Duodenum

Segments
(1) bulbus duodenum dan segmen
pendek postbulbar:
 intraperitoneal + bergerak bebas
(2) duodenum desenden :
 retroperitoneal melekat pada caput pancreas
(3) horisontal = segment
transversal :
 retroperitoneal menyilang vertebra
(4) duodenum asenden :
 retroperitoneal ascending ke level duodenojejunal junction

VARIATIONS:
 "mobile duodenum" / "water-trap duodenum"= long postbulbar segment with undulation /
redundancy
 duodenum inversum / duodenum reflexum= distal duodenum ascends to the right of spine to
the level of duodenal bulb + then crosses spine horizontally + fixated in normal location
Grainger
Chapter 48 -
The duodenum

Daniel J. Nolan

ANATOMY AND NORMAL APPEARANCES

Ukuran panjang duodenum 20-30 cm dan merupakan bagian usus halus yang paling pendek,
paling lebar dan paling tidak mobile .Meskipun secara anatomi duodenum adalah bagian dari
usus halus, secara radiologi dipisahkan ok pemeriksaanya termasuk dalam gastroinestinal atas.
Duodenum berbentuk lingkaran yang tidak komplit ( C loop; basch) melingkupi kaput pankreas
dan dibagi dalam bagian I, II, III & IV.
Bagian I,
 Duodenal cap atau bulbus, juga disebut bagian superior duodenum.
 Dimulai dari pylorus, the first part passes superiorly, posteriorly and to the right before
turning down at the superior duodenal flexure to become the second part. Its direction varies
slightly, depending on the degree of stomach distension. Peritoneum covers the whole of its
anterior part where it is related to the gallbladder, but posteriorly it is devoid of peritoneum.

Bagian II,
 descending
Bagian III,
 horizontal
Bagian IV,
 ascending

The second part of the duodenum passes down anterior to the right kidney and posterior to the
transverse colon. Above and below the transverse colon it is covered with peritoneum. It is about
7.5 cm long and ends at the inferior duodenal flexure. The duodenum turns to the left and
passes horizontally in front of the spinal column as the third part before it turns up and ascends
in front and to the left of the abdominal aorta as the fourth part to end at the duodenojejunal
flexure (ligament of Treitz).
The anterior surface of the third part is covered with peritoneum except where it is crossed by
the superior mesenteric vessels and the root of the mesentery. The right border of the fourth
part gives attachment to the upper part of the root of the mesentery, the left layer of which is
continued over its anterior and left side. The main arteries supplying the duodenum are derived
from the right gastric, gastroduodenal, right gastroepiploic, and the superior and inferior
pancreaticoduodenal arteries.
At barium examination parallel, or nearly parallel, folds are seen passing upwards from the base
of the duodenal cap. They are effaced when the hypotonic duodenum is distended by gas at
1064
The ampulla of Vater can be seen in about two thirds of patients during routine double-contrast
barium examination and the accessory papilla of Santorini's duct in about one quarter[2] . The
ampulla of Vater is recognized by its fold pattern: a hooded fold and a distal longitudinal fold are
usual, and oblique folds are frequently present. The accessory papilla is sited about 10 mm
proximal to the ampulla. On a prone view the ampulla lies on the medial wall and the accessory
papilla on the anterior wall.

RADIOLOGICAL INVESTIGATION
Barium studies
Duodenal ileus, duodenal obstruction and perforation can be diagnosed on plain abdominal
radiographs. The barium examination is the principal radiological technique for examining the
lumen of the duodenum. Views of the duodenal cap and at least one view of the duodenum as
far as the ligament of Treitz should be included in all routine barium examinations of the upper
gastrointestinal tract.
Views of the duodenal cap and the proximal second part of the duodenum can be taken with the
table horizontal after the first stage of stomach examination. It is easier to detect and
demonstrate abnormalities if the duodenum is relaxed. Hypotonia is produced by intravenous
injection of 20 mg of hyoscine butylbromide (Buscopan) or 0.2 mg of glucagon. With the table
horizontal, the patient is first turned onto the right side so that barium fills the duodenum - this
occurs quickly following the use of hyoscine butylbromide which relaxes the pylorus. The patient
is next rotated onto the left side and gas passes rapidly from the stomach into the duodenum.
Then, with the patient in the right anterior oblique position, a number of double-contrast views of
the duodenal cap ( Fig. 48.1 ) and duodenal loop ( Fig. 48.2 ) are taken. Excellent views can be
obtained by elevating the head of the table slightly so that barium drains from the superior
duodenal flexure into the second part of the duodenum.
Double-contrast views of the duodenal cap and the duodenal loop are also taken with the patient
prone or prone oblique, with the left side slightly raised.

Hypotonic duodenography
Hypotonic duodenography is performed as a separate study if the duodenal loop is the prime
area of interest. The tubeless method gives adequate views of the duodenum in many cases. The
barium suspension and effervescent agent are given, and when barium is present in the
duodenum a smooth muscle relaxant is injected intravenously. Duodenal intubation gives
consistently better results. The quantity of barium and air being insufflated can be controlled and
there is no overlying barium in the gastric antrum or the jejunal loops[3] . A duodenal catheter is
advanced so that its tip is positioned in the lower part of the descending duodenum and about 40
ml of barium suspension is injected. The smooth muscle relaxant is then injected intravenously.
Air is injected through the catheter to distend the duodenum, and radiographs of the duodenal
loop are taken. Lesions that cause narrowing of the duodenum are often demonstrated better by
a single-contrast barium column.
1065
Hypotonic duodenography is indicated in the evaluation of equivocal findings at routine barium
studies and when primary lesions of the duodenal loop are suspected.
Water-soluble contrast studies
If plain radiographs fail to demonstrate the presence of free gas in patients with suspected
perforation of the stomach or duodenum, water-soluble contrast medium is used. The water-
soluble contrast medium (about 50 ml) should preferably be injected through a nasogastric tube
into the stomach. The examination is either performed under fluoroscopic control or a right
decubitus radiograph is taken after a short interval.
Other imaging techniques
Angiography can be invaluable in the diagnosis of massive upper gastrointestinal bleeding from
the duodenum when more conventional methods have failed to locate the bleeding site.
Ultrasound and CT are used to evaluate secondary involvement of the duodenum by malignant
disease[4] and CT may also be helpful in assessing the extent of spread of duodenal
neoplasms[4] [5] .
PEPTIC ULCERATION
The incidence of benign peptic ulceration of the duodenum and its complications is decreasing,
mostly because patients who present with typical peptic symptoms respond effectively to medical
treatment. A number of aetiological factors may play a part in the development of duodenal
ulceration, the strongest of which is infection of the gastroduodenal mucosa by Helicobacter
pylori; virtually all peptic ulcer patients are colonized by the bacterium[6] . Eradication of the
bacterium leads to ulcer healing and asignificant decrease in the incidence of relapse. A number
of epidemiological factors appear to play a role. Men are more likely than women to develop
duodenal ulcers, and the incidence is higher in first-degree relatives. There are also weak
associations of duodenal ulceration with smoking and alcohol intake[6] .
Most patients with suspected peptic ulceration are examined endoscopically, but the double-
contrast barium examination remains an excellent examination for demonstrating duodenal
ulcers. Ulcer craters in the duodenum may be small, large, single or multiple, and are shown on
double-contrast barium studies as sharply defined, constant collections of barium ( Fig. 48.3 ),
sometimes with a surrounding zone of oedema or radiating folds. Most ulcer craters have a
diameter of less than 10 mm. Anterior wall ulcers are normally shown best on the prone view;
they may have the appearance of a ring shadow on the supine view as a result of the barium
dropping out of the centre of the crater. The duodenal bulb may also be distorted, although quite
large ulcers may be present without significant deformity. The degree of deformity varies
considerably and when marked can result in duodenal stenosis. Duodenal deformity may remain
following previous ulceration even in the absence of any active ulceration.
Giant duodenal ulcers
The term 'giant duodenal ulcer' is given to a benign ulcer crater with a radiographic diameter
greater than 2 cm. Abdominal pain, vomiting, and weight loss are frequent symptoms;
haemorrhage occurs in the majority of patients[7] . About half require urgent admission to
hospital at some stage. The ulcer, because of its large size, may be mistaken for the duodenal
bulb ( Fig. 48.4 ), a pseudodiverticulum, or a true diverticulum[7] . Patients with giant duodenal
ulcers have a high mortality rate caused by delay in the diagnosis, complications such as
haemorrhage and obstruction, and, frequently, advanced age. Few giant ulcers heal following
medical treatment. Barium studies show them as being constant in size and shape - often round
or oval with a sharp outline ( Fig. 48.4 ). There is a tendency for barium to remain in the crater,
1066
and a late radiograph taken hours after the examination may show the residual barium. The floor
may be irregular, particularly when the ulcer is penetrating an adjacent organ.
Postbulbar ulceration
Peptic ulcers are an infrequent finding in the postbulbar part of the duodenum but are
occasionally seen and mostly occur on the concave border of the second part or in the immediate
postbulbar area ( Fig. 48.5 ). The ulcer is shown as a typical crater, frequently with spasm of the
opposite wall. There may be narrowing of the lumen and thickening of the mucosal folds. In
some cases scar formation may obscure the ulcer crater. Postbulbar ulcers usually fail to heal on
medical treatment; haemorrhage, often massive, is variously reported as occurring in 37-80% of
patients. Stenosis, perforation, penetration into an adjacent organ such as the pancreas, and
occasionally obstructive jaundice are other complications[8] .
Complications of peptic ulceration
The principal complications of duodenal ulceration are perforation, bleeding, stenosis, and
penetration of adjacent organs. Free perforation is an acute emergency and is usually diagnosed
on the clinical and plain radiographic findings. Occasionally, a water-soluble contrast examination
may be necessary to confirm the diagnosis. The perforation is sometimes localized or 'walled-off'
with marked deformity of the duodenum due to the adjacent inflammatory reaction. Bleeding
caused by duodenal ulceration is diagnosed by endoscopy and/or angiography. Duodenal stenosis
may become quite marked and result in obstruction. Barium examination in this situation will
show an excessive amount of fluid in a dilated stomach with considerable delay in emptying, and
it may not be possible to demonstrate the duodenum.
GASTRIC HETEROTOPIA
Gastric heterotopia is present in a small percentage of normal people[9] . Irregular filling defects,
varying in size from 1 to 6 mm, are seen in the duodenal cap extending from the pylorus distally
( Fig. 48.6 ). Gastric heterotopia should be differentiated from nodular lymphoid hyperplasia of
the duodenal bulb.
DIVERTICULA
Duodenal diverticula ( Fig. 48.7 ) are a common finding on barium studies, present in 2-5% of
examinations. They are mostly in the descending part of the duodenum, with 85% arising from
the medial surface[10] . Frequently they are in contact with the pancreas and may be embedded
in its surface. The diverticula are lined with intestinal epithelium; the majority cause no clinical
symptoms and are an incidental finding on barium examination. Occasionally a diverticulum
contains aberrant pancreatic, gastric, or other functioning tissue and is the site of ulceration,
perforation,
1067
Symptoms may also develop due to the retention of food or a foreign body. Cholangitis or
pancreatitis may result from the aberrant insertion of the common bile duct or pancreatic duct
into a duodenal diverticulum[11] . Inverted intraluminal diverticula may be misdiagnosed as
pedunculated polyps.
NEOPLASMS
Benign neoplasms
Benign neoplasms of the duodenum are uncommon and often symptomless. Brunner's gland
hyperplasia is seen as single or multiple polypoid lesions in the first part of the duodenum ( Fig.
48.8 ), often with a characteristic cobblestone appearance. Patients usually present with typical
symptoms of peptic ulceration. A single Brunner's gland adenoma is occasionally seen. Benign
lymphoid hyperplasia [12] is an occasional finding in the duodenum and is shown as multiple
small rounded filling defects of uniform size ( Fig. 48.9 ). Other benign neoplasms of the
duodenum include leiomyomas, tubular adenomas, villous adenomas, lipomas ( Fig. 48.10 ),
neurogenic tumours, hamartomas, and adenomas of the papilla of Vater. Benign neoplasms are
dis-cussed in more detail in the chapter on the small intestine ( Ch. 49 ).
Malignant neoplasms
Primary carcinoma
Malignant neoplasms of the duodenum are uncommon; primary carcinoma is probably the most
frequently encountered. Carcinomas can be classified into carcinoma of the papilla of Vater and
true carcinoma of the duodenum, the former being the type most frequently encountered.
Jaundice, often intermittent in the early stages, is the usual clinical presentation of carcinoma of
the papilla. Barium studies show an enlarged papilla of Vater with irregular borders, sometimes
with spiculation and ulceration[13] ( Fig. 48.11 ). Nonpapillary carcinomas of the duodenum are
adenocarcinomas and usually present clinically as duodenal obstruction, although the modes of
presentation are varied and can mimic peptic ulceration, hiatal hernia, pancreatic or biliary
disease[14] . Barium examination shows the neoplasm as an ulcerative, polypoid or annular
lesion ( Fig. 48.12 ). On CT, primary carcinoma is seen mostly as a mass surrounding the
duodenum ( Fig. 48.13 ). Other malignant primary neoplasms occasionally encountered in the
duodenum include sarcomas ( Fig. 48.14 ) and lymphomas.
1068
Secondary involvement
The duodenum may be invaded by malignant neoplasms from adjacent organs or be the site of
metastases. Carcinoma and lymphoma of the stomach can spread directly across the pylorus to
involve the duodenum. This is reported to occur in up to 40% of lymphomas and 25% of
adenocarcinomas of the gastric antrum[15] ( Fig. 48.15 ).
1069
Carcinoma of the head of the pancreas frequently causes changes in the duodenal loop. There
may be widening of the duodenal loop, a double contour, irregularity of the inner border, and
stricturing or distortion of the valvulae conniventes. The reversed '3' sign of Frostberg[16] is
often quoted as being characteristic, but is an infrequent finding ( Fig. 48.16 ). Carcinoma of the
tail of the pancreas may compress or invade the duodenum, resulting in mucosal destruction, the
patients presenting with bleeding or obstruction[17] ( Fig. 48.17 ).
The duodenum may be invaded by carcinomas in other adjacent organs. Carcinoma of the colon,
particularly of the hepatic flexure, may distort and invade the duodenal loop[18] . Abdominal
pain, weight loss, vomiting and bleeding are the usual presenting features. The infiltrating lesion
may show on barium studies as destruction of the mucosal pattern, stricturing ( Fig. 48.18 ), a
postbulbar ulcer with associated deformity, or a duodenocolic fistula[4] [18] . Carcinoma of the
right kidney may invade the duodenum, although this is uncommon. The distal half of the first
part of the duodenum may be displaced, compressed, or infiltrated by carcinoma of the
gallbladder[19] . Carcinoma of the bile duct occasionally spreads to the duodenum and, rarely,
enlarged neoplastic retroperitoneal lymph glands may also invade the duodenum. CT is
particularly helpful for determining the origin and extent of malignant neoplasms that secondarily
invade the duodenum.
The duodenum may be the site of metastatic deposits from malignancies elsewhere including
carcinoma of the colon[4] , kidney[20] , uterus[21] , malignant melanoma[22] , and breast.
Duodenal stenting
Patients with inoperable primary or secondary carcinoma of the duodenum causing obstruction
can benefit from palliation of their symptoms by stenting of the stenotic segment. Self-expanding
1070
metal stents that conform to the duodenum effectively relieve the symptoms of obstruction[23]
[24] ( Fig. 48.15 ).
OTHER CONDITIONS
Pancreatitis
The duodenum can become involved in both acute and chronic pancreatitis. Evidence of
duodenal ileus may be seen on plain radiographs in acute pancreatitis. Mucosal oedema, seen
best at the junction of the first and second parts of the duodenum, enlargement of the duodenal
loop, and enlargement of the papilla of Vater are characteristic findings on barium studies. The
head of the pancreas is enlarged in chronic pancreatitis, with appearances similar to those seen
in carcinoma of the pancreas.
Crohn's disease
The duodenum is affected in about 4% of patients with Crohn's disease of the ileum, jejunum, or
colon[25] . Epigastric pain, vomiting and weight loss, and episodic diarrhoea are the presenting
symptoms. The radiological appearances of Crohn's disease in the duodenum are similar to those
in the more distal parts of the small intestine. The valvulae conniventes are frequently thickened.
At a more advanced stage of the disease there may be strictures (single, multiple, short or long),
with eccentric or concentric narrowing[25] . When multiple strictures are present the intervening
portions often show excessive distensibility. Cobblestoning, asymmetry, and skip lesions may be
seen but fissure ulcers, sinuses, and fistulas are uncommon in the duodenum. The disease may
cause tubular narrowing of the antrum and proximal duodenum in continuity ( Fig. 48.19 ),
resulting in the 'pseudo post-Billroth I' appearance[26] .
Tuberculosis
Tuberculosis of the duodenum is rare. Patients present with ulcer-like symptoms, or symptoms
suggestive of gastric outlet obstruction. Barium studies show narrowing of the lumen, sometimes
with destruction of the mucosa and ulceration, mostly involving the descending duodenum[27] .
Sinuses do occur but are rare. Tuberculous mesenteric lymphadenitis, in the absence of intrinsic
duodenal tuberculosis, may produce extrinsic pressure on the duodenum and cause
obstruction[28] .
Radiation damage
Damage to the duodenum from radiotherapy is very uncommon, probably because the
epigastrium is rarely treated with high-dose irradiation. When the paracaval and para-aortic
nodes are treated with doses in the range of 45-60 Gy (4500-6000 rad) there is an appreciable
incidence of radiation damage to the stomach and duodenum[29] . The radiological changes of
radiation damage are seen mostly in the second part of the duodenum as ulceration, thickening
of the mucosal folds, and stricture formation.
Progressive systemic sclerosis
In patients with neuromuscular disorders, particularly progressive systemic sclerosis and visceral
myopathy, the duodenum is frequently involved, resulting in dilatation which may be marked in
the second, third and fourth parts. The dilated duodenum may be slow to empty and the grossly
dilated atonic organ may give a sump effect[30] [31] .
Intramural haematoma
A preoperative radiological diagnosis of intramural haematoma of the duodenum is important
because it may allow treatment by conservative means and prevent unnecessary surgical
intervention[32] [33] . The most common cause of intramural haematoma is blunt abdominal
trauma; other causes include anticoagulant therapy and blood dyscrasias. There can be
considerable variation in patients' ages but duodenal haematomas occur mostly in children.
Patients usually present to hospital a few days after the initial onset of illness, their symptoms
having become worse
1071
owing to increased swelling as the clot absorbs serum over a few days[32] . Abdominal pain and
vomiting are the usual presenting features, with perhaps minimal upper abdominal distension.
Plain abdominal radiographs may show gaseous distension of the stomach and duodenum, and a
fluid level in the obstructed loop on a horizontal-ray radiograph. Intramural haematoma is usually
seen on barium studies as a concentric obstructive lesion in the duodenum ( Fig. 48.20 ). There
may be dilatation of the stomach proximal to the duodenum. Infiltration of blood and oedema
1072
may result in thickening of the valvulae conniventes, producing a 'coiled spring' appearance[34] .
CT shows the extent of the haematoma-seen as a large mixed attenuation mass, characteristic of
haematoma, surrounding the duodenum[35] ( Fig. 48.21 ).
Traumatic rupture
The duodenum is a relatively uncommon site of intestinal ruptures that result from blunt
abdominal trauma[36] . However, it is important to recognize traumatic rupture of the duodenum
because of the high mortality in patients treated inadequately[36] . A crushing injury to the
upper abdomen or back is a common cause and the most frequent site of rupture is at the
junction of the second and third parts of the duodenum. Traumatic lesions of the duodenum are
sometimes recognized during CT of the abdomen following road traffic injuries. These may be
due to direct trauma (from seatbelt, etc.) or deceleration alone.
Unlike intraperitoneal perforation the physical signs are frequently minimal or absent and it is
therefore important to obtain excellent radiographs[37] . The characteristic radiological
appearances on plain radiographs give a positive diagnosis in 33% of cases. They include
bubbles, streaks, or pockets of air outlining the right kidney or both kidneys, air outlining the
psoas muscle on one or both sides, retroperitoneal air in the infradiaphragmatic and pelvic
regions, mediastinal and cervical emphysema, subcutaneous emphysema in the right flank, and
intraperitoneal air, either encapsulated or free[36] . Nonspecific findings include scoliosis,
obliteration of the psoas margin, and segmental duodenal ileus[38] . A frequent surgical finding
is extensive emphysema in the transverse mesocolon; however, the air bubbles may be difficult
to distinguish radiologically from semiliquid faeces in the lumen of the transverse colon[38] .
When plain radiographs show no evidence of retroperitoneal air in suspected cases, the
duodenum should be examined with water-soluble contrast medium. All these signs are better
identified by CT.
Superior mesenteric artery compression syndrome
The superior mesenteric artery compression syndrome is an unusual form of high intestinal
obstruction thought to be caused by narrowing of the normal angle between the aorta and
superior mesenteric artery[39] . Most patients are asthenic and symptoms often develop
following weight loss, particularly when the patient is bedridden with a chronic wasting
disease[39] . During a symptomatic episode, barium meal examination shows strong to-and-fro
peristalsis and duodenal dilatation due to compression of the third part of the duodenum.
Superior mesenteric artery compression is seen as a sharp cut-off in the right anterior oblique
position, with the compression and proximal dilatation persisting in the prone position[40] . A
mild degree of to-and-fro peristalsis in very thin people can, however, be regarded as normal[40]
. Initial treatment is aimed at weight gain, and duodenojejunostomy is reserved for patients who
fail to respond to dietary treatment.
Compression from aortic aneurysm
Abdominal aortic aneurysms may compress the third part of the duodenum and they occasionally
cause obstruction[41] . The duodenum, when faintly opacified with oral contrast medium and
stretched around an aneurysm, can be misinterpreted as a contained leak or as a patch of
perianeurysmal inflammation.
Aortoduodenal fistula
The majority of fistulas between the aorta and the gastrointestinal tract develop during or
following the surgical repair of abdominal aneurysms, or in occlusive vascular disease[42] .
Aortoenteric fistulas most often involve the duodenum, particularly the third part. Patients
present with a characteristic combination of abdominal pain, gastrointestinal bleeding, and a
pulsatile mass. barium examination shows an extrinsic mass compressing the third part
1073
of the duodenum, a persisting barium collection, and in some cases extraluminal tracking of
barium[43] [44] . Lateral aortography may show the lesion to best advantage. CT during the
arterial phase of enhancement may also be diagnostic.
Bouveret's syndrome
On rare occasions a gallstone may become impacted in the duodenal cap, Bouveret's syndrome,
causing gastric outlet obstruction. The condition is named after Bouveret who, in 1896, reported
the first two cases[35] . Barium examination shows the calculus as a radiolucent mass filling the
entire duodenal cap with a thin coat of barium suspension between the periphery of the calculus
and the wall of the duodenum[35] [45] . The mortality is high and it is therefore important to
recognize this complication of gallstone disease.
Duodenal varices
Varices are encountered occasionally in the duodenal cap and loop. They occur mainly in patients
with extrahepatic portal hypertension[46] , but may occur in portal hypertension without
evidence of extrahepatic obstruction[47] .