Small intestine & ampulla
Inflammatory disorders
Peptic duodenitis
Authors: Hasan Samra, M.D., Mohamed Mostafa, M.D.
Deputy Editor-in-Chief: Raul S. Gonzalez, M.D.
Last author update: 13 April 2020
Last staff update: 1 June 2022
Copyright: 2003-2024, PathologyOutlines.com, Inc.
PubMed Search: Peptic duodenitis
Table of Contents
Definition / general | Essential features | Terminology | ICD coding | Epidemiology | Sites | Pathophysiology | Etiology | Clinical features | Diagnosis | Laboratory | Endoscopic findings | Prognostic factors | Case reports | Treatment | Microscopic (histologic) description | Microscopic (histologic) images | Sample pathology report | Differential diagnosis | Additional references | Board review style question #1 | Board review style answer #1 | Board review style question #2 | Board review style answer #2Cite this page: Samra H, Mostafa M. Peptic duodenitis. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/smallbowelduodenitis.html. Accessed April 24th, 2024.
Definition / general
- Histologic findings indicative of duodenal mucosa injury as a result of chronic exposure to increased gastric secretion
Essential features
- Primarily involves proximal duodenum
- Histologic features include gastric foveolar metaplasia and Brunner gland hyperplasia
- Usually mild and regresses with treatment
Terminology
- Also termed chronic nonspecific duodenitis
ICD coding
- ICD-10: K29.80 - duodenitis without bleeding
Epidemiology
- Median age: 58 years (Hum Pathol 2010;41:1593)
- Foveolar metaplasia can be seen in up to 26.3% of patient population (Lab Invest 2016;96 Suppl 1:187A)
Sites
- Duodenum, usually proximal segment
Pathophysiology
- Chronic exposure of the duodenal mucosa to excessive gastric acidity in proportion to duodenal bicarbonate contents, resulting in injury to the lining mucosa (Monogr Pathol 1990;31:69)
Etiology
- Medications (in particular NSAIDs) (Aliment Pharmacol Ther 2012;36:48)
- Helicobacter pylori infection (though recent data suggests H. pylori might not be implicated as much as it was believed) (Hum Pathol 2010;41:1593, Lab Invest 2016;96 Suppl 1:187A)
- Idiopathic (Aliment Pharmacol Ther 2013;38:946)
Clinical features
- May be asymptomatic (incidental finding) or cause dyspepsia, abdominal pain, hematemesis
- In advanced cases: symptoms related to gastric outlet obstruction or acute abdominal pain (clinical features of peritonitis) secondary to duodenal perforation
Diagnosis
- Endoscopy with biopsy
Laboratory
- Negative celiac sprue serology (antitissue transglutaminase, endomysial antibodies, deamidated gliadin peptide)
Endoscopic findings
- Mucosal erythema
- Mucosal nodularity (Mod Pathol 2005;18:1134)
- Mucosal erosion and ulceration
Prognostic factors
- Good prognosis as most cases regress with treatment
Case reports
- 56 year old man with foveolar gastric metaplasia of atypical appearance (J Med Case Rep 2016;10:355)
- 72 year old man with duodenal obstruction secondary to Brunner gland hyperplasia (Pathologica 2017;109:414)
- 80 year old man with carcinoma arising from gastric foveolar metaplasia in the duodenum after 9 years of observation (Clin J Gastroenterol 2018;11:391)
Treatment
- Stop the offending medication
- Proton pump inhibitors
- Treat underlying infection, like H. pylori (Histopathology 2006;48:417)
- Surgical intervention for perforated peptic duodenitis or gastric outlet obstruction
Microscopic (histologic) description
- Foveolar metaplasia of the surface duodenal epithelium
- Brunner gland hyperplasia (Brunner glands seen above the muscularis mucosae)
- Expansion of the lamina propria by mixed inflammatory cell infiltrate, including few neutrophils that usually do not infiltrate the epithelium
- Mildly increased intraepithelial lymphocytes, usually corresponding to Marsh 1 lesion (Mod Pathol 2005;18:1134)
- Mild villous blunting can be seen (World J Gastroenterol 2005;11:686)
- Severe cases may show mucosal erosion, ulceration or regenerative changes, like mucin depletion, nuclear hyperchromasia and increased mitotic activity
- H. pylori very rarely present in metaplastic epithelium
Microscopic (histologic) images
Contributed by Mohamed Mostafa, M.D.
Surface foveolar metaplasia and Brunner gland hyperplasia
Foveolar metaplasia and lamina propria expansion
H. pylori associated peptic duodenitis
Surface foveolar metaplasia
Contributed by @RaulSGonzalezMD on Twitter
Peptic duodenitis
Sample pathology report
- Duodenum (D1 / D2), biopsy:
- Duodenal mucosa with preserved villous architecture and gastric metaplasia, suggestive of peptic injury
Differential diagnosis
- Celiac sprue:
- Positive celiac serology
- Marked increased intraepithelial lymphocytes and prominent villous blunting
- Improvement with gluten elimination
- May also show concomitant peptic injury / gastric metaplasia
- Crohn’s disease:
- Nonnecrotizing granulomas
- Involvement of other locations in the gastrointestinal tract
Additional references
Board review style question #1
Which of the following histologic findings are most likely to be encountered in peptic duodenitis?
- Cryptitis and crypt abscess formation
- Lamina propria expansion and nonnecrotizing granulomas
- Marked intraepithelial lymphocytosis and moderate villous blunting
- Scattered lymphoid follicles in the lamina propria
- Surface foveolar metaplasia and Brunner gland hyperplasia
Board review style answer #1
E. Surface foveolar metaplasia and Brunner gland hyperplasia
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Board review style question #2
Regarding peptic duodenitis, which one of the following is true?
- Affects primarily duodenal mucosa distal to ampulla of Vater
- Always associated with Helicobacter pylori gastritis
- Histologic findings result from excessive bile reflux
- Medication is always a culprit
- Presents with mild symptoms and regresses with treatment
Board review style answer #2
E. Presents with mild symptoms and regresses with treatment
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