Difference between revisions of "Duodenum"

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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.
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**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===
===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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**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=[[Neuroendocrine tumour|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}}


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=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====
*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.
 
===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:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Giardiasis_duodenum_high.jpg Giardiasis - high mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Giardiasis_duodenum_low.jpg Giardiasis - low mag. (WC)].
*www:
**[http://path.upmc.edu/cases/case278.html Giardiasis - several crappy images (upmc.edu)].
 
===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 (NSAIDs).
*[[Crohn's disease]] (usually focal/patchy).
*Portal hypertension.
*[[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:
**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>
 
===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==
:''Peptic duodenitis'' redirects here.
===General===
===General===
*Considered a consequence of [[peptic ulcer disease]] (usu. due to [[Helicobacter gastritis]]).
*This is not very well defined as [[plasma cell]]s are present in a normal duodenum.
**This is disputed; Genta ''et al.'' considers 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>
 
===Gross===
*Duodenal erythema.


===Microscopic===
===Microscopic===
Features:<ref name=Ref_GLP145>{{Ref GLP|145}}</ref>
Features:
*Gastric foveolar metaplasia - '''key feature'''.
*"Abundant" lamina propria plasma cells.
*Villous blunting.
*[[Brunner's gland hyperplasia]].
*[[Brunner's gland hyperplasia]].
*+/-Inflammation - neutrophils. (???)
*Ulceration. (???)


DDx:
DDx:
*[[Acute duodenitis]].
*[[Normal duodenum]].
*[[Brunner's gland hyperplasia]].
 
===Stains===
Foveolar metaplasia:
*[[PAS stain]] +ve.<ref name=Ref_GLP145>{{Ref GLP|145}}</ref>
*[[Mucicarmine stain]] +ve.


===Sign out===
===Sign out===
====Foveolar metaplasia only====
<pre>
<pre>
DUODENUM, BIOPSY:
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA WITH FOCAL GASTRIC FOVEOLAR METAPLASIA.
- MODERATE NON-SPECIFIC CHRONIC DUODENTIS (SMALL BOWEL MUCOSA WITH VILLOUS
- BRUNNER'S GLANDS NOT IDENTIFIED.
  BLUNTING, PROMINENT BRUNNER'S GLANDS, ABUNDANT LAMINA PROPRIA PLASMA CELLS
- VILLI AND INTRAEPITHELIAL LYMPHOCYTES WITHIN NORMAL LIMITS (NEGATIVE FOR CELIAC DISEASE).
  AND OCCASIONAL INTRAEPITHELIAL LYMPHOCYTES, WITHOUT FOVEOLAR METAPLASIA).
- NEGATIVE FOR ACUTE DUODENITIS.
- NEGATIVE FOR DYSPLASIA.
</pre>
</pre>


====Chronic duodenitis====
==Peptic duodenitis==
<pre>
{{Main|Peptic duodenitis}}
DUODENUM, BIOPSY:
- SMALL BOWEL MUCOSA AND SUPERFICIAL SUBMUCOSA WITH BRUNNER'S GLAND HYPERPLASIA AND GASTRIC FOVEOLAR METAPLASIA.
 
COMMENT:
The findings are consistent with a chronic duodenitis.
</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==
:''Brunner's gland hamartoma'' redirects here.
:''Brunner's gland hamartoma'' redirects here.
*Abbreviated ''BGH''.
*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===
*Benign.
*Benign.
*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 }}
*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>  
</ref>  


Note:
Note:
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*Prominent Brunner's gland.
*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.
**Tubular structures - formed by cells abundant cytoplasm that is clear with eosinophilic "cobwebs" and a round, small basal nucleus without a nucleolus.
**Brunner's gland in the lamina propria.{{fact}}
**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>
*+/-Pancreatic acini and ducts.<ref name=pmid16928936/>
*+/-Pancreatic acini and ducts.<ref name=pmid16928936/>


DDx:
DDx:
*Foveolar metaplasia (isolated) - see [[peptic duodenitis]].
*[[Peptic duodenitis]].
*[[Peptic duodenitis]].


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*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526515/figure/F3/ BGH (nih.gov)].<ref name=pmid18583897/>
*[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/>
*[http://www.ajronline.org/content/187/3/715.full BGH (ajronline.org)].<ref name=pmid16928936/>


===Sign out===
===Sign out===
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DUODENUM, BIOPSY:
DUODENUM, BIOPSY:
- CONSISTENT WITH BRUNNER'S GLAND HYPERPLASIA.
- 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.
- NEGATIVE FOR DYSPLASIA.
</pre>
</pre>
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The epithelium matures appropriately.  There is no increase in intraepithelial lymphocytes.  No foveolar metaplasia of the epithelium is identified.
The epithelium matures appropriately.  There is no increase in intraepithelial lymphocytes.  No foveolar metaplasia of the epithelium is identified.
==Helicobacter duodenitis==
*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>
*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>


=Weird stuff=
=Weird stuff=
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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>
 
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:
*[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)].
 
===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]].
 
===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.
Line 499: Line 298:
*[[Adenocarcinoma of the duodenum]].
*[[Adenocarcinoma of the duodenum]].


Images:
====Images====
*[http://commons.wikimedia.org/wiki/File:Small_intestine_neuroendocrine_tumour_low_mag.jpg Neuroendocrine tumour - low mag. (WC)].
<gallery>
*[http://commons.wikimedia.org/wiki/File:Small_intestine_neuroendocrine_tumour_intermed_mag.jpg Neuroendocrine tumour - intermed. mag. (WC)].
Image:Small_intestine_neuroendocrine_tumour_low_mag.jpg | Neuroendocrine tumour - low mag. (WC)
*[http://commons.wikimedia.org/wiki/File:Small_intestine_neuroendocrine_tumour_high_mag.jpg Neuroendocrine tumour - high 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==
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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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