Duodenum (PBR 2) Flashcards
90% of tumors in the duodenal bulb are:
a. benign
b. malignant
a. Benign
In the second and third portions of the duodenum, tumors are 50% benign and 50% malignant
In the fourth portion of the duodenum, most tumors are malignant
benign tumors of the duodenum usually present as smooth, polypoid filling defects
Presentation of benign tumors of the duodenum
Small, smooth, polypoid filling defects
CT is helpful, but not specific, in predicting malignancy
Biopsy is required
What are the signs of malignancy of duodenal lesions?
- Central necrosis
- Ulceration or excavation
- Exophytic or intramural mass
- Evidence of tumor beyond the duodenum
Most common/frequent malignant tumor of the duodenum
Duodenal adenocarcinoma
Rare lesion
Malignant tumor of the duodenum are most commonly located at what part?
Periampullary region
Rare in the bulb
What are the morphologic patterns of duodenal adenocarcinoma
- Polypoid mass
- Ulcerative mass
- Annular constricting lesion
CT and MR finding of duodenal adenocarcinoma
Enhancing intramural or exophytic soft tissue mass with frequently a bilobed “dumbbell” shape
Central necrosis and ulceration occur
Regional adenopathy, hepatic metastases, and local extent of tumor are demonstrated for surgical planning
Metastases to the duodenum occurs in what layer?
In the wall or subserosa presenting with wall thickening
As the tumor grows, it may extend into the lumen and present as an intraluminal mass that may ulcerate
Most common primary malignancy to metastasize to the duodenum
Breast, lung, and other GI malignancies
The duodenum may be invaded by tumors of adjacent organs including the pancreas and kidney
Presentation of lymphoma in the duodenum
Nodules with thickened folds
The nodules associated with lymphoma are distinctly larger than those seen with benign lymphoid hyperplasia
Presentation of duodenal adenoma
Polypoid lesion that may be pedunculated or sessile
Adenomas account for about half of the neoplasms of the duodenum
Multiple adenomatous polyps are associated with polyposis syndromes
This adenoma have a high incidence of malignant degeneration and a characteristic “cauliflower” appearance on double- contrast UGI series
Villous adenoma
GISTs of the duodenum present as what kind of mass?
Intramural, endoluminal, or exophytic mass
Most commonly in the 2nd or 3rd portion of the duodenum
Ulceration is common
Malignant tumors range up to 20 cm size and are most common in the more distal duodenum
Second most common primary malignant tumor of the duodenum
Malignant gastrointestinal stromal tumors
This presents as small (1 to 3 mm) polypoid nodules diffusely throughout the duodenum
The condition is usually benign, especially in children
It is associated with immunodeficiency states in some adults
Lymphoid hyperplasia
No evidence supports the concept that lymphoid hyperplasia is a precursor to lymphoma
This may cause a lobulated mass at the base of the duodenal bulb
The diagnosis of this disease is suggested by characteristic location and change in configuration with peristalsis, which may
be observed on UGI
Gastric mucosa prolapse
Prolapse through the pylorus during peristalsis
This lesion has the appearance of areae gastricae in the duodenal bulb, or as clusters of 1- to 3-mm plaques on the smooth duodenal bulb mucosa
It may also appear as a solitary polyp that is indistinguishable from other polypoid lesions of the duodenum
Heterotopic gastric mucosa in the duodenal bulb is common on endoscopy (12%) but seen infrequently on imaging
This glands are located in the submucosa of the proximal two-thirds of the duodenum and secrete an alkaline substance that buffers gastric acid
Brunner glands
Brunner gland lesion smaller than 5 mm are termed what?
Hyperplasia
Lesions larger than 5 mm are termed hamartomas
Larger lesions are more likely to be symptomatic
All lesions are benign and without cellular atypia
Diffuse nodular gland hyperplasia is a common cause of multiple nodules, often with a cobblestone appearance
True or false
True
Brunner gland hamartoma usually presents as a solitary nodule and is identical in appearance to other benign duodenal nodules
Ectopic pancreas may occur in what portion of the duodenum
Most commonly in the proximal descending portion
A solitary mass with central dimple is most characteristic
Valvulae conniventes, or Kercking folds, of the small bowel begin where?
Second portion of the duodenum and continue throughout the remainder of the bowel
How many milimeters is duodenal thickening?
Folds greater than 2 to 3 mm
This refers to inflammation of the duodenum without discrete ulcer formation
Duodenitis
What i the the major cause of duodenitis?
H . pylori infection
Alcohol and anti-inflammatory medications are additional causes
UGI findings of duodenitis
- Thickening (>4 mm) of the proximal duodenal folds
- Nodules or nodular folds (enlarged Brunner glands), 3. Deformity of the duodenal bulb
- Erosions
CT shows nonspecific wall thickening and inflammatory changes
This diseases thicken the duodenal folds by paraduodenal inflammation
May also cause mass impressions on the duodenal lumen
CT or US demonstrates the extent and nature of the paraduodenal process
Pancreatitis and cholecystitis
Crohn disease involves what part of the duodenum?
First and second portions
Almost always associated with contiguous involvement of the stomach
Duodenal involvement is manifest by thickened folds, aphthous ulcers, erosions, and single or multiple strictures
Frequent cause of of traveler’s diarrhea
Gardiasis
Imaging finding of gardiasis
- Distorted thickened folds in the duodenum and jejunum
- Hypermotility and spasm
- Increased secretions
This is caused by trauma, anticoagulation, and bleeding disorders
The regular pattern of thickened folds resembles a stack of coins
Partial or complete duodenal obstruction is usually present
Intramural hemorrhage
Mural hematomas may result in a large mass
The fixed retroperitoneal position of the third portion of the duodenum makes it susceptible to blunt abdominal trauma and compression against the lumbar spine
Most frequent cause of duodenal ulcers?
H. pylori infection - 95% of cases
Additional causes include anti-inflammatory medications, Crohn disease, Zollinger–Ellison syndrome, viral infections, or penetrating pancreatic cancer
Duodenal ulcers are associated with acid hypersecretion
Most common location of duodenal ulcers?
In the duodenal bulb with the anterior wall being most often involved
Imaging diagnosis of a duodenal ulcer depends on what finding?
Demonstration of the ulcer crater or niche
Usual size of of duodenal ulcers
Smaller than 1 cm diameter
Giant ulcers larger than 2 cm resemble diverticuli or a deformed bulb
Ulcer craters have no mucosal lining and therefore no mucosal relief pattern, and do not contract with peristalsis
True or false
True
Ulcer scarring may cause a pattern of radiating folds with a central barium collection that is indistinguishable from an acute ulcer
Postbulbar ulcers represent about 5% of the total, but are more commonly associated with what disease?
Serious upper GI hemorrhage
Most involve the second and third portions of the duodenum, which are frequently narrowed
Complications of duodenal ulcer
Obstruction
Bleeding
Perforation
*Creator’s notes: Similar to gastric ulcer
This is caused by a gastrin-secreting neuroendocrine tumor (gastrinoma)
Zollinger-Ellison syndrome
Most frequent location of gastrinomas?
Pancreas (75%)
Duodenum (15%) and in 10% in extraintestinal sites (liver, lymph nodes, and ovary)
The tumor is malignant in 60% of cases
Gastrinomas also occur as part of what hereditary syndrome?
Multiple endocrine neoplasia, type I (MEN-I)
*Creator’s notes:
Parathyroid adenoma
Pituitary gland tumor
Pancreatic islet cell tumor (gastrinoma)
UGI finding of Zollinger-Ellison syndrome
- Multiple peptic ulcers in the stomach, duodenal bulb, and, most characteristically, in the postbulbar duodenum
- Hypersecretion with high-volume gastric fluid diluting the barium and impairing mucosal coating
- Thick edematous folds in the stomach, duodenum, and proximal jejunum
Most common location of duodenal diverticula
Inner aspect of the descending duodenum (2nd part)
How to differentiate duodenal diverticular from ulcers if UGI series?
By demonstration of mucosal folds entering the neck of the diverticulum and change in appearance with peristalsis
CT scan finding of duodenal diverticula
On CT they may be filled with fluid and mimic a pancreatic pseudocyst, or they may contain air and fluid and mimic a pancreatic abscess
Rare complications of duodenal diverticula
Perforation and hemorrhage
Diverticuli adjacent to the ampulla of Vater may rarely obstruct the common bile duct or pancreatic duct
These are caused by a thin, incomplete, congenital diaphragm that is stretched by moving intraluminal contents to form a “windsock” configuration within the duodenum
Intraluminal duodenal diverticula
The diverticulum is partially obstructing eventually resulting in postprandial epigastric pain and fullness.
Some patients present with vomiting or GI bleeding
This is the most common congenital anomaly of the pancreas
Annular pancreas
Pancreatic tissue encircles the descending duodenum and narrows its lumen
UGI findings of annular pancreas
Typically demonstrates eccentric or concentric narrowing of the descending duodenum
Annular pancreas is associated with a high incidence of postbulbar peptic ulceration in adults
CT confirms the diagnosis by demonstration of pancreatic tissue encircling the duodenum
Refers to bleeding with the site of origin proximal to the ligament of Treitz
UGI hemorrhage
Causes of upper GI hemorrhage
Approximate order of frequency:
- Duodenal ulcer
- Esophageal varices
- Gastric ulcer
- Acute hemorrhagic gastritis
- Esophagitis
- Mallory–Weiss tear
- Neoplasm
- Vascular malformation
- Vascular enteric fistula
Endoscopy is less accurate than a UGI series in demonstrating the bleeding site
True or false
False
Endoscopy is much more accurate than a UGI series in demonstrating the bleeding site
Barium studies should be avoided in patients in the acute stages of UGI hemorrhage
