Difference between revisions of "Duodenum"

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Duodenum (view source)

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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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<pre>
<pre>
DUODENUM, BIOPSY:  
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.
- SMALL BOWEL MUCOSA WITHIN NORMAL LIMITS.
- NEGATIVE FOR FINDINGS SUGGESTIVE OF CELIAC DISEASE.
- NEGATIVE FOR FINDINGS SUGGESTIVE OF CELIAC DISEASE.
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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>
*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>
 
===Microscopic===
Features:
#Foveolar epithelium.
#Gastric glands - body-type or antral-type.
 
DDx:
*Foveolar metaplasia.
 
====Images====
www:
*[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>
 
===Sign out===
<pre>
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA AND BRUNNER'S GLANDS WITHIN NORMAL LIMITS.
- GASTRIC HETEROTOPIA, BODY-TYPE MUCOSA.
</pre>


==Celiac sprue==
==Celiac sprue==
*[[AKA]] ''celiac disease''.
{{main|Celiac sprue}}
{{main|Celiac sprue}}
===General===
*Etiology: autoimmune.
====Epidemiology====
*Associated with:
**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====
Treatment:
*Gluten free diet.
**''Mnemonic'': BROW = barley, rye, oats, wheat.
Serologic testing:
*Anti-transglutaminase antibody.
**Alternative test: anti-endomysial antibody.
*IgA -- assoc. with celiac sprue.
===Microscopic===
Features:<ref name=Ref_PBoD843>{{Ref PBoD|843}}</ref>
*Intraepithelial lymphocytes (IELs) - '''key feature'''.
**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>
**Criteria for number varies:
*** > 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:
*[http://commons.wikimedia.org/wiki/File:Coeliac_path.jpg Celiac sprue (WC)].
Notes:
*If you see acute inflammatory cells, i.e. neutrophils, consider Giardiasis and other infectious etiologies.
*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.
*Flat lesions without IELs are unlikely to be celiac sprue.
*Mucosa erosions are rare in celiac sprue; should prompt consideration of an alternate diagnosis (infection, medications, Crohn's disease).
===Grading===
Rarely done - see ''[[celiac sprue]]'' article.


==Giardiasis==
==Giardiasis==
===General===
{{Main|Giardiasis}}
*Etiology:
**Flagellate protozoan ''Giardia lamblia''.
 
*Treatment
**Antibiotics, e.g. metronidazole (Flagyl).
 
===Gross===
*Diffuse changes.
*May have scattered white spots.<ref name=pmid19906109>{{Cite journal  | last1 = Biyikoğlu | first1 = I. | last2 = Babali | first2 = A. | last3 = Cakal | first3 = B. | last4 = Köklü | first4 = S. | last5 = Filik | first5 = L. | last6 = Astarci | first6 = MH. | last7 = Ustün | first7 = H. | last8 = Ustündağ | first8 = Y. | last9 = Akbal | first9 = E. | title = Do scattered white spots in the duodenum mark a specific gastrointestinal pathology? | journal = J Dig Dis | volume = 10 | issue = 4 | pages = 300-4 | month = Nov | year = 2009 | doi = 10.1111/j.1751-2980.2009.00399.x | PMID = 19906109 | URL = http://onlinelibrary.wiley.com/doi/10.1111/j.1751-2980.2009.00399.x/pdf }}</ref>
 
===Microscopic===
Features:
*+/-Loss of villi.
*Intraepithelial lymphocytes.
**+Other inflammatory cells, especially PMNs, close to the luminal surface.
*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.
 
Note:
*Changes are typically diffuse, i.e. if multiple biopsies are done the changes are present in all fragments.<ref name=pmid18354756>{{Cite journal  | last1 = Freeman | first1 = HJ. | title = Pearls and pitfalls in the diagnosis of adult celiac disease. | journal = Can J Gastroenterol | volume = 22 | issue = 3 | pages = 273-80 | month = Mar | year = 2008 | doi =  | PMID = 18354756 }}</ref>
 
DDx:
*[[Celiac disease]] - near perfect mimic; missing giardia organisms.
 
====Images====
<gallery>
Image:Giardiasis_duodenum_high.jpg | Giardiasis - high mag. (WC)
Image:Giardiasis_duodenum_low.jpg | Giardiasis - low mag. (WC)
</gallery>
www:
*[http://path.upmc.edu/cases/case278.html Giardiasis - several crappy images (upmc.edu)].
 
===Stains===
*Methylene blue +ve.<ref name=pmid23285438>{{Cite journal  | last1 = Rajurkar | first1 = MN. | last2 = Lall | first2 = N. | last3 = Basak | first3 = S. | last4 = Mallick | first4 = SK. | title = A simple method for demonstrating the giardia lamblia trophozoite. | journal = J Clin Diagn Res | volume = 6 | issue = 9 | pages = 1492-4 | month = Nov | year = 2012 | doi = 10.7860/JCDR/2012/4358.2541 | PMID = 23285438 }}</ref>
 
===IHC===
*CD117 +ve.<ref name=pmid18835628>{{Cite journal  | last1 = Sinelnikov | first1 = I. | last2 = Sion-Vardy | first2 = N. | last3 = Shaco-Levy | first3 = R. | title = C-kit (CD117) immunostain is useful for the diagnosis of Giardia lamblia in duodenal biopsies. | journal = Hum Pathol | volume = 40 | issue = 3 | pages = 323-5 | month = Mar | year = 2009 | doi = 10.1016/j.humpath.2008.07.015 | PMID = 18835628 }}</ref>
 
===Sign out===
<pre>
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA WITH BRUNNER'S GLANDS AND MICROORGANISMS CONSISTENT WITH GIARDIA.
</pre>


==Acute duodenitis==
==Acute duodenitis==
*Abbreviated ''AD''.
*Abbreviated ''AD''.
===General===
{{Main|Acute duodenitis}}
DDx:
*Infection.
**Helicobactor organisms in the [[stomach]].
*Medications ([[NSAID]]s).
*[[Crohn's disease]] (usually focal/patchy).
*[[Portal hypertension]] (portal hypertensive duodenopathy).<ref name=pmid12003421>{{Cite journal  | last1 = Shudo | first1 = R. | last2 = Yazaki | first2 = Y. | last3 = Sakurai | first3 = S. | last4 = Uenishi | first4 = H. | last5 = Yamada | first5 = H. | last6 = Sugawara | first6 = K. | title = Duodenal erosions, a common and distinctive feature of portal hypertensive duodenopathy. | journal = Am J Gastroenterol | volume = 97 | issue = 4 | pages = 867-73 | month = Apr | year = 2002 | doi = 10.1111/j.1572-0241.2002.05602.x | PMID = 12003421 }}</ref>
*[[Celiac sprue]].
 
===Microscopic===
Features:
*Intraepithelial lymphocytes.
*Neutrophils - "found without searching" - '''key feature'''.
*Eosinophils - "found without searching" - '''key feature'''.
*Plasma cells (increased).
 
Notes:
*One needs stomach concurrent biopsies to r/o Helicobactor.
*Erosions make celiac sprue much less likely.
*Presence of chronic inflammation useful for NSAIDs vs. Helicobacter organisms:
**[[NSAID]]s 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.
***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>
 
===Sign out===
<pre>
DUODENUM, BIOPSY:
- ACUTE DUODENITIS.
</pre>
 
====Acute on chronic duodenitis====
<pre>
DUODENUM, BIOPSY:
- ACUTE ON CHRONIC DUODENITIS.
</pre>
 
=====Micro=====
The sections show small bowel mucosa with intraepithelial neutrophils. The epithelium shows nuclear hyperchromasia, pseudostratification and nuclear enlargement; however, it matures toward the surface (reactive changes of the epithelium).
 
Brunner's glands are found focally in the lamina propria. Gastric foveolar-type epithelium
is identified. Lamina propria plasma cells are abundant.


==Chronic duodenitis==
==Chronic duodenitis==
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==Peptic duodenitis==
==Peptic duodenitis==
===General===
{{Main|Peptic duodenitis}}
*A somewhat controversial type of [[chronic duodenitis]].
*Considered to be a consequence of [[peptic ulcer disease]] ([[Helicobacter gastritis]]).
*One of the key components of the diagnosis is foveolar metaplasia and it is disputed that this is really due to Helicobacter.
**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>
 
===Microscopic===
Features:<ref name=Ref_GLP145>{{Ref GLP|145}}</ref>
*Gastric foveolar metaplasia - '''key feature'''.
*[[Brunner's gland hyperplasia]].
*+/-Inflammation - neutrophils.{{fact}}
*Ulceration.{{fact}}
 
DDx:
*[[Chronic duodenitis]] not otherwise specified - no foveolar metaplasia, abundant plasma cells.
*[[Acute duodenitis]].
*[[Brunner's gland hyperplasia]].
 
====Images====
<gallery>
Image:Duodenum_with_foveolar_metaplasia_-_low_mag.jpg | Duodenum with foveolar metaplasia - low mag. (WC/Nephron)
Image:Duodenum_with_foveolar_metaplasia_-_intermed_mag.jpg | Duodenum with foveolar metaplasia - intermed. mag. (WC/Nephron)
Image:Duodenum_with_foveolar_metaplasia_-_alt_-_very_high_mag.jpg | Duodenum with foveolar metaplasia - very high mag. (WC/Nephron)
</gallery>
===Stains===
Foveolar metaplasia:
*[[PAS stain]] +ve.<ref name=Ref_GLP145>{{Ref GLP|145}}</ref>
*[[Mucicarmine stain]] +ve.
 
===Sign out===
====Foveolar metaplasia only====
<pre>
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA WITH FOCAL GASTRIC FOVEOLAR METAPLASIA.
- BRUNNER'S GLANDS NOT IDENTIFIED.
- VILLI AND INTRAEPITHELIAL LYMPHOCYTES WITHIN NORMAL LIMITS (NEGATIVE FOR CELIAC DISEASE).
- NEGATIVE FOR ACUTE DUODENITIS.
</pre>
 
====Chronic duodenitis====
<pre>
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA WITH BRUNNER'S GLAND IN THE LAMINA PROPRIA AND
  GASTRIC FOVEOLAR METAPLASIA -- CONSISTENT WITH CHRONIC DUODENITIS.
- NEGATIVE FOR ACUTE DUODENITIS.
- NEGATIVE FOR MALIGNANCY.
</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. Gastric foveolar-type epithelium is identified. Intraepithelial neutrophils are not identified.
 
The epithelium matures appropriately. There is no increase in intraepithelial lymphocytes.


==Brunner's gland hyperplasia==
==Brunner's gland hyperplasia==
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DDx:
DDx:
*Foveolar metaplasia (isolated) - see [[peptic duodenitis]].
*[[Peptic duodenitis]].
*[[Peptic duodenitis]].


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- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.
- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.
- PROMINENT BRUNNER'S GLANDS WITH EXTENSION INTO THE LAMINA PROPRIA.
- PROMINENT BRUNNER'S GLANDS WITH EXTENSION INTO THE LAMINA PROPRIA.
</pre>
====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>
</pre>


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==Whipple disease==
==Whipple disease==
===General===
{{Main|Whipple's disease}}
Etiology:
*Infection - caused by ''Tropheryma whipplei''<ref name=pmid11777846>{{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> a rod-shaped organisms.<ref name=pmid11764080>{{Cite journal  | last1 = Alkan | first1 = S. | last2 = Beals | first2 = TF. | last3 = Schnitzer | first3 = B. | title = Primary diagnosis of whipple disease manifesting as lymphadenopathy: use of polymerase chain reaction for detection of Tropheryma whippelii. | journal = Am J Clin Pathol | volume = 116 | issue = 6 | pages = 898-904 | month = Dec | year = 2001 | doi = 10.1309/7678-E2DW-HFJ5-QYUJ | PMID = 11764080 }}</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.
 
DDx:
*[[Mycobacterium avium complex]] (MAC).
 
====Images====
<gallery>
Image:Whipple_disease_-_intermed_mag.jpg | Whipple disease - intermed. mag. (WC)
Image:Whipple_disease_-a-_high_mag.jpg | Whipple disease - high mag. (WC)
Image:Whipple2.jpg | Whipple disease - poor quality - low mag. (WC)
</gallery>
===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==
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==Gangliocytic paraganglioma==
==Gangliocytic paraganglioma==
*Abbreviated ''GP''.
*Abbreviated ''GP''.
===General===
{{Main|Gangliocytic paraganglioma}}
*Extremely rare.<ref name=pmid22340577>{{Cite journal  | last1 = Wu | first1 = GC. | last2 = Wang | first2 = KL. | last3 = Zhang | first3 = ZT. | title = Gangliocytic paraganglioma of the duodenum: a case report. | journal = Chin Med J (Engl) | volume = 125 | issue = 2 | pages = 388-9 | month = Jan | year = 2012 | doi =  | PMID = 22340577 }}</ref>
*May be associated with [[neurofibromatosis type 1]].<ref name=pmid12754392>{{Cite journal  | last1 = Castoldi | first1 = L. | last2 = De Rai | first2 = P. | last3 = Marini | first3 = A. | last4 = Ferrero | first4 = S. | last5 = De Luca | first5 = V. | last6 = Tiberio | first6 = G. | title = Neurofibromatosis-1 and Ampullary Gangliocytic Paraganglioma Causing Biliary and Pancreatic Obstruction. | journal = Int J Gastrointest Cancer | volume = 29 | issue = 2 | pages = 93-98 | month =  | year = 2001 | doi =  | PMID = 12754392 }}</ref>
*Classified a [[neuroendocrine tumour]].<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>
*Usually has a mix of the features seen in: [[neuroendocrine tumour]]s, [[paraganglioma]]s and [[ganglioneuroma]]s.
 
Clinical - presentation:<ref name=pmid21599949/>
*GI bleed ~ 45% of cases.
*Abdominal pain ~ 43% of cases.
*[[Anemia]] ~ 15% of cases.
 
===Gross===
*Classically in the duodenum ~90% of cases.<ref name=pmid21599949>{{Cite journal  | last1 = Okubo | first1 = Y. | last2 = Wakayama | first2 = M. | last3 = Nemoto | first3 = T. | last4 = Kitahara | first4 = K. | last5 = Nakayama | first5 = H. | last6 = Shibuya | first6 = K. | last7 = Yokose | first7 = T. | last8 = Yamada | first8 = M. | last9 = Shimodaira | first9 = K. | title = Literature survey on epidemiology and pathology of gangliocytic paraganglioma. | journal = BMC Cancer | volume = 11 | issue =  | pages = 187 | month =  | year = 2011 | doi = 10.1186/1471-2407-11-187 | PMID = 21599949 }}</ref>
 
===Microscopic===
Features - three components:<ref name=pmid15740625>{{Cite journal  | last1 = Wong | first1 = A. | last2 = Miller | first2 = AR. | last3 = Metter | first3 = J. | last4 = Thomas | first4 = CR. | title = Locally advanced duodenal gangliocytic paraganglioma treated with adjuvant radiation therapy: case report and review of the literature. | journal = World J Surg Oncol | volume = 3 | issue = 1 | pages = 15 | month = Mar | year = 2005 | doi = 10.1186/1477-7819-3-15 | PMID = 15740625 }}</ref><ref>URL: [http://surgpathcriteria.stanford.edu/gitumors/gangliocytic-paraganglioma/printable.html http://surgpathcriteria.stanford.edu/gitumors/gangliocytic-paraganglioma/printable.html]. Accessed on: 31 May 2012.</ref>
#Ganglion cells = large cells with:
#*Round large nucleus.
#*Prominent [[nucleolus]].
#*Moderate or abundant cytoplasm.
#Epithelioid cells (neuroendocrine component):
#*Arranged in nests or cords.
#*Stippled chromatin.
#Spindle cells ([[Schwannoma|schwannian]] component):
#*Moderate or abundant cytoplasm.
#*Nucleus spindle-shaped or ellipsoid.
 
DDx:<ref name=pmid15740625/>
*Poorly differentiated carcinoma.
*[[Neuroendocrine tumour]].
*[[Paraganglioma]].
 
Images:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Gangliocytic_paraganglioma_-_intermed_mag.jpg GP - intermed. mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Gangliocytic_paraganglioma_-_very_high_mag.jpg GP - very high mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Gangliocytic_paraganglioma_-_2_-_intermed_mag.jpg GP - 2 - intermed. mag. (WC)].
*www:
**[http://www.wjso.com/content/3/1/15/figure/F2 Epithelioid cells of a GP (wjso.com)].
**[http://www.wjso.com/content/3/1/15/figure/F4 Ganglion cell in a GP (wjso.com)].
**[http://www.pubcan.org/images/large/Fig_5-17_A.jpg Ganglion cells in a GP (pubcan.org)].<ref>URL: [http://www.pubcan.org/printicdotopo.php?id=5028 http://www.pubcan.org/printicdotopo.php?id=5028]. Accessed on: 15 April 2012.</ref>
**[http://www.surgicalpathologyatlas.com/glfusion/mediagallery/media.php?f=0&sort=0&s=20080802175012135 GP (surgicalpathologyatlas.com)].
 
===IHC===
*Synaptophysin +ve.
*CD56 +ve.
*Chromogranin A +ve.
*HU +ve in ganglion-like cells.
*S100 +ve in spindle cells & sustentacular cells.


==Pseudomelanosis duodeni==
==Pseudomelanosis duodeni==
===General===
{{Main|Pseudomelanosis duodeni}}
*Rare.
*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 }}
</ref>
 
Associations:<ref name=pmid18253910/>
*[[Hypertension]] ~90% of cases.
*Iron supplementation ~75% of cases.
*End-stage renal disease ~60% of cases.
 
Note:
*The associations are different than for ''[[melanosis coli]]''.
 
===Gross/endoscopic===
*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>
 
===Microscopic===
Features:
*Dark pigment in the lamina propria macrophages.
 
Images:
*[http://path.upmc.edu/cases/case616.html Pseudomelanosis duodeni - several images (upmc.edu)].
 
===Stains===
*Prussian blue +ve ~80% of cases.<ref name=pmid18253910/>


=Tumours=
=Tumours=
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*[[AKA]] ''duodenal adenocarcinoma''.
*[[AKA]] ''duodenal adenocarcinoma''.
*[[AKA]] ''duodenal carcinoma''.
*[[AKA]] ''duodenal carcinoma''.
 
{{Main|Adenocarcinoma of the duodenum}}
===General===
*Duodenum - most common site in small bowel.
**[[Ampulla of Vater]] most common site in the duodenum - see ''[[ampullary carcinoma]]''.
 
Risk factors:
*[[Crohn's disease]].
*[[Celiac sprue]].
*[[Familial adenomatous polyposis]] (FAP).
*[[HNPCC]].
*[[Peutz-Jeghers syndrome]].
 
===Gross===
*Mass ulcerating or exophytic.
 
Image:
<gallery>
Image:Duodenal adenocarcinoma.png | Duodenal adenocarcinoma - endoscopy. (WC/Samir)
</gallery>
 
===Microscopic===
Features:
*Similar to large bowel adenocarcinomas - see ''[[colorectal tumours]]'' article.
 
DDx:
*[[Ampullary carcinoma]].
 
===IHC===
*SMAD4 -ve/+ve.<ref name=pmid15157044>{{Cite journal  | last1 = Bläker | first1 = H. | last2 = Aulmann | first2 = S. | last3 = Helmchen | first3 = B. | last4 = Otto | first4 = HF. | last5 = Rieker | first5 = RJ. | last6 = Penzel | first6 = R. | title = Loss of SMAD4 function in small intestinal adenocarcinomas: comparison of genetic and immunohistochemical findings. | journal = Pathol Res Pract | volume = 200 | issue = 1 | pages = 1-7 | month =  | year = 2004 | doi =  | PMID = 15157044 }}</ref>


==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>


==Ampullary tumours==
==Ampullary tumours==
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===Sign out===
===Sign out===
*Ampullary carcinoma - has separate staging.
*Ampullary carcinoma - has separate staging.
==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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