Duodenum (PBR 2)

Question 1

90% of tumors in the duodenal bulb are:

a. benign
b. malignant

Answer 1

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

Question 2

Presentation of benign tumors of the duodenum

Answer 2

Small, smooth, polypoid filling defects

Question 3

CT is helpful, but not specific, in predicting malignancy
Biopsy is required

What are the signs of malignancy of duodenal lesions?

Answer 3

1. Central necrosis
2. Ulceration or excavation
3. Exophytic or intramural mass
4. Evidence of tumor beyond the duodenum

Question 4

Most common/frequent malignant tumor of the duodenum

Answer 4

Duodenal adenocarcinoma

Rare lesion

Question 5

Malignant tumor of the duodenum are most commonly located at what part?

Answer 5

Periampullary region

Rare in the bulb

Question 6

What are the morphologic patterns of duodenal adenocarcinoma

Answer 6

1. Polypoid mass
2. Ulcerative mass
3. Annular constricting lesion

Question 7

CT and MR finding of duodenal adenocarcinoma

Answer 7

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

Question 8

Metastases to the duodenum occurs in what layer?

Answer 8

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

Question 9

Most common primary malignancy to metastasize to the duodenum

Answer 9

Breast, lung, and other GI malignancies

The duodenum may be invaded by tumors of adjacent organs including the pancreas and kidney

Question 10

Presentation of lymphoma in the duodenum

Answer 10

Nodules with thickened folds

The nodules associated with lymphoma are distinctly larger than those seen with benign lymphoid hyperplasia

Question 11

Presentation of duodenal adenoma

Answer 11

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

Question 12

This adenoma have a high incidence of malignant degeneration and a characteristic “cauliflower” appearance on double- contrast UGI series

Answer 12

Villous adenoma

Question 13

GISTs of the duodenum present as what kind of mass?

Answer 13

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

Question 14

Second most common primary malignant tumor of the duodenum

Answer 14

Malignant gastrointestinal stromal tumors

Question 15

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

Answer 15

Lymphoid hyperplasia

No evidence supports the concept that lymphoid hyperplasia is a precursor to lymphoma

Question 16

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

Answer 16

Gastric mucosa prolapse

Prolapse through the pylorus during peristalsis

Question 17

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

Answer 17

Heterotopic gastric mucosa in the duodenal bulb is common on endoscopy (12%) but seen infrequently on imaging

Question 18

This glands are located in the submucosa of the proximal two-thirds of the duodenum and secrete an alkaline substance that buffers gastric acid

Answer 18

Brunner glands

Question 19

Brunner gland lesion smaller than 5 mm are termed what?

Answer 19

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

Question 20

Diffuse nodular gland hyperplasia is a common cause of multiple nodules, often with a cobblestone appearance

True or false

Answer 20

True

Brunner gland hamartoma usually presents as a solitary nodule and is identical in appearance to other benign duodenal nodules

Question 21

Ectopic pancreas may occur in what portion of the duodenum

Answer 21

Most commonly in the proximal descending portion

A solitary mass with central dimple is most characteristic

Question 22

Valvulae conniventes, or Kercking folds, of the small bowel begin where?

Answer 22

Second portion of the duodenum and continue throughout the remainder of the bowel

Question 23

How many milimeters is duodenal thickening?

Answer 23

Folds greater than 2 to 3 mm

Question 24

This refers to inflammation of the duodenum without discrete ulcer formation

Answer 24

Duodenitis

Question 25

What i the the major cause of duodenitis?

Answer 25

H . pylori infection Alcohol and anti-inflammatory medications are additional causes

Question 26

UGI findings of duodenitis

Answer 26

1. Thickening (>4 mm) of the proximal duodenal folds 2. Nodules or nodular folds (enlarged Brunner glands), 3. Deformity of the duodenal bulb 4. Erosions CT shows nonspecific wall thickening and inflammatory changes

Question 27

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

Answer 27

Pancreatitis and cholecystitis

Question 28

Crohn disease involves what part of the duodenum?

Answer 28

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

Question 29

Frequent cause of of traveler's diarrhea

Answer 29

Gardiasis

Question 30

Imaging finding of gardiasis

Answer 30

1. Distorted thickened folds in the duodenum and jejunum 2. Hypermotility and spasm 3. Increased secretions

Question 31

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

Answer 31

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

Question 32

Most frequent cause of duodenal ulcers?

Answer 32

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

Question 33

Most common location of duodenal ulcers?

Answer 33

In the duodenal bulb with the anterior wall being most often involved

Question 34

Imaging diagnosis of a duodenal ulcer depends on what finding?

Answer 34

Demonstration of the ulcer crater or niche

Question 35

Usual size of of duodenal ulcers

Answer 35

Smaller than 1 cm diameter Giant ulcers larger than 2 cm resemble diverticuli or a deformed bulb

Question 36

Ulcer craters have no mucosal lining and therefore no mucosal relief pattern, and do not contract with peristalsis True or false

Answer 36

True Ulcer scarring may cause a pattern of radiating folds with a central barium collection that is indistinguishable from an acute ulcer

Question 37

Postbulbar ulcers represent about 5% of the total, but are more commonly associated with what disease?

Answer 37

Serious upper GI hemorrhage Most involve the second and third portions of the duodenum, which are frequently narrowed

Question 38

Complications of duodenal ulcer

Answer 38

Obstruction Bleeding Perforation *Creator's notes: Similar to gastric ulcer

Question 39

This is caused by a gastrin-secreting neuroendocrine tumor (gastrinoma)

Answer 39

Zollinger-Ellison syndrome

Question 40

Most frequent location of gastrinomas?

Answer 40

Pancreas (75%) Duodenum (15%) and in 10% in extraintestinal sites (liver, lymph nodes, and ovary) The tumor is malignant in 60% of cases

Question 41

Gastrinomas also occur as part of what hereditary syndrome?

Answer 41

Multiple endocrine neoplasia, type I (MEN-I) *Creator's notes: Parathyroid adenoma Pituitary gland tumor Pancreatic islet cell tumor (gastrinoma)

Question 42

UGI finding of Zollinger-Ellison syndrome

Answer 42

1. Multiple peptic ulcers in the stomach, duodenal bulb, and, most characteristically, in the postbulbar duodenum 2. Hypersecretion with high-volume gastric fluid diluting the barium and impairing mucosal coating 3. Thick edematous folds in the stomach, duodenum, and proximal jejunum

Question 43

Most common location of duodenal diverticula

Answer 43

Inner aspect of the descending duodenum (2nd part)

Question 44

How to differentiate duodenal diverticular from ulcers if UGI series?

Answer 44

By demonstration of mucosal folds entering the neck of the diverticulum and change in appearance with peristalsis

Question 45

CT scan finding of duodenal diverticula

Answer 45

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

Question 46

Rare complications of duodenal diverticula

Answer 46

Perforation and hemorrhage Diverticuli adjacent to the ampulla of Vater may rarely obstruct the common bile duct or pancreatic duct

Question 47

These are caused by a thin, incomplete, congenital diaphragm that is stretched by moving intraluminal contents to form a “windsock” configuration within the duodenum

Answer 47

Intraluminal duodenal diverticula The diverticulum is partially obstructing eventually resulting in postprandial epigastric pain and fullness. Some patients present with vomiting or GI bleeding

Question 48

This is the most common congenital anomaly of the pancreas

Answer 48

Annular pancreas Pancreatic tissue encircles the descending duodenum and narrows its lumen

Question 49

UGI findings of annular pancreas

Answer 49

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

Question 50

Refers to bleeding with the site of origin proximal to the ligament of Treitz

Answer 50

UGI hemorrhage

Question 51

Causes of upper GI hemorrhage

Answer 51

Approximate order of frequency: 1. Duodenal ulcer 2. Esophageal varices 3. Gastric ulcer 4. Acute hemorrhagic gastritis 5. Esophagitis 6. Mallory–Weiss tear 7. Neoplasm 8. Vascular malformation 9. Vascular enteric fistula

Question 52

Endoscopy is less accurate than a UGI series in demonstrating the bleeding site True or false

Answer 52

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