Keywords

17.1 Duodenal Diverticulum

Duodenal diverticulum is a pouch of the duodenal wall. Extramural diverticulum, which is very similar to colonic diverticulum, is quite common up to 5% of the population and usually is located near the ampulla of Vater (Figs. 17.1 and 17.2) [1,2,3]. Extramural diverticulum may be single or multiple. Great majority of duodenal diverticula are asymptomatic. Some patients may experience nonspecific abdominal discomfort, which can be worse or brought on by eating and relieved by vomiting, belching, or assuming certain posture. Complications, such as jaundice, cholangitis, acute pancreatitis, ulceration (Fig. 17.3), bleeding (Fig. 17.4), and perforation, can be caused by obstruction or inflammation. Foreign body can be impacted in the diverticular sac causing nonspecific symptoms (Fig. 17.5). Second type of duodenal diverticulum is intramural diverticulum. It protrudes into the duodenal lumen so it looks like a mass with communicating hole.

Fig. 17.1
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Duodenal diverticulum. Extramural diverticulum usually is located near the ampulla of Vater

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Fig. 17.2
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Duodenal diverticulum. Occasionally, it is located at the anti-mesenteric border and is asymptomatic

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Fig. 17.3
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Ulceration of duodenal diverticulum. Ulceration within the diverticulum can be caused by obstruction or inflammation

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Fig. 17.4
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Bleeding from duodenal diverticulum. There is a significant upper gastrointestinal bleeding from duodenal diverticulum

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Fig. 17.5
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Foreign body of duodenal diverticulum. Foreign body can be impacted in the diverticular sac

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17.2 Angiodysplasia

Duodenal angiodysplasia is a collection of small arteries that have come to the surface (Fig. 17.6). It may cause recurrent and low-grade bleeding, although massive hemorrhage is also possible [4]. However, in most cases, angiodysplasia is found incidentally. In endoscopy, angiodysplasia is a 5–10 mm, cherry red, arborizing, ectatic vessel, sometimes radiating from a central vessel. It may have a surrounding halo. There are many treatment modalities for bleeding angiodysplasias. Ablation treatment using argon plasma coagulation apparatus is simple and effective (Fig. 17.7).

Fig. 17.6
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Duodenal angiodysplasia. The vessels are ectatic and thin. Usually, it has a surrouding halo

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Fig. 17.7
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Coagulation therapy of bleeding duodenal angiodysplasias. Ablation treatment using argon plasma coagulation is simple and effective in bleeding angiodysplasias. (left) Aberrant blood vessels were frequently found in the duodenal mucosa, (right) Argon plasma coagulation applied on the prominent angiodysplasia suspected to cause bleeding

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17.3 Duodenal Varix

Duodenal varix can develop in patients with portal hypertension and rarely cause bleeding. It is unlikely that most of duodenal varices are prominent as esophageal varices. Sometimes they cause a potentially serious consequence of portal hypertension and may result in massive bleeding (Fig. 17.8).

Fig. 17.8
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Bleeding duodenal varix. (a) Endoscopy revealed markedly tortuous varices with pumping in the second portion of duodenum. (b) Duodenal variceal bleeding secondary to liver cirrhosis was successfully treated with using hemoclips

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17.4 Henoch-Schonlein Purpura

Henoch-Schonlein purpura is a vasculitis syndrome. It most commonly affects children. The classic triad of symptoms are a palpable purpura, abdominal pain, and hematuria that typically begins after an upper respiratory infection. Gastrointestinal symptoms include abdominal pain, vomiting, diarrhea, intestinal obstruction, and intussusception. In endoscopy, the bowel wall may be edematous, and there are multiple variable-sized erosive/ulcerative lesions with normal intervening mucosa (Fig. 17.9).

Fig. 17.9
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The gastrointestinal manifestation in Henoch-Schonlein purpura. There are multiple variable-sized erosive/ulcerative lesions with normal intervening mucosa

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17.5 Ascaris lumbricoides

Duodenal parasites are uncommon. Ascaris lumbricoides can be found in the bile duct or in the duodenal lumen. It is a 20–30 cm, grey to white, long, tubular worm, which can move very quickly. The endoscopist can remove the living worm with a biopsy force (Figs. 17.10 and 17.11).

Fig. 17.10
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Duodenal parasites (Ascaris lumbricoides). Ascaris lumbricoides can be found in the duodenal lumen

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Fig. 17.11
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Duodenal Ascaris lumbricoides. It is a 20–30 cm, grey to white, long, tubular worm

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17.6 Marginal Ulcer

The frequency of performing gastrectomy has increased due to the frequent detection of early gastric cancer and increasing morbid obesity [5, 6]. In previous study, the incidence of marginal ulcer after partial gastrectomy was 8.6%, and a significant number of patients (27.1%) had gastrectomy to treat peptic ulcer disease-associated complications. Half of these individuals experienced severe clinical conditions such as massive bleeding episodes or severe anemia (Figs. 17.12 and 17.13) [7].

Fig. 17.12
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Marginal ulcer. Ulceration at the gastrojejunal anastomosis is found in a patient with gastrectomy and Billroth I anastomosis

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Fig. 17.13
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Marginal ulcer. It develops at the margin of a gastrojejunostomy, primarily on the jejunal side. Most marginal ulcers respond to medical therapy, but sometimes complicated cases could happen

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