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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.
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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.
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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.
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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.
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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.
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Video Endoscopic Sequence 5 of 5.
Salmonella syndromes can be divided into gastroenteritis,
enteric fever, bacteremia, localized infection, and a chronic
carrier state.
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Video Endoscopic Sequence 1 of 3.
Unusual Mass of the Duodenum
Incidentally we find this rather long mass with smooth
texture. Apparently could correspond to a hyperplastic
polyp.
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Video Endoscopic Sequence 2 of 3.
With the polypectomy snare we pass this mass through the pylorus.
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Video Endoscopic Sequence 3 of 3.
Another aspect of this mass
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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.
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Video Endoscopic Sequence 2 of 4.
The gastric antrum is observed deformed.
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Video Endoscopic Sequence 3 of 4.
The neoplasia is observed ulcerated and necrotic.
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Video Endoscopic Sequence 4 of 4.
The fistula is observed below and to the posterior wall
the pancreatic segment is observed into the fistula.
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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.
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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.
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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.
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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.
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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.
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Video Endoscopic Sequence 2 of 7.
Duodenal lymphangiectasia
At eleven o''clock, the pappilla of Vater
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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.
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Video Endoscopic Sequence 4 of 7.
On biopsy chyle was released indicating dilated lacteals or
a lactocele.
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Video Endoscopic Sequence 5 of 7.
Chyle was released
Intestinal lymphangiectasia can present as malabsorption
and protein-losing enteropathy.
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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
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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
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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%.
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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.
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Infiltrating Pancreatic Cancer into the Duodenal Bulb
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Duodenal Adenocarcinoma.
Post bulbar Adenocarcinoma.
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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.
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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.
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Video Endoscopic Sequence 1 of 4.
Brun ner's Gland Adenoma
Brunner's gland adenoma (BGA) of the duodenum appear
to be nodular hyperplasia of the normal Brunner's gland
with an unusual admixture of normal tissues, including
ducts, adipose tissue and lymphoid tissue.
Overgrowth of Brunner's gland forming a tumour larger
than 1cm in size in diameter is referred to as BGA and less
than 1cm as Brunner's gland hyperplasia.
The etiology of Brunner's gland adenoma remains obscure.
Concurrent H. pylori infection is very common in patients
with Brunner's gland adenoma. However, the role of H.
pylori infection in the pathogenesis and development of
Brunner's gland hyperplasia remains unclear.
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Video Endoscopic Sequence 2 of 4.
Endoscopy of Brunner's Gland Adenoma
Normal Brunner's glands are found in the highest
concentration in the proximal duodenum and found
normally extending to the proximal jejunum. These glands
secrete a viscous alkaline fluid that is thought to protect
the duodenal mucosa from the effects of gastric acid. This
fluid also contains a glycoprotein that binds to the mucosa
to further protect it. Brunner's glands also secrete
enterogastrone, a hormone that inhibits gastric acid
secretion. The precise etiology of Brunner's gland
hyperplasia has not been completely elucidated. One
theory is that the glands are stimulated to proliferate by
increased acid production. However, no studies have
confirmed this hypothesis.
Brunner's gland adenomas are rare duodenal lesions that
can present with hemorrhage or signs and symptoms of
obstruction. They are not true adenomas, but are actually
hamartomas with little to no malignant potential. These
lesions should be treated with endoscopic polypectomy if
possible, but surgical resection is an acceptable option.
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Video Endoscopic Sequence 3 of 4.
Brunner’s glands consist of submucosal mucin-secreting
glands located exclusively in the duodenum. They extend
from the pylorus distally for a variable distance, usually at
the first and second portions of the duodenum, and less
frequently, stopping at the third and fourth portions.
Brunner’s glands secrete an alkaline fluid composed of
viscous mucin, whose function appears to protect the
duodenal epithelium from acid chyme of the stomach.
It is a tumor without malignant predisposition. The
malignant type is rare.
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Video Endoscopic Sequence 4 of 4.
Las glándulas de Brunner, localizadas en la submucosa y
las capas profundas de la mucosa del duodeno, son más
numerosas en la primera porción del duodeno, y su número
decrece progresivamente en la segunda, tercera y cuarta
porción. Debido a su localización profunda, la proliferación
de las glándulas de Brunner dan como resultado una masa
submucosa. Histologicamente, las glándulas de Brunner
son las glándulas submucosas acinotubulares ramificadas,
revestidas por grandes células que muestran el citoplasma
tejido ligeramente con la tinción de hematoxilina-eosina.
Cambios quisticos pueden ocurrir dentro del acini y la
atipia celular no está presente por lo general.
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