Difference between revisions of "Duodenum"

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Duodenum (view source)

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===Sign out===
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<pre>
Duodenum, Biopsy:
- Small bowel mucosa and Brunner's glands within normal limits.</pre>
<pre>
Duodenum, Biopsy:
- Small bowel mucosa within normal limits.
</pre>
<pre>
Duodenum, Biopsy:
- Small bowel mucosa within normal limits.
- NEGATIVE for findings suggestive of celiac disease.
</pre>
<pre>
Small Bowel (Duodenum), Biopsy:
- Small bowel mucosa within normal limits.
- NEGATIVE for findings suggestive of celiac disease.
</pre>
====Block letters====
<pre>
<pre>
DUODENUM, BIOPSY:  
DUODENUM, BIOPSY:  
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==Gastric heterotopia of the duodenum==
==Gastric heterotopia of the duodenum==
*[[AKA]] ''heterotopic gastric mucosa''.
*[[AKA]] ''heterotopic gastric mucosa''.
===General===
{{Main|Gastric heterotopia of the duodenum}}
*Common ~15% of cases in one series.<ref name=pmid22295146>{{Cite journal  | last1 = Terada | first1 = T. | title = Pathologic observations of the duodenum in 615 consecutive duodenal specimens: I. benign lesions. | journal = Int J Clin Exp Pathol | volume = 5 | issue = 1 | pages = 46-51 | month =  | year = 2012 | doi =  | PMID = 22295146 }}</ref>
*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>
 
===Gross===
*Typically nodules/polyps.<ref name=pmid6840712>{{Cite journal  | last1 = Shousha | first1 = S. | last2 = Spiller | first2 = RC. | last3 = Parkins | first3 = RA. | title = The endoscopically abnormal duodenum in patients with dyspepsia: biopsy findings in 60 cases. | journal = Histopathology | volume = 7 | issue = 1 | pages = 23-34 | month = Jan | year = 1983 | doi =  | PMID = 6840712 }}</ref>
 
===Microscopic===
Features:
#Foveolar epithelium.
#Gastric glands - body-type or antral-type.
 
DDx:
*Foveolar metaplasia (isolated) - see [[chronic duodenitis]].
*Foveolar gastric-type dysplasia.<ref>{{Cite journal  | last1 = Park | first1 = do Y. | last2 = Srivastava | first2 = A. | last3 = Kim | first3 = GH. | last4 = Mino-Kenudson | first4 = M. | last5 = Deshpande | first5 = V. | last6 = Zukerberg | first6 = LR. | last7 = Song | first7 = GA. | last8 = Lauwers | first8 = GY. | title = Adenomatous and foveolar gastric dysplasia: distinct patterns of mucin expression and background intestinal metaplasia. | journal = Am J Surg Pathol | volume = 32 | issue = 4 | pages = 524-33 | month = Apr | year = 2008 | doi = 10.1097/PAS.0b013e31815b890e | PMID = 18300795 }}</ref>
 
====Images====
<gallery>
Image: Gastric heterotopia in the duodenum -- low mag.jpg | GH - low mag. (WC)
Image: Gastric heterotopia in the duodenum -- intermed mag.jpg | GH - intermed. mag. (WC)
Image: Gastric heterotopia in the duodenum -- high mag.jpg | GH - high mag. (WC)
</gallery>
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 WITH GASTRIC (BODY-TYPE) HETEROTOPIA.
- NEGATIVE FOR SIGNIFICANT PATHOLOGY.
</pre>
 
====Alternate====
<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==
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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]].
*[[Gastric heterotopia of the duodenum]].
 
====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.
- NEGATIVE FOR DYSPLASIA.
</pre>
 
<pre>
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA WITH FOCAL GASTRIC FOVEOLAR METAPLASIA.
- BRUNNER'S GLANDS NOT IDENTIFIED.
- NEGATIVE FOR ACUTE DUODENITIS.
- NEGATIVE FOR DYSPLASIA.
</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>
 
<pre>
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA WITH PROMINENT BRUNNER'S GLANDS AND FOCAL GASTRIC
  FOVEOLAR METAPLASIA.
- NEGATIVE FOR ACUTE 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. 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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==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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==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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*Commonly found in association foveolar metaplasia - especially in sporadic cases ~60% of cases.
*Commonly found in association foveolar metaplasia - especially in sporadic cases ~60% of cases.
**In FAP ~30% of cases have foveolar metaplasia.<ref name=pmid16837629>{{Cite journal  | last1 = Rubio | first1 = CA. | title = Gastric duodenal metaplasia in duodenal adenomas. | journal = J Clin Pathol | volume = 60 | issue = 6 | pages = 661-3 | month = Jun | year = 2007 | doi = 10.1136/jcp.2006.039388 | PMID = 16837629 | PMC = 1955048}}</ref>
**In FAP ~30% of cases have foveolar metaplasia.<ref name=pmid16837629>{{Cite journal  | last1 = Rubio | first1 = CA. | title = Gastric duodenal metaplasia in duodenal adenomas. | journal = J Clin Pathol | volume = 60 | issue = 6 | pages = 661-3 | month = Jun | year = 2007 | doi = 10.1136/jcp.2006.039388 | PMID = 16837629 | PMC = 1955048}}</ref>
*A colonscopy is recommended in individuals with nonampullary duodenal adenomas, as they are likely at increased risk of large bowel adenomas.<ref name=pmid26811631>{{Cite journal  | last1 = Lim | first1 = CH. | last2 = Cho | first2 = YS. | title = Nonampullary duodenal adenoma: Current understanding of its diagnosis, pathogenesis, and clinical management. | journal = World J Gastroenterol | volume = 22 | issue = 2 | pages = 853-61 | month = Jan | year = 2016 | doi = 10.3748/wjg.v22.i2.853 | PMID = 26811631 }}</ref>


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- TUBULAR ADENOMA.
- TUBULAR ADENOMA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
-- NEGATIVE FOR HIGH-GRADE DYSPLASIA.
</pre>
====Alternate====
<pre>
Polyp (Nonampullary), Duodenum, Polypectomy:
    - Tubular adenoma, NEGATIVE for high-grade dysplasia.
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>
</pre>


Michael
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