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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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| **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> |
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| ===Duodenal nodules DDX=== | | ===Duodenal nodules DDX=== |
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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>
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| | |
| ===Microscopic===
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| Features:
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| #Foveolar epithelium.
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| #Gastric glands - body-type or antral-type.
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| | |
| DDx:
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| *Foveolar metaplasia.
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| ====Images====
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| www:
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| *[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>
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| ===Sign out===
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA AND BRUNNER'S GLANDS WITHIN NORMAL LIMITS.
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| - GASTRIC HETEROTOPIA, BODY-TYPE MUCOSA.
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| </pre>
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|
| ==Celiac sprue== | | ==Celiac sprue== |
| | *[[AKA]] ''celiac disease''. |
| {{main|Celiac sprue}} | | {{main|Celiac sprue}} |
| ===General===
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| *Etiology: autoimmune.
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|
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| ====Epidemiology====
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| *Associated with:
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| **The skin condition ''[[dermatitis herpetiformis]]''.<ref>TN 2007 D22</ref>
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| **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>
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| **Risk factor for ''gastrointestinal T cell lymphoma'' - known as: ''enteropathy-associated T cell lymphoma'' (EATL).
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|
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| ====Clinical====
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| Treatment:
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| *Gluten free diet.
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| **''Mnemonic'': BROW = barley, rye, oats, wheat.
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| Serologic testing:
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| *Anti-transglutaminase antibody.
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| **Alternative test: anti-endomysial antibody.
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| *IgA -- assoc. with celiac sprue.
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|
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| ===Microscopic===
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| Features:<ref name=Ref_PBoD843>{{Ref PBoD|843}}</ref>
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| *Intraepithelial lymphocytes (IELs) - '''key feature'''.
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| **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>
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| **Criteria for number varies:
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| *** > 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>
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| *** > 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>
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| *Loss of villi - '''important feature'''.
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| **Normal duodenal biopsy should have 3 good villi.
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| *Plasma cells - abundant (weak feature).
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| *Macrophages.
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| *Mitosis increased (in the crypts).
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| *+/-Collagen band (pink material in mucosa) - "Collagenous sprue"; must encompass ~25% of mucosa.
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| Image:
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| *[http://commons.wikimedia.org/wiki/File:Coeliac_path.jpg Celiac sprue (WC)].
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| Notes:
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| *If you see acute inflammatory cells, i.e. neutrophils, consider Giardiasis and other infectious etiologies.
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| *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.
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| *Flat lesions without IELs are unlikely to be celiac sprue.
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| *Mucosa erosions are rare in celiac sprue; should prompt consideration of an alternate diagnosis (infection, medications, Crohn's disease).
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|
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| ===Grading===
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| Rarely done - see ''[[celiac sprue]]'' article.
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| ==Giardiasis== | | ==Giardiasis== |
| ===General===
| | {{Main|Giardiasis}} |
| *Etiology:
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| **Flagellate protozoan ''Giardia lamblia''.
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| *Treatment
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| **Antibiotics, e.g. metronidazole (Flagyl).
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| ===Gross===
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| *Diffuse changes.
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| *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 }}</ref>
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| ===Microscopic===
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| Features:
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| *+/-Loss of villi.
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| *Intraepithelial lymphocytes.
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| **+Other inflammatory cells, especially PMNs, close to the luminal surface.
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| *Flagellate protozoa -- '''diagnostic feature'''.
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| **Organisms often at site of bad inflammation.
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| **Pale/translucent on H&E.
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| **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>
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| ***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.
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| Note:
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| *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>
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| DDx:
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| *[[Celiac disease]] - near perfect mimic; missing giardia organisms.
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| ====Images====
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| <gallery>
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| Image:Giardiasis_duodenum_high.jpg | Giardiasis - high mag. (WC)
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| Image:Giardiasis_duodenum_low.jpg | Giardiasis - low mag. (WC)
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| </gallery>
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| www:
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| *[http://path.upmc.edu/cases/case278.html Giardiasis - several crappy images (upmc.edu)].
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| ===Stains===
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| *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>
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| ===Sign out===
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA WITH BRUNNER'S GLANDS AND MICROORGANISMS CONSISTENT WITH GIARDIA.
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| </pre>
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|
| ==Acute duodenitis== | | ==Acute duodenitis== |
| *Abbreviated ''AD''. | | *Abbreviated ''AD''. |
| ===General===
| | {{Main|Acute duodenitis}} |
| DDx:
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| *Infection.
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| **Helicobactor organisms in the [[stomach]].
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| *Medications ([[NSAID]]s).
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| *[[Crohn's disease]] (usually focal/patchy).
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| *[[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>
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| *[[Celiac sprue]].
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| ===Microscopic===
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| Features:
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| *Intraepithelial lymphocytes.
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| *Neutrophils - "found without searching" - '''key feature'''.
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| *Eosinophils - "found without searching" - '''key feature'''.
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| *Plasma cells (increased).
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| Notes:
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| *One needs stomach concurrent biopsies to r/o Helicobactor.
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| *Erosions make celiac sprue much less likely.
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| *Presence of chronic inflammation useful for NSAIDs vs. Helicobacter organisms:
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| **[[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.
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| ***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>
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| ===Sign out===
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| <pre>
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| DUODENUM, BIOPSY:
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| - ACUTE DUODENITIS.
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| </pre>
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| | |
| ====Acute on chronic duodenitis====
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| <pre>
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| DUODENUM, BIOPSY:
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| - ACUTE ON CHRONIC DUODENITIS.
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| </pre>
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| | |
| =====Micro=====
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| 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).
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| Brunner's glands are found focally in the lamina propria. Gastric foveolar-type epithelium
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| is identified. Lamina propria plasma cells are abundant.
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| ==Chronic duodenitis== | | ==Chronic duodenitis== |
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| ==Peptic duodenitis== | | ==Peptic duodenitis== |
| ===General===
| | {{Main|Peptic duodenitis}} |
| *A somewhat controversial type of [[chronic duodenitis]].
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| *Considered to be a consequence of [[peptic ulcer disease]] ([[Helicobacter gastritis]]).
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| *One of the key components of the diagnosis is foveolar metaplasia and it is disputed that this is really due to Helicobacter.
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| **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>
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| ===Microscopic===
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| Features:<ref name=Ref_GLP145>{{Ref GLP|145}}</ref>
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| *Gastric foveolar metaplasia - '''key feature'''.
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| *[[Brunner's gland hyperplasia]].
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| *+/-Inflammation - neutrophils.{{fact}}
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| *Ulceration.{{fact}}
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| DDx:
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| *[[Chronic duodenitis]] not otherwise specified - no foveolar metaplasia, abundant plasma cells.
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| *[[Acute duodenitis]].
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| *[[Brunner's gland hyperplasia]].
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| ====Images====
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| <gallery>
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| Image:Duodenum_with_foveolar_metaplasia_-_low_mag.jpg | Duodenum with foveolar metaplasia - low mag. (WC/Nephron)
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| Image:Duodenum_with_foveolar_metaplasia_-_intermed_mag.jpg | Duodenum with foveolar metaplasia - intermed. mag. (WC/Nephron)
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| Image:Duodenum_with_foveolar_metaplasia_-_alt_-_very_high_mag.jpg | Duodenum with foveolar metaplasia - very high mag. (WC/Nephron)
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| </gallery>
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| ===Stains===
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| Foveolar metaplasia:
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| *[[PAS stain]] +ve.<ref name=Ref_GLP145>{{Ref GLP|145}}</ref>
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| *[[Mucicarmine stain]] +ve.
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| ===Sign out===
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| ====Foveolar metaplasia only====
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA WITH FOCAL GASTRIC FOVEOLAR METAPLASIA.
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| - BRUNNER'S GLANDS NOT IDENTIFIED.
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| - VILLI AND INTRAEPITHELIAL LYMPHOCYTES WITHIN NORMAL LIMITS (NEGATIVE FOR CELIAC DISEASE).
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| - NEGATIVE FOR ACUTE DUODENITIS.
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| </pre>
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| | |
| ====Chronic duodenitis====
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| <pre>
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| DUODENUM, BIOPSY:
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| - SMALL BOWEL MUCOSA WITH BRUNNER'S GLAND IN THE LAMINA PROPRIA AND
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| GASTRIC FOVEOLAR METAPLASIA -- CONSISTENT WITH CHRONIC DUODENITIS.
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| - NEGATIVE FOR ACUTE DUODENITIS.
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| - NEGATIVE FOR MALIGNANCY.
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| </pre>
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| | |
| =====Micro=====
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| 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.
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| The epithelium matures appropriately. There is no increase in intraepithelial lymphocytes.
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|
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| ==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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| 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> |
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| =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> 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>
| |
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| Epidemiology:
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| *Very rare.
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| *Classically middle aged men.
| |
| | |
| ====Clinical====
| |
| *Malabsorption (diarrhea), arthritis + others.
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| **Symptoms are non-specific.
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| | |
| Treatment:
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| *Antibiotics - for months and months.
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| | |
| ===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.
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| **Macrophages usually abundant - '''key feature''' that should raise Dx in DDx.
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| **Organisms periodic acid-Schiff (PAS) positive.
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| 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]].
| |
| | |
| ===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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| *[[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= |