Overview of Pathological Findings in the Duodenum

Table 3.26 Pathological findings in the duodenum

Duodenal ulcer Bulbitis Polypoid lesions Sprue Crohn disease Whipple disease Diverticula Changes associated with diseases in adjacent organs

 

Fig. 3.134 Duodenal ulcer

Fig. 3.135 Bulbitis

Fig. 3.136 Polypoid lesions in the duodenal bulb

Fig. 3.137 Sprue

Fig. 3.138 Bulbar diverticulum

Fig. 3.139 Inflammation and necrosis in the duodenum of a patient with pancreatitis

Duodenal Ulcer: Clinical Features

Duodenal ulcer is an epithelial defect in the bulbar or descending duodenum that penetrates the muscularis mucosae and extends into the submucosa (Fig. 3.141). The precipitating causes include Helicobacter pylori infection (detectable in more than 90% of cases) and the ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs). Additional risk factors include nicotine abuse, alcohol abuse, and stress.

Clinical Aspects

A duodenal ulcer cannot be diagnosed from the clinical presentation alone. The symptoms range from typical nocturnal pain and vague or crampy abdominal discomfort to an almost complete absence of complaints, particularly with NSAID-induced ulcers.

Location

Ninety percent of duodenal ulcers occur in the duodenal bulb. Ulcers are usually located on the anterior wall of the bulb, less commonly on the posterior wall and lesser curvature. Ulcers on the greater curvature are rare (Fig. 3.140). Multiple “kissing” ulcers are found on the anterior and posterior walls in 10-20% of cases. Ulcers located distal to the bulb should raise suspicion of Zollinger-Ellison syndrome.

Fig. 3.140 Frequency distribution of duodenal ulcers

Fig. 3.141a–d Duodenal ulcer

Duodenal Ulcer: Diagnosis and Treatment

Additional Studies

Always biopsy the gastric antrum and body (H. pylori?) for histology, rapid urease testing, or both.

Biopsy the ulcer only if it does not heal or in order to exclude a particular diagnosis (Crohn disease).

Treatment and Follow-Up

The patient is treated with proton pump inhibitors (PPI). If H. pylori is detected, eradication therapy is indicated (see p. 103).

An uncomplicated duodenal ulcer that shows good clinical response does not require endoscopic follow-up. If complaints persist, the patient should undergo repeat endoscopy with biopsy (Crohn disease?), and further tests should be performed to exclude Zollinger-Ellison syndrome.

Fig. 3.142 Duodenal ulcer

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