Duodenitis

Published on 20/07/2015 by admin

Filed under Radiology

Last modified 22/04/2025

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 Upper GI, CECT

• Best diagnostic clue

image Upper GI: Aphthous ulcers, fold thickening, luminal spasm of duodenal bulb (± gastric antrum)
image CECT: Mural thickening of duodenum ± adjacent inflammation

TOP DIFFERENTIAL DIAGNOSES

• Cholecystitis
• Pancreatitis
• Ureteral colic

PATHOLOGY

• Gastritis commonly coexists with duodenitis

image Similar findings of mucosal erosions, fold thickening, luminal spasm

CLINICAL ISSUES

• Most common signs/symptoms

image Abdominal pain, nausea, vomiting
• Other signs/symptoms

image Gastrointestinal bleeding with deeper ulceration
• Epidemiology

image Helicobacter pylori infection and NSAID use
• Treated with proton-pump inhibitors (plus antibiotics for H. pylori)

DIAGNOSTIC CHECKLIST

• Duodenitis often coexists with gastritis
• Symptoms are indistinguishable from peptic ulcers

image Presence of only superficial (aphthous) erosions and fold thickening distinguishes duodenitis from duodenal ulcer
• Diagnosis usually established by endoscopy
image
(Left) Spot film from an upper GI series shows aphthous ulcers image in the gastric antrum and duodenal bulb, along with thickened duodenal folds image, classic features of duodenitis and gastritis.

image
(Right) Spot film from an upper GI series shows nodular fold thickening image and lack of distensibility in the gastric antrum due to gastritis.
image
(Left) Another spot film from the upper GI series shows spasm and fold thickening of the duodenum image, due to duodenitis.

image
(Right) Axial CECT in the same patient shows luminal narrowing and mural thickening of the 2nd portion of duodenum, with surrounding inflammation image due to duodenitis.

TERMINOLOGY

Definitions

• Duodenal inflammation from any cause

IMAGING

General Features

• Best diagnostic clue

image Upper GI: Aphthous ulcers in duodenal bulb; fold thickening in antrum and duodenal bulb
image CECT: Mural thickening of duodenum ± adjacent inflammation
• Location

image Duodenum
• Size

image Ulcers 3-7 mm
• Morphology

image Discrete erosions with surrounding mound of edema in ring-like fashion

Imaging Recommendations

• Best imaging tool

image Upper GI, CECT
• Protocol advice

image Oral and IV contrast

Radiographic Findings

• Radiography

image Ectopic gas in retroperitoneal space, free air, gastric distension

Fluoroscopic Findings

• Upper GI

image Duodenal spasm, fold thickening
image Superficial or deep ulcerations
image Delayed gastric emptying or outlet obstruction

CT Findings

• CECT

image Duodenal narrowing, fold thickening, gastric distension with air or fluid
image Ectopic gas or fluid with perforation
image Extravasation of oral contrast into anterior pararenal space or peritoneal cavity
image Fluid adjacent to thickened duodenum

Ultrasonographic Findings

• Mural thickening of duodenum
• Fluid in anterior pararenal space

DIFFERENTIAL DIAGNOSIS

Cholecystitis

• Gallstones on US or CT, stone impacted in gallbladder neck, mural thickening > 3 mm
• Positive sonographic Murphy sign
• Pericholecystic fat stranding in omentum on CECT

Pancreatitis

• Diffuse or focal pancreatic enlargement
• Peripancreatic fluid or infiltration

image Especially along Gerota fascia, anterior pararenal spaces, lesser sac, transverse mesocolon
• Nonenhancing areas on CECT if necrosis present

Ureteral Colic

• Nephromegaly, hydronephrosis, high-attenuation stone in ureter
• Perirenal fluid due to forniceal rupture

Annular Pancreas

• Congenital anomaly due to persistence of 2 ventral buds of pancreas
• Uncinate tissue surrounds duodenum, potentially mimicking mural thickening from inflammation or tumor
• May cause gastric outlet obstruction
• Presents in 1st decade; 1/2 of patients present in adulthood

Duodenal Trauma

• Duodenum may be crushed against vertebral body in rapid deceleration injuries
• Pediatric patients often develop duodenal hematoma without perforation

image Best treated conservatively if no extravasation on UGI
• Perforation results in ectopic gas and fluid in anterior pararenal space

PATHOLOGY

General Features

• Etiology

image Helicobacter pylori   infection is most common etiology
image Nonsteroidal anti-inflammatory drug (NSAID) use is next most common cause
image Much less common causes

– Crohn disease
– Radiation therapy
– Pancreatitis
– Viral or other bacterial infection
– Sarcoidosis
• Associated abnormalities

image Gastritis commonly coexists with duodenitis

– Similar findings of mucosal erosions, fold thickening, luminal spasm

Staging, Grading, & Classification

• Duodenitis ± perforation

Gross Pathologic & Surgical Features

• Inflammation of mucosa and submucosal edema
• Superficial (aphthous) erosions  or deep ulcers

Microscopic Features

• Mucosal ulceration
• Submucosal inflammatory infiltrate

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Abdominal pain, nausea, vomiting
• Other signs/symptoms

image Gastrointestinal bleeding with deeper ulceration

Demographics

• Age

image Usually > 40 years old
image Children can be affected, especially with causes other than H. pylori infection
• Epidemiology

image H. pylori infection
image Increases with age

– 20% occurrence rate at age 20, 40% occurrence rate at age 40, 60% occurrence rate at age 60

Natural History & Prognosis

• Can cause chronic pain, perforation, and GI bleeding
• Rarely strictures result from inadequate treatment

image May cause symptoms of gastric outlet obstruction

Treatment

• H. pylori treated with antibiotics and proton-pump inhibitors (PPIs)

image Usually 2 antibiotics and protein pump inhibitor
• Peptic ulcer disease treated with PPIs alone

DIAGNOSTIC CHECKLIST

Consider

• Duodenitis often coexists with gastritis
• Symptoms are indistinguishable from peptic ulcers

image Diagnosis usually established by endoscopy

Image Interpretation Pearls

• Presence of only superficial (aphthous) erosions and fold thickening distinguishes duodenitis from duodenal ulcer
image
Upper GI series in the same patient illustrates a spasm of the same portion of the duodenum, as well as duodenal fold thickening image.

image
Axial CECT in a 64-year-old man who presented with upper abdominal pain, nausea, and vomiting demonstrates luminal narrowing and mural thickening of the 2nd portion of the duodenum, with surrounding inflammation image.

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