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

 

 

 

GastroduodenalHistoplasmosis3

Video Endoscopic Sequence 1 of 12.

Gastrointestinal Histoplasmosis

Third part of the duodenum

This is a 50 year-old female with weight loss of 20 lbs and epigastric pain.

 Of the few case reports of duodenal histoplasmosis
 described in the literature, most have presented with
 nonspecific symptoms, such as weight loss or abdominal
 pain, or no symptoms at all.

 The differential diagnosis for the inflammatory lesions
 of gastrointestinal histoplasmosis includes idiopathic
 inflammatory bowel disease (ulcerative colitis and Crohn
 disease), lymphoma, sarcoidosis, and other infections.

 

 

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

 

GastroduodenalHistoplasmosis4

Video Endoscopic Sequence 2 of 12.

Gastrointestinal Histoplasmosis in Patient with AIDS

Gastrointestinal Histoplasmosis

Third part of the duodenum

 Intestinal involvement is most common, particularly of the
 terminal ileum because of its abundant lymphoid tissue,
 although lesions may occur anywhere from the mouth to the
 anus. Patients may present with hematochezia, melena,
 intestinal obstruction or perforation, and peritonitis.
 Gastrointestinal bleeding is more common in patients with
 AIDS.

GastroduodenalHistoplasmosis1

Video Endoscopic Sequence 3 of 12.

A nodule at the pre-pyloric antrum that resemble a heterotopic pancreas,

Nodule with a central dimple. The biopsies also display histoplasmosis.

 On endoscopy, GI lesions may appear as segments of
 inflamed or thickened bowel, ulcerations, strictures, polyps,
 or tumor-like lesions . This variation in gross appearance
 makes GIH a great imitator of other GI disorders, most
 notably inflammatory bowel diseases and GI malignancies.

 

GastroduodenalHistoplasmosis2

Video Endoscopic Sequence 4 of 12.

 Other findings include ulcerations, polypoid lesions, and
 masses mimicking carcinoma. Ulcerative lesions may be
 mistakenly diagnosed as inflammatory bowel disease.
 Biliary tract involvement has been rarely reported.
 Peritonitis is distinctly rare, with only a few reports
 described in the literature. Serological tests for antibodies
 are useful for diagnosis, but may be falsely negative in
 immunocompromised individuals. Antigen detection is
 sensitive in this population. Although histopathology and
 tissue cultures are specific, limitations include insensitivity
 and need for invasive procedures. Antifungal options
 include intravenous amphotericin B for severe or unstable
 disease and oral itraconazole for stable disease.

 While the clinical presentation of GIH is often vague
 and nonspecific, it should be considered on the differential
 diagnosis in patients with a variety of different upper or
 lower GI symptoms.

 

GastroduodenalHistoplasmosis5

Video Endoscopic Sequence 5 of 12.

 In patients with disseminated histoplasmosis, the
 gastrointestinal (GI) tract is one of the most commonly
 affected.organ systems with approximately 70% of patients
 demonstrating some GI involvement at autopsy. While
 gastrointestinal histoplasmosis (GIH) may involve any
 portion of the GI tract, nearly 90% of lesions involve the
 lower GI tract, most commonly the ileocecal region or colon

 This is thought to be due to the abundance of gutassociated
 lymphoid tissue (GALT) in these areas, such as
 Peyer’s patches in the terminal ileum, which may serve
 as entry sites for macrophages filled with H. capsulatum
 yeasts.

 Given the discrepancy between autopsy data and clinically
 reported data, the incidence of GIH is underestimated and
 clinicians should consider this diagnosis
 in AIDS patients at risk, specifically those with advanced
 immunosuppression (i.e., CD4+ cell counts <100 cells/mm3).

GastroduodenalHistoplasmosis6

Video Endoscopic Sequence 6 of 12.

 Although common at autopsy, GIH is rarely recognized
 clinically with GI symptoms being reported in <10% of
 cases of disseminated infection. This may be due, in part,
 to the nonspecific manifestations of GIH, namely, fever,
 weight loss, diarrhea, and abdominal pain. In aminority of
 cases.

GastroduodenalHistoplasmosis8

Video Endoscopic Sequence 7 of 12.

GastroduodenalHistoplasmosis9

Video Endoscopic Sequence 8 of 12.

 Multiple biopsies were taken which showed duodenal
 mucosa with granulomatous inflammation. Gomori’s
 methenamine silver (GMS) stain identified macrophages
 with small intracellular yeasts consistent with disseminated
 histoplasmosis.

GastroduodenalHistoplasmosis11

Video Endoscopic Sequence 9 of 12.

 Histologically, GIH first appears as focal lesions in the
 submucosa and lamina propria, but the gross appearance of
 these lesions is highly variable.

GastroduodenalHistoplasmosis12

Video Endoscopic Sequence 10 of 12.

 

GastroduodenalHistoplasmosis13

Video Endoscopic Sequence 11 of 12.

 

GastroduodenalHistoplasmosis14

Video Endoscopic Sequence 12 of 12.

 

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

 

 

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.

UnusualLargeMass1

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.

UnusualLargeMass2

Video Endoscopic Sequence 2 of 3.

With the polypectomy snare we pass this mass through the pylorus.
 

 

UnusualLargeMass3

Video Endoscopic Sequence 3 of 3.

Another aspect of this mass

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.

BrunnerGlandAdenomax1

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.

BrunnerGlandAdenomax2

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.

BrunnerGlandAdenomax3

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.

BrunnerGlandAdenomax4

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.