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Duodenum


Peptic Ulceration, Gastric Heterotopia, Duodenal Diverticula

Peptic Ulceration

Definition

  • Mucosal ulceration occurring within an acidic part of the GI tract ▸ it is often associated with H. pylori infection ▸ duodenal ulcers are 2–3x more common than gastric ulcers

    • ▪

      Bulbar ulcers (95%): these are usually benign

      • –

        Location: anterior wall > posterior wall

    • ▪

      Postbulbar ulcers (5%): these are usually malignant (95%) and fail to heal on medical treatment

      • –

        Location: these are usually seen on the concave border of the 2 nd part of the duodenum or within the immediate postbulbar area ▸ frequently spasm of opposite wall

  • Risk factors: surgery ▸ severe head injury ▸ steroids ▸ COPD

Radiological features

Barium studies

A duodenal ulcer appears as a sharply defined constant collection of barium (± surrounding oedema or radiating folds)

  • Postbulbar ulcer: a typical crater is seen – often with spasm of the opposite wall (± thickened mucosal folds and a narrowed lumen) ▸ scar formation may obscure the ulcer crater

  • Kissing ulcers: this describes two ulcers opposite each other on the anterior and posterior walls

  • Giant duodenal ulcer: a benign ulcer crater measuring >2 cm ▸ it is constant in size and shape and often has a sharp round or oval outline ▸ its floor may be irregular (particularly when the ulcer is penetrating an adjacent organ) ▸ due to its size it may simulate a deformed duodenal bulb or diverticulum

  • A ‘cloverleaf’ or ‘hourglass’ deformity: this can occur when an ulcer heals with scarring

Pearls

  • Multiple postbulbar ulcers occur in the Zollinger–Ellison syndrome

  • Ulcer complications: perforation ▸ bleeding ▸ stenosis ▸ penetration of any adjacent organs

    • ▪

      Perforation: this can be localized or ‘walled off’ with marked duodenal deformity due to the adjacent inflammatory reaction

Gastric Heterotopia

Definition

  • Gastric mucosa occurring in various ectopic locations within the bowel (e.g. the duodenum, small bowel or rectum) ▸ it is found in a small percentage of normal people

Radiological features

Barium meal

Irregular filling defects (varying in size from 1 to 6 mm) seen within the duodenal cap, extending from the pylorus distally

Pearls

  • This should be differentiated from lymphoid hyperplasia of the duodenal bulb

Duodenal Diverticula

Definition

  • Serosal and mucosal herniations through the muscular wall of the duodenum (seen in 2–5% of barium studies)

Clinical presentation

  • It is usually an asymptomatic incidental finding (symptoms may occur due to the retention of food or a foreign body) ▸ it is a rare cause of haemorrhage or perforation

  • Occasionally it may contain aberrant pancreatic, gastric or other functioning tissue – it then becomes a possible site of ulceration, perforation or gangrene

  • Cholangitis or pancreatitis may result from the aberrant insertion of the common bile duct or pancreatic duct into an intraluminal diverticulum (with associated impaired biliary drainage)

Radiological features

  • It is usually found within the 2 nd part of the duodenum with most (85%) arising from the medial periampullary surface ▸ the diverticulum is frequently in contact with the pancreas (and may be embedded in its surface)

Pearl

  • Duodenal ulceration with spasm or scarring may deform the duodenum, producing a pseudodiverticulum – these are deformable (unlike an ulcer)

Postbulbar duodenal ulcer. Characteristic appearance with an ulcer crater (asterisk) in the middle of a stricture produced by spasm and oedema. †

Gastric heterotopia. Multiple small irregular filling defects of varying size are seen in the duodenal cap. *

UGI study demonstrates intraluminal diverticulum or wind sock configuration (D). ••

Duodenal ulceration. The duodenal cap is deformed and a moderate-sized ulcer crater is outlined with barium. †

Giant duodenal ulcer replacing the duodenal cap. *

Anterior wall duodenal ulcer. (A) prone projection. The ulcer (arrow) is dependent, and so fills with barium. (B) supine projection. The ulcer, which is now on the non-dependent wall of the cap, is outlined with a ring of barium (arrow). †

Duodenal ulcer. Barium collects in an ulcer on the dependent (posterior) wall of the duodenal cap. †

Benign and Malignant Duodenal Tumours

Benign Tumours

Types and Appearances on Barium Studies

Lipoma

An intraluminal filling defect (3-4 cm in size) which is sharply marginated, solitary and sessile ▸ it is easily deformed by peristalsis or compression on fluoroscopy

Brunner's gland hyperplasia

These are single or multiple polypoid lesions within the 1 st part of the duodenum (often with a characteristic cobblestone appearance) ▸ a single Brunner's gland adenoma is occasionally seen as a 1 cm smooth polypoid mass

  • The Brunner's glands normally produce alkaline secretions to protect the duodenal mucosa from gastric acid

Adenomatous polyps

Intraluminal filling defects (<1 cm) which can be solitary, sessile or polypoid ▸ they are seen as a soft tissue mass on CT

Villous adenomas

These have a characteristic ‘cauliflower’ or ‘soap bubble’ appearance (caused by trapping of barium in the crevices between the multiple frond-like tumour projections) ▸ they are often 2–3 cm in size

Benign lymphoid hyperplasia

This is seen as multiple small rounded filling defects of uniform size

  • This may be a normal finding in children ▸ in adults it can be associated with hypogammaglobulinaemia and giardiasis

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