Duodenum Miscellaneous, El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy

 

 

 
Small hole of which bile emerges at anterior wall of duodenal bulb.

 Ectopic opening of the common bile duct (CBD) into The
 Duodenal Bulb.

 Small hole of which bile emerges at anterior wall of
 duodenal bulb.

 The GI tract is an extremely rare congenital anomaly. The
 clinical implications and frequency of this anomaly are not
 clearly known.

 Although an ectopic opening of the CBD is rare, it may be
 associated with severe pancreaticobiliary disorders.
 Endoscopists should be aware of this anomaly and know
 what to do in case they encounter the condition.
 Small hole of which bile emerges at anterior wall of
 duodenal bulb.

 An ectopic opening of the common bile duct in the duodenal
 bulb is an extremely rare anomaly and one that should not
 be dismissed as just a benign congenital variant because it
 is associated with recurrent duodenal ulcer, biliary pain,
 choledocholithiasis, and recurrent cholangitis. Caution
 must be exercised before diagnosing such ectopia because
 duodenal ulcer also can cause a choledochoduodenal
 fistula. To make the diagnosis of ectopic common bile duct,
 there must be no evidence of a papillary structure in the
 lower duodenum. A good history, thoughtful endoscopy,
 and good pancreaticobiliary imaging is key to proper
 diagnosis.

 See in the Gastric Ulcer3 Chapter an ulcero the pre-piloric
 antrum with probably ectopic opening of CBD

 For more endoscopic details download the video clips by
 clicking on the endoscopic images.
 All endoscopic images shown in this Atlas contain video
 clips.

 
Multiple Duodenal Erosions due to Acute Gastroenteritis Gastrointestinal infections secondary to Salmonella Enteritis. This is the case of a 42 year-old woman with acute diarrhea, (loose watery stools) fever chills, nausea and vomiting and acute abdominal pain with diffuse nonfocal abdominal tenderness, patient was hospitalized management with intravenous fluids and broad spectrum antibiotics.

Video Endoscopic Sequence 1 of 5.

 Multiple Duodenal Erosions due to Acute Gastroenteritis Gastrointestinal infections secondary to Salmonella Enteritis.

 This is the case of a 42 year-old woman with acute diarrhea,
 (loose watery stools) fever chills, nausea and vomiting and
 acute abdominal pain with diffuse nonfocal abdominal
 tenderness, patient was hospitalized management with
 intravenous fluids and broad spectrum antibiotics.

 

Duodenal Involvement in Salmonella, Gastroenteritis usually starts 12 to 48 h after ingestion of organisms, with nausea and cramping abdominal pain followed by diarrhea, fever, and sometimes vomiting. Usually the stool is watery but may be a pastelike semisolid. Rarely, mucus or blood is present. The disease is usually mild, lasting 1 to 4 days. Occasionally, a more severe, protracted illness occurs. If the infection is more severe, a disruption of the intestinal mucosa can occur with necrosis and ulceration, non-typhoidal salmonella. In rare cases, Salmonella infection mimics inflammatory bowel disease or pseudoappendicitis.

Video Endoscopic Sequence 2 of 5.

Duodenal Involvement in Salmonella

 Gastroenteritis usually starts 12 to 48 h after ingestion of
 organisms, with nausea and cramping abdominal pain
 followed by diarrhea, fever, and sometimes vomiting.
 Usually the stool is watery but may be a pastelike
 semisolid. Rarely, mucus or blood is present. The disease
 is usually mild, lasting 1 to 4 days. Occasionally, a more
 severe, protracted illness occurs.

 If the infection is more severe, a disruption of the intestinal
 mucosa can occur with necrosis and ulceration,
 non-typhoidal salmonella.

 In rare cases, Salmonella infection mimics inflammatory
 bowel disease or pseudoappendicitis.
Nontyphoidal Salmonellosis. Salmonella infection most commonly begins with ingestion of bacteria in contaminated food or water. However, direct contact with animal and human carriers has also been implicated. Reptile and amphibian carriers are the most commonly recognized sources of direct contact Studies involving healthy human volunteers required a median dose of 1 million bacteria to produce disease. However, point outbreaks suggest as few as 200 bacteria may produce nontyphoid gastroenteritis

Video Endoscopic Sequence 3 of 5.

Nontyphoidal Salmonellosis

  • Prognosis of patients with simple gastroenteritis is excellent except for very young infants or patients with debilitating diseases.
  • The prognosis for Salmonella meningitis or endocarditis is poor.

    • Salmonella infection most commonly begins with ingestion of bacteria in contaminated food or water. However, direct contact with animal and human carriers has also been implicated. Reptile and amphibian carriers are the most commonly recognized sources of direct contact Studies involving healthy human volunteers required a median dose of 1 million bacteria to produce disease. However, point outbreaks suggest as few as 200 bacteria may produce nontyphoid gastroenteritis.

     
Salmonella organisms are gram-negative bacilli in the family Enterobacteriaceae. Differences in lipopolysaccharide (LPS) and flagellar structure generate the antigenic variation that is reflected in the more than 2,000 known serotypes. The principal reservoirs for nontyphoidal Salmonella organisms are poultry, livestock, reptiles, and pets. The mode of transmission is ingestion of foods of animal origin, including poultry, red meats, unpasteurized milk, and eggs that have been contaminated by infected animals or an infected human. Contact with infected reptiles, such as iguanas, pet turtles, and tortoises, and ingestion of contaminated water are other modes of transmission.

Video Endoscopic Sequence 4 of 5.

 Salmonella organisms are gram-negative bacilli in the
 family Enterobacteriaceae. Differences in
 lipopolysaccharide (LPS) and flagellar structure generate
 the antigenic variation that is reflected in the more than
 2,000 known serotypes. The principal reservoirs for
 nontyphoidal Salmonella organisms are poultry, livestock,
 reptiles, and pets. The mode of transmission is ingestion of
 foods of animal origin, including poultry, red meats,
 unpasteurized milk, and eggs that have been contaminated
 by infected animals or an infected human. Contact with
 infected reptiles, such as iguanas, pet turtles, and tortoises,
 and ingestion of contaminated water are other modes of
 transmission.
Salmonella syndromes can be divided into gastroenteritis, enteric fever, bacteremia, localized infection, and a chronic carrier state.

Video Endoscopic Sequence 5 of 5.

 Salmonella syndromes can be divided into gastroenteritis,
 enteric fever, bacteremia, localized infection, and a chronic
 carrier state.
Extensive neoplasia of the head of pancreas that invades he duodenal bulb and causes pancreato duodenal fistula. The patient had gastrojejunum anastomosis in a public hospital.

  Video Endoscopic Sequence 1 of 4.

 Extensive neoplasia of the head of pancreas that invades
 the duodenal bulb and causes pancreato duodenal fistula.
 The patient had gastrojejunum anastomosis in a public
 hospital. See that anastomosis.

 
The gastric antrum is observed deformed.

Video Endoscopic Sequence 2 of 4.

The gastric antrum is observed deformed.
The neoplasia is observed ulcerated and necrotic.

Video Endoscopic Sequence 3 of 4.

The neoplasia is observed ulcerated and necrotic.

 
Se observa la neoplasia ulcerada y hacia abajo y pared posterior un agujero excavado (fístula), donde se observan los acinos pancreáticos. Más rasgos endoscópicos descargar el video presionado sobre la imagen y observar estos en pantalla completa.

Video Endoscopic Sequence 4 of 4.

 The fistula is observed below and to the posterior wall
 the pancreatic segment is observed into the fistula.

 
Duodenal Carcinoid. A 58 year-old female who came from the republic of Guatemala with your husband who is thorax surgeon. She has this small sessile lesion at the duodenal bulb.

Video Endoscopic Sequence 1 of 4.

Duodenal Carcinoid.

 A 58 year-old female who came from the republic of
 Guatemala with your husband who is thorax surgeon.
 She has this small sessile lesion at the duodenal bulb.
 
Duodenal Carcinoid. The tip of this small sessile lesion suggest an early ulceration that is typical for this tumor. In the duodenum, a small submucosal nodule located in the duodenal bulb is typical. In the Ileum , they are generally larger and may ulcerate. Most common in middle -aged patients. Duodenal carcinoids may cause obstruction or symptoms due to peptide secretion. Distal small bowel carcinoids cause obstructive symptoms such as abdominal pain, vomiting due to kinking from mesenteric involvement Ulcerated ileal carcinoids cause acute, episodic, or occult gastrointestinal bleeding.

Video Endoscopic Sequence 2 of 4.

 Duodenal Carcinoid.

 The tip of this small sessile lesion suggest an early
 ulceration that is typical for this tumor.
 In the duodenum, a small submucosal nodule located in
 the duodenal bulb is typical. In the Ileum , they are
 generally larger and may ulcerate.
 Most common in middle-aged patients. Duodenal
 carcinoids may cause obstruction or symptoms due to
 peptide secretion. Distal small bowel carcinoids cause
 obstructive symptoms such as abdominal pain, vomiting
 due to kinking from mesenteric involvement.
 Ulcerated ileal carcinoids cause acute, episodic, or occult
 gastrointestinal bleeding. 

Video Endoscopic Sequence 3 of 4.

Pancreatic Heterotopia.

 In addition to the described carcinoide in the duodenum
 Patient had this mass 
 Antral nodule with typically central depression and intact
 overlying, antral mucosa.
The histopatologic study of the above case. Carcinoid tumor is a term applied to low-grade neuroendocrine tumors. They are composed of uniform cells with ampholilic cytoplasm, round nuclei, and inconspicuous nucleoli and arranged in nest, ribbons, cords, glands, and trabeculae Mitotic figures are scarce. More aggresive atypical or intermediate grade carcinoid tumors have increased numbers of mitotic figures and sometimes areas of necrosis.

Sequence 4 of 4.

 The histopatologic study of the above case.
 Carcinoid tumor is a term applied to low-grade
 neuroendocrine tumors. They are composed of uniform
 cells with ampholilic cytoplasm, round nuclei, and
 inconspicuous nucleoli and arranged in nest, ribbons,
 cords, glands, and trabeculae Mitotic figures are
 scarce. More aggresive atypical or intermediate grade
 carcinoid tumors have increased numbers of mitotic
 figures and sometimes areas of necrosis.
ntestinal lymphangiectasia is characterized by a focal dilatation of intestinal mucocal and submucosal lymphatic ducts and may induce protein-losing enteropathy, steatorrhea, lymphocytopenia, chylous ascites, hypocalcemia, etc. Since transient ?functional? duodenal lymphangiectasia (DL) was firstly described in healthy volunteers after nasogastric olive oil infusion, there were several reports describing endoscopic evidence of DL in patients without clinical evidence of malabsorption.

Video Endoscopic Sequence 1 of 7.

Duodenal lymphangiectasia

 Intestinal lymphangiectasia is characterized by a focal
 dilatation of intestinal mucocal and submucosal lymphatic
 ducts and may induce protein-losing enteropathy,
 steatorrhea, lymphocytopenia, chylous ascites,
 hypocalcemia, etc. Since transient “functional” duodenal
 lymphangiectasia (DL) was firstly described in healthy
 volunteers after nasogastric olive oil infusion, there were
 several reports describing endoscopic evidence of DL in
 patients without clinical evidence of malabsorption.
Lymphangiectasia2

Video Endoscopic Sequence 2 of 7.

Duodenal lymphangiectasia

At eleven o''clock, the pappilla of Vater
The nature of white submucosal areas as was at first uncertain: on biopsy chyle was released indicating dilated lacteals or a lactocele.

Video Endoscopic Sequence 3 of 7.

 The nature of white submucosal areas as was at first
 uncertain: on biopsy chyle was released indicating dilated
 lacteals or a lactocele.

 White tips to the intestinal villi are commonly seen but
 even after histological examination the cause is not always
 clear. Often this is due to endoscopically visible normal
 filled lacteals as shown. Recent ingestion of fat-containing
 fluids or food is the likely explanation in most cases.
 It may in some patients be associated with obstruction to
 lymphatic flow.

 DL without evidence of clinically significant malabsorption
 is not infrequently found during routine upper endoscopies.
On biopsy chyle was released indicating dilated lacteals or a lactocele.

Video Endoscopic Sequence 4 of 7.

 On biopsy chyle was released indicating dilated lacteals or
 a lactocele.
Intestinal lymphangiectasia can present as malabsorption and protein-losing enteropathy.

Video Endoscopic Sequence 5 of 7.

Chyle was released

 Intestinal lymphangiectasia can present as malabsorption
 and protein-losing enteropathy.

 
The histopathological appearances of lymphangiectasia with endotheliumlined lymphatics is shown.

Video Endoscopic Sequence 6 of 7.

 The histopathological appearances of lymphangiectasia
 with endotheliumlined lymphatics is shown.

 

 

 

 Click on the image to enlarge in a new windows

 
Section shows lakes of ectatic lymphatic vessels within the lamina propria of the small intestine.

Video Endoscopic Sequence 7 of 7.

 Section shows lakes of ectatic lymphatic vessels within the
 lamina propria of the small intestine.

 

 

 

 

  Click on the image to enlarge in a new windows

 
Pancreatic Cancer that Infiltrates the Duodenal Wall.

 Pancreatic Cancer that Infiltrates the Duodenal Wall.

The cat scan showed a tumor of the head, this nodule is in the second part of the duodenum that was proven to be by biopsies adenocarcinoma.

 Among cancers of the gastrointestinal tract, it is the third
 most common malignancy and the fifth leading cause of
 cancer-related mortality. The disease is difficult to
 diagnose in its early stages, and most patients have
 incurable disease by the time they present with symptoms.
 The overall 5-year survival rate for this disease is less
 than 5%.
Mycobacterium Avium Complex of the Duodenum. Endoscopically Mycobacterium Avium and Mycobacterium Tuberculosis infection can be suspected by the presence of tiny, punctate white nodules or exudate. Both illnesses can cause ulcers, bleeding, diarrhea, and malabsorption Mycobacterium Avium Complex infection occurs in the small intestine in patient with HIV disease, typically presents with weight loss, fever, diarrhea and abdominal paint. The duodenum is most commonly involved in 90% of the cases.

Mycobacterium Avium Complex of the Duodenum.

 Endoscopically Mycobacterium Avium and
 Mycobacterium Tuberculosis infection can be suspected
 by the presence of tiny, punctate white nodules or exudate.
 Both illnesses can cause ulcers, bleeding, diarrhea, and
 malabsorption.
 Mycobacterium Avium Complex infection occurs in the
 small intestine in patient with HIV disease, typically
 presents with weight loss, fever, diarrhea and abdominal
 paint. The duodenum is most commonly involved in 90% of
 the cases.
       

Infiltrating Pancreatic Cancer into the duodenal bulb.

Infiltrating Pancreatic Cancer into the Duodenal Bulb   
Post bulbar Adenocarcinoma.

Duodenal Adenocarcinoma.

Post bulbar Adenocarcinoma.

 
Choledoscopy. A 20 year-old female that undergone open cholecystectomy due to choledocolitiasis a T-Tube was placed. A choledoscopy was performed 6 week after surgery through the fistula.

Choledoscopy.

 A 20 year-old female that undergone open cholecystectomy
 due to choledocolitiasis a T-Tube was placed.
 A choledoscopy was performed 6 week after surgery
 through the fistula.
 
Lymphocytic Duodenitis. This is a type of Duodenitis. with dense infiltration of the surface and foveolar epithelium by T lymphocytes, and associated chronic infiltrates are in the lamina propria Because of similar histopathology relative to celiac disease, lymphocytic gastritis has been proposed to result from intraluminal antigens. High anti-H pylori antibody titers have been found in patients with lymphocytic duodenitis and, in limited studies, the inflammation disappeared after H pylori eradication. However, many patients with lymphocytic gastritis are serologically negative for H pylori. A number of cases may develop secondary to intolerance to gluten and drugs such as ticlopidine.

Lymphocytic Duodenitis.

 This is a type of Duodenitis. with dense infiltration of the
 surface and foveolar epithelium by T lymphocytes, and
 associated chronic infiltrates are in the lamina propria
 Because of similar histopathology relative to celiac
 disease, lymphocytic gastritis has been proposed to result
 from intraluminal antigens. High anti–H pylori antibody
 titers have been found in patients with lymphocytic
 duodenitis and, in limited studies,
 the inflammation disappeared after H pylori eradication.
 However, many patients with lymphocytic gastritis are
 serologically negative for H pylori. A number of cases may
 develop secondary to intolerance to gluten and drugs such
 as ticlopidine.