Duodenal Ulcer

 Deformity of bulb (edema and spasm and scarring)


image Pseudodiverticula balloon-out between areas of fibrosis and spasm

image “Cloverleaf” deformity of bulb due to pseudodiverticula


• CT with IV and oral contrast medium for diagnosis of perforation
image Wall thickening, luminal narrowing of duodenum

image Extraluminal intra- or retroperitoneal gas ± enteric contrast medium




TOP DIFFERENTIAL DIAGNOSES




• Duodenal inflammation

• Duodenal stricture

• Duodenal carcinoma


CLINICAL ISSUES




• 2-3x more frequent than gastric ulcers

• Burning, gnawing, or aching pain at epigastrium 2-4 hours after meals, relieved by antacids/food

• Pain episodes occurring in clusters of days to weeks followed by longer pain-free intervals


DIAGNOSTIC CHECKLIST




• Barium upper GI series and CT are complementary in diagnosis of ulcers and complications

• Eradication of Helicobacter pylori   is 1st step of treatment
image Proton-pump inhibitors are also effective

• Effective medical treatment has made surgical treatment much less common

image
(Left) Graphic illustrates a duodenal ulcer with a deformed bulb due to converging folds and spasm.


image
(Right) Film from an upper GI series shows a “cloverleaf” deformation of the duodenal bulb, with the ulcer image at the center of the cloverleaf. The other lobes of the cloverleaf are the duodenal bulb fornices or recesses. The pylorus image is marked for orientation.

image
(Left) Axial CECT in a 42-year-old man presenting with acute severe abdominal pain and guarding shows extensive free intraperitoneal gas image from a perforated duodenal ulcer.


image
(Right) Axial CECT in the same patient demonstrates a thickened gastric wall image, probably due to gastritis. Ventral to the duodenal bulb and antrum are small collections of extraluminal gas and oral contrast medium image that confirm an ulcer as the source of perforation.


TERMINOLOGY


Synonyms




• Peptic ulcer disease


Definitions




• Mucosal erosion of duodenum


IMAGING


General Features




• Best diagnostic clue
image Sharply marginated barium collection with folds radiating to edge of ulcer crater on upper GI series

• Location
image 95%  of ulcers are in duodenal bulb, 5% postbulbar 
– Bulbar ulcers: Apex, central portion, or base of bulb

– Postbulbar ulcers: Medial wall of proximal descending duodenum above papilla of Vater

image 50% of duodenal ulcers located on anterior wall

• Size
image Most ulcers are < 1 cm at time of diagnosis

• Morphology
image Round or ovoid barium collections

image 5% of duodenal ulcers have linear configuration


Fluoroscopic Findings




• Fluoroscopic-guided double-contrast barium studies
image Bulbar ulcers
– Persistent, small, round, ovoid or linear ulcer niche

– Smooth, radiolucent ulcer mound of edematous mucosa

– Radiating folds converge centrally at edge of ulcer crater

– Ring shadow: Barium-coating rim of unfilled anterior wall ulcer crater (air-contrast view)

– Deformity of bulb (edema and spasm and scarring)

– Residual depression of central portion of scar mimics active ulcer crater

– Pseudodiverticula balloon out between areas of fibrosis and spasm

– “Cloverleaf” deformity of bulb due to pseudodiverticula

image Postbulbar ulcers
– Smooth, rounded indentation on wall opposite ulcer crater (edema and spasm)

– Ring stricture: Eccentric narrowing (scarring)

image Giant duodenal ulcers (> 2 cm)
– Always located in duodenal bulb

– Virtually replaces bulb, mistaken for scarred or normal bulb

– Key clue: Fixed or unchanging configuration

– Focal narrowing → outlet obstruction (edema and spasm)


CT Findings




• CECT (with water-soluble oral contrast)
image Signs of penetration and perforation
– Wall thickening, luminal narrowing of duodenum

– Infiltration of surrounding fat or organs (pancreas)

– Extraluminal intra- or retroperitoneal gas ± enteric contrast medium

– Presence of intra- and extraperitoneal gas in upper abdomen is essentially diagnostic of perforated duodenum


Imaging Recommendations




• Best imaging tool
image Fluoroscopic-guided double-contrast barium studies

image Low-density barium: Upright/prone compression views

image CT with IV and oral contrast medium for diagnosis of perforation

• Protocol advice
image Prone compression views at fluoroscopy to observe anterior wall ulcers

image “Positive” oral contrast medium helps confirm perforation on CT


DIFFERENTIAL DIAGNOSIS


Duodenal Inflammation




• Duodenitis: Inflammation without frank ulceration

• Crohn disease
image Usually gastric antral involvement

image Aphthous ulcers earliest abnormality observed

image Thickened, nodular folds, “cobblestone” appearance

image Asymmetric duodenal narrowing, outward duodenal wall ballooning between fibrotic areas

image Smooth, tapered areas of narrowing extend from apical portion of bulb to descending duodenum

image 1 or more strictures in 2nd or 3rd portions of duodenum → marked obstruction, proximal dilatation (megaduodenum)

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Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Duodenal Ulcer

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