J Roentgenol 187 (3): 715-22. doi:10.2214/AJR.05.0564. PMID 16928936.
  7. ↑ Franzin, G.; Musola, R.; Ghidini, O.; Manfrini, C.; Fratton, A. (Dec 1985). "Nodular hyperplasia of Brunner's glands.". Gastrointest Endosc 31 (6): 374-8. PMID 4076734.
  8. ↑ Yang H, Dixon MF, Zuo J, Fong F, Zhou D, Corthésy I, Blum A (March 1995). "Helicobacter pylori infection and gastric metaplasia in the duodenum in China". J Clin Gastroenterol 20 (2): 110–2. doi:10.1097/00004836-199503000-00007. PMID 7769188.
  9. ↑ 9.0 9.1 9.2 Langman JM, Rowland R (July 1990). "Activity of duodenal disaccharidases in relation to normal and abnormal mucosal morphology". J. Clin. Pathol. 43 (7): 537–40. PMC 502575. PMID 2116456. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC502575/.
  10. ↑ Murray IA, Smith JA, Coupland K, Ansell ID, Long RG (February 2001). "Intestinal disaccharidase deficiency without villous atrophy may represent early celiac disease". Scand. J. Gastroenterol. 36 (2): 163–8. PMID 11252408.
  11. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 613217
  12. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 185535
  13. ↑ Goulet O, Salomon J, Ruemmele F, de Serres NP, Brousse N (2007). "Intestinal epithelial dysplasia (tufting enteropathy)". Orphanet J Rare Dis 2: 20. doi:10.1186/1750-1172-2-20. PMC 1878471. PMID 17448233. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1878471/.
  14. ↑ Chetty, R. (Apr 2008). "Requiem for the term 'carcinoid tumour' in the gastrointestinal tract?". Can J Gastroenterol 22 (4): 357-8. PMID 18414708.
  15. ↑ Klöppel, G.; Perren, A.; Heitz, PU. (Apr 2004). "The gastroenteropancreatic neuroendocrine cell system and its tumors: the WHO classification.". Ann N Y Acad Sci 1014: 13-27. PMID 15153416.
  16. ↑ Klöppel G (July 2003). "[Neuroendocrine tumors of the gastrointestinal tract]" (in German). Pathologe 24 (4): 287–96. doi:10.1007/s00292-003-0636-7. PMID 14513276.
  17. ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/SmallbowelNET_11protocol.pdf. Accessed on: 29 March 2012.
  18. ↑ Kim, JA.; Choi, WH.; Kim, CN.; Moon, YS.; Chang, SH.; Lee, HR. (Mar 2011). "Duodenal somatostatinoma: a case report and review.". Korean J Intern Med 26 (1): 103-7. doi:10.3904/kjim.2011.26.1.103. PMID 21437171.
  19. ↑ Meneghetti, AT.; Safadi, B.; Stewart, L.; Way, LW. (Dec 2005). "Local resection of ampullary tumors.". J Gastrointest Surg 9 (9): 1300-6. doi:10.1016/j.gassur.2005.08.031. PMID 16332486.
  20. ↑ 20.0 20.1 Rubio, CA. (Jun 2007). "Gastric duodenal metaplasia in duodenal adenomas.". J Clin Pathol 60 (6): 661-3. doi:10.1136/jcp.2006.039388. PMC 1955048. PMID 16837629. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955048/.
  21. ↑ Lim, CH.; Cho, YS. (Jan 2016). "Nonampullary duodenal adenoma: Current understanding of its diagnosis, pathogenesis, and clinical management.". World J Gastroenterol 22 (2): 853-61. doi:10.3748/wjg.v22.i2.853. PMID 26811631.

External links

Review article(s)

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