Duodenum - Imaging Findings beyond endoscopy

Transcription

1 Duodenum - Imaging Findings beyond endoscopy Poster No.: C-1706 Congress: ECR 2012 Type: Educational Exhibit Authors: I. Ferreira, S. Magalhães, A. B. Ramos, M. Certo, J. Pires ; V.N. Famalicão/PT, Porto/PT Keywords: Neoplasia, Inflammation, Diagnostic procedure, CT, Conventional radiography, Abdomen DOI: /ecr2012/C-1706 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 28

2 Learning objectives Despite being the shortest part of the small intestine, duodenum can be involved by several and sometimes "life threatening" pathologies. In this poster we present a comprehensive review of duodenal pathologies with their imaging characteristics, at computed tomography (CT) and barium contrast studies. This exhibit intends to be a helpful tool for radiology residents. Page 2 of 28

3 Background Upper endoscopic examinations are usually performed until the second duodenal portion. Barium contrast and abdominal CT studies can be important techniques when endoscopic studies are normal, by showing extra-luminal pathology and abnormal findings in the third and fourth duodenal segments. Barium contrast studies are also important for the diagnosis of neurogenic disturbs. Page 3 of 28

4 Imaging findings OR Procedure details 1 - Congenital anomalies Congenital duodenal anomalies are relatively rare. They can be divided in two groups: anomalies causing intestinal obstruction, always presented in neonates, and those with incomplete or without obstruction, which can present later in life. The first ones need surgical correction, while the diseases in the second group can sometimes be managed with clinical treatment or even without treatment. Association with other abnormalities such as vertebral malformation (Figure 1), cardiovascular and renal anomalies should be investigated. Intra-luminal diverticula are described below. 2 - Inflamatory disease A - Peptic disease Patients with dyspeptic symptoms usually perform an endoscopic study, relegating barium contrast examinations to a second plan. Nevertheless, contrast studies can be quite useful in delineating the extent of peptic disease when there is a stricture that enables the endoscope to pass, and for surgical planning Fig. 2 on page 9. Perforated duodenal ulcers are not infrequently found in the emergency room. CT scan is usually performed for diagnosis and can show duodenal wall thickening, periduodenal fluid, retroperitoneal air or free intraperitoneal air [1]. Fig. 3 on page 10 B - Crohn's Disease The frequency of duodenal involvement by Crohn disease varies widely in the literature, most commonly ranging from 0,5% to 4%. Barium contrast studies of the duodenum can define the extent of the disease and its complications such as strictures. Page 4 of 28

5 Primary involvement tends to be expressed as ulcer or stricture formation, while secondary involvement typically occurs as a fistulous communication from an adjacent affected loop of small bowel or colon [2]. Fig. 4 on page Diverticula There are two types of duodenal diverticula: extraluminal and intraluminal. Extraluminal diverticula are frequent (2% to 5%) and are usually acquired. They rarely have any clinical relevance, even though there are some reports of complications such as gastrointestinal bleeding. In some cases, diverticula can simulate cystic lesions of the pancreatic head or other clinical features such as those presented in Fig. 5 on page 12. Diverticula are more frequent on the 2 portion. nd duodenal portion, followed by the 3 rd and 4 th Intraluminal diverticula are very rare and result from failure of normal recanalization of the duodenum after epithelial cell occlusion of the foregut lumen in the 7-week human nd embryo [3]. Most frequently, they arise from the 2 duodenal portion. They can present late in life, more often on the 30's, and the symptoms include vomiting, epigastric pain and abdominal fullness [4] Fig. 6 on page Neoplasm 4. A - Non-malignant / Pre-malignant: Polyps and Lipomas Retrospective studies have reported duodenal polyps in up to 1,5% of patients referred to upper endoscopy [5]. They can be sporadic or associated to familial adenomatous polyposis and Peutz-Jeghers syndromes. In the majority of cases, polyps are incidental findings in CT and barium studies Fig. 7 on page 14 performed for other causes. If they are bigger than 2 cm endoscopic removal is not always feasible and then CT or barium studies can help evaluating its extension for proper surgical plan Fig. 8 on page 15. Page 5 of 28

6 Lipomas are relatively rare and usually asymptomatic Fig. 9 on page 16. Less than 20 cases submitted to specific treatment are reported in the literature (all of them symptomatic). 4. B - Malignant: Tumours of the small bowel are much less frequent than colon or gastric neoplasms. The symptoms are usually nonspecific, most of the times consisting of abdominal discomfort/ pain and nausea or vomiting. Although all histologic types can arise in duodenum, the most frequent is adenocarcinoma [6]. Adenocarcinoma Adenocarcinoma is the most frequent malignant tumour of the duodenum, usually found in older people, with the incidence peak around the 70ths. As other bowel tumours, it can present with melena or other form of gastrointestinal bleeding, abdominal pain, jaundice or obstruction Fig. 10 on page 16. The diagnosis is frequently made in patients with an advanced tumour stage. Lymphoma Lymphoma is more frequent in the ileum followed by the jejunum and duodenum according to the distribution of lymphoid tissue. The histologic pattern is also different: T type in the proximal small bowel and B type in the distal small bowel. Imaging findings are quite variable Fig. 11 on page 17. However, aneurysmal dilatation secondary to internal ulceration in an annular lesion is the classic appearance [7]. Sarcoma Sarcoma accounts for only 10% of small bowel neoplasms, and is more frequent in the jejunum and ileum. There are no specific imaging features. Tumour growth is usually extraluminal. Fig. 12 on page 18 Page 6 of 28

7 5- Vascular Superior Mesenteric Artery Syndrome There is some controversy around this syndrome, because the relationship between anatomic findings and symptoms is not well established. At the origin of the superior mesenteric artery, there are some pouches of fat, increasing the angle and the distance to the aorta artery. This angle normally ranges between 45 and 60º [8]. The aorto-mesenteric distance is normally between 10 to 28 mm [9]. The decrease of these fat pads shortens the aorto-mesenteric distance and the angle, causing rd compression of the 3 duodenal portion (and left renal vein) between the aorta and the superior mesenteric artery Fig. 13 on page 19. This syndrome is more frequent in thin people with anorexia or bulimia. There is also a well established relationship with patients submitted to orthopaedic surgery for scoliosis correction and this syndrome. The main symptoms at presentation are nausea, vomiting and abdominal pain. 6- Iatrogenic Duodenal rupture due to double balloon enteroscopy This new scope, first reported in 2001 [10], allows theoretically the visualisation of the entire small bowel, overcoming the limitations of conventional endoscopy. This procedure has an overall rate of complications that range from 1,2% to 1,9% [11], encompassing bleeding, perforation and pancreatitis among others. Perforation is the most serious complication, with an incidence of 0,4% [12]. Fig. 14 on page 20 Duodenal bulb stenosis due to atypical biliodigestive anastomosis Biliodigestive anastomosis is a difficult surgical procedure depending on the patient pathology, surgery findings, and surgeon skills. Although leaks and anastomosis dehiscence are the most frequent complications, others such as duodenal bulb stenosis can occur Fig. 15 on page Miscellaneous Page 7 of 28

8 Familial amyloid polyneuropathy This rare disease, also known as Corino de Andrade's disease, remains endemic in some regions of Portugal. The main clinical characteristics of this disease are paraesthesia, muscular weakness and autonomic dysfunction. The gastrointestinal involvement is usually late, after muscular disability, and can course with dismotility Fig. 16 on page 22. Extrinsic compression The incidence of abdominal aorta aneurysm (AAA) is higher in people older than 60 years old, particularly in men. Food intolerance or vomiting after AAA surgery is not always related to motility disorders Fig. 17 on page 22. Fistula from pancreatic pseudocyst Pancreatic pseudocyst is a well-known complication of pancreatitis. The diagnosis is usually made with ultrasound or CT and a proper clinical history. Pseudocyst drainage can be done surgically, percutaneously or endoscopically. Percutaneous CT or ultrasound guided drainage can also help to determine if a fistula for adjacent organs is present Fig. 18 on page 23 when contrast is injected through the drain. Page 8 of 28

9 Images for this section: Fig. 1 Page 9 of 28

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25 Conclusion The absence of abnormal findings in upper endoscopy does not warrant that the duodenum is not ill. Barium studies have the advantage to allow a dynamic study. Even though patient complaints may frequently point out to some other directions, clinicians always need to look to the duodenum. Page 25 of 28

26 Personal Information Page 26 of 28

27 References [1] Ongolo-Zogo P, Borson O, Garcia P, Gruner L, Valette PJ. Acute gastroduodenal peptic ulcer perforation: contrast-enhanced and thin-section spiral CT findings in 10 patients. Abdom Imaging 1999; 24: [2] Poggioli G, Stocchi L, Laureti S, et al. Duodenal involvement of Crohn's disease: three different clinicopathologic patterns. Dis Colon Rectum 1997; 40: [3] Afridi SA, Fichtenbaum CJ, Taubin H. Review of duodenal diverticula. Am J Gastroenterol 1991; 86: [4] Nance FC. Intraluminal duodenal diverticula. Surg Gynecol Obstet 1967; 124: [5] Firas H. Al-Kawas. Gastroenterol Hepatol (N Y) May; 7(5): [6] Bilimoria KY, Bentrem DJ, Wayne JD, et al. Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years. Ann Surg 2009; 249:63. [7] Lee, 4ª edição [8] Gustafsson L, Falk A, Lukest PJ, Gamklou R. Diagnosis and treatmente of superior mesenteric artery syndrome. BR J Surg 1984:71: [9] Sapkas G, O'Brien JP. Vascular compression of the duodenum (cast syndrome) associated with the treatment of spinal deformities. A report of six cases. Arch Orthop Trauma Surg 1981; 98:7. [10] Yamamoto H, Sekine Y, Sato Y, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001; 53:216. [11] Möschler O, May A, Müller MK, et al. Complications in and performance of doubleballoon enteroscopy (DBE): results from a large prospective DBE database in Germany. Endoscopy 2011; 43:484. Page 27 of 28

28 [12] Gerson LB, Tokar J, Chiorean M, et al. Complications associated with double balloon enteroscopy at nine US centers. Clin Gastroenterol Hepatol 2009; 7:1177. Page 28 of 28