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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=
===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.
 
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===
==Basic DDx==
*Celiac.
*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===
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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=
==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>
==Acute duodenitis==
**Risk factor for ''gastrointestinal T cell lymphoma'' - known as: ''enteropathy-associated T cell lymphoma'' (EATL).
*Abbreviated ''AD''.
{{Main|Acute duodenitis}}


====Clinical====
==Chronic duodenitis==
Treatment:
===General===
*Gluten free diet.
*This is not very well defined as [[plasma cell]]s are present in a normal duodenum.
**''Mnemonic'': BROW = barley, rye, oats, wheat.


Serologic testing:
===Gross===
*Anti-transglutaminase antibody.
*Duodenal erythema.
**Alternative test: anti-endomysial antibody.
*IgA -- assoc. with celiac sprue.


===Microscopic===
===Microscopic===
Features:<ref name=Ref_PBoD843>{{Ref PBoD|843}}</ref>
Features:
*Intraepithelial lymphocytes - '''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.
*Loss of villi - '''important feature'''.
*[[Brunner's gland hyperplasia]].
**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>
 
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''.


*Treatment
===Gross===
**Antibiotics, e.g. metronidazole (Flagyl).
*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]].
 
Image:
*[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/>
 
===Sign out===
<pre>
DUODENUM, BIOPSY:
- CONSISTENT WITH BRUNNER'S GLAND HYPERPLASIA.
- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.
</pre>
 
<pre>
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA WITHOUT SIGNIFICANT PATHOLOGY.
- 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>
 
====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.


Notes:
The epithelium matures appropriately.  There is no increase in intraepithelial lymphocytes.  No foveolar metaplasia of the epithelium is identified.
*Giardiasis can look (histologically) a lot like celiac disease.


Images:
==Helicobacter duodenitis==
*[http://commons.wikimedia.org/wiki/File:Giardiasis_duodenum_high.jpg Giardiasis - high mag. (WC)].
*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>
*[http://commons.wikimedia.org/wiki/File:Giardiasis_duodenum_low.jpg Giardiasis - low mag. (WC)].
*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>


==Acute duodenitis==
=Weird stuff=
===Etiology (DDx)===
==Disaccharidases deficiency==
*Infection.
===General===
**Helicobactor organisms in the [[stomach]].
*Common among asians.
*Medications (NSAIDs).
*Includes: lactase, sucrase, and maltase.
*Crohn's disease (usually focal/patchy).
**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>
*Celiac sprue.
**Maltase and sucrase only affected in moderate and severe lesions.


===Microscopic===
===Microscopic===
Features:
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).
*Neutrophils - "found without searching" - '''key feature'''.
*+/-Inflammation (only in moderate and severe).
*Eosinophils - "found without searching" - '''key feature'''.
 
*Plasma cells (increased).
DDx:
*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>


Notes:
Notes:
*One needs stomach concurrent biopsies to r/o Helicobactor.
*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>
*Erosions make celiac sprue much less likely.
*Presence of chronic inflammation useful for NSAIDS vs. Helicobacter 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.
***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>
 
==Whipple's disease==
===General===
====Epidemiology====
*Very rare.
*Classically middle aged men.


====Clinical====
==Whipple disease==
*Malabsorption (diarrhea), arthritis + others.
{{Main|Whipple's disease}}
**Symptoms are non-specific.


Treatment:
==Microvillous inclusion disease==
*Antibiotics - for months and months.
{{Main|Microvillous inclusion disease}}
This rare disease presents very shortly after birth.  


====Etiology====
==Tufting enteropathy==
*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>
*[[AKA]] ''intestinal epithelial dysplasia''.
===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>


===Microscopic===
===Microscopic===
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>
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>
*Infectious microorganism typically found in macrophages.
*Villous atrophy
**Macrophages usually abundant - '''key feature''' that should raise Dx in DDx.
*Mononuclear cell infiltration of the lamina propria
**Organisms periodic acid-Schiff (PAS) positive.
*Abnormal surface enterocytes:
**Focal crowding -- resembling tufts.
 


Micrograph: [http://en.wikipedia.org/wiki/File:Whipple2.jpg Whipple's disease] - wikipedia.org.
==Gangliocytic paraganglioma==
*Abbreviated ''GP''.
{{Main|Gangliocytic paraganglioma}}


DDx:
==Pseudomelanosis duodeni==
*Mycobacterium avium intracellulare (MAI).
{{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 178: Line 268:
*[[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]]
*[[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>
DDx:
*[[Adenocarcinoma of the duodenum]].
====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.


Images:
Comment:
*[http://commons.wikimedia.org/wiki/File:Small_intestine_neuroendocrine_tumour_low_mag.jpg Neuroendocrine tumour - low mag. (WC)].
The tumour stains as follows:
*[http://commons.wikimedia.org/wiki/File:Small_intestine_neuroendocrine_tumour_intermed_mag.jpg Neuroendocrine tumour - intermed. mag. (WC)].
POSITIVE: AE1/AE3, CD56, synaptophysin.
*[http://commons.wikimedia.org/wiki/File:Small_intestine_neuroendocrine_tumour_high_mag.jpg Neuroendocrine tumour - high mag. (WC)].
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==
=External links=
===Review article(s)===
===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}}
*{{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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