IMAGING

SPECTRUM OF
DUODENAL
EMERGENCIES

Sri Nur Ramadhani

Departemen Radiologi Fakultas Kedokteran Universitas Hasanuddin
2023
INTRODUCTION
The duodenum is the first portion of the small bowel and
is anatomically divided into four segments. Duodenal
emergencies are discussed, from common to uncommon
entities, including peptic ulcer disease, inflammatory
and infectious conditions, oncologic and iatrogenic
processes, traumatic injuries, vascular and congenital
pathologic conditions, and their complication
 ANATOMY
DUODENUM
 4

The duodenum is divided into four segments and has two flexures, the superior and
inferior duodenal flexures
 5

Anatomic relationships of the duodenum at CT

6
 IMAGING APPROACH
7

Plain radiography can be useful in detecting pneumoperitoneum in

some cases of perforation, with images obtained in the upright
position being more sensitive for detection than those obtained in the
supine position. Plain radiographs can also be obtained to assess for
the presence of foreign bodies and stent position. Upper
gastrointestinal series and/or MRI can be used to confirm or further
evaluate duodenal pathologic conditions diagnosed at CT but are not
part of the imaging algorithm performed in the acute setting
INFLAMMATORY
AND INFECTIOUS
CONDITIONS OF
THE DUODENUM
Peptic ulcer disease is a common entity, affecting
about 5%–10% of the world population. It is
caused by an acid peptic injury of the
gastroduodenal mucosal barrier leading to a
defect in the mucosa, which can progressively
penetrate through the muscularis into the deeper
layers
 DUODENAL ULCER 10

The direct signs of duodenal ulcer at cross-sectional imaging are occasionally

visualized and include focal discontinuity of the mucosal hyperenhancement and
luminal outpouching
 HEMORRHAGIC DUODENAL ULCER 11

The most commonly used imaging modality to assess for an actively bleeding duodenal ulcer is three-
phase CT angiography. Nonenhanced CT images may reveal high-attenuating intraluminal material in
the duodenum, with Hounsfield units ranging between 30 and 45, and the highest-attenuation clot is
generally found near the bleeding site (sentinel clot). When dual-energy CT is performed, iodine maps
can be created to depict iodine content, which makes more evident the presence of the intraluminal
contrast blush
 12
PERFORATED DUODENAL ULCER

On CT images, a perforated duodenal ulcer is suspected when there is extraluminal intraperitoneal or

retroperitoneal gas, depending on which segment of the duodenum is involved. Additional findings
include focal duodenal wall thickening, surrounding fat stranding, and discontinuity of the duodenal
wall. When oral contrast material is administered, extraluminal extravasation of oral contrast material
may be seen
 13
DUODENAL ULCER +ABSCESS FORMATION

Plain radiography may detect perforation when free air is depicted under the diaphragm on upright
abdominal (or chest) radiographs. Complications of perforated posterior duodenal ulcers to the
retroperitoneum or adjacent organs such as the pancreas, gallbladder, common bile duct, and liver
include abscess formation and fistulization to the biliary tree
 14
INFLAMATORY CONDITIONS OF DUODENUM

H. pylori is the most common infectious cause of acute duodenitis. CT findings of acute infectious
duodenitis are nonspecific and include circumferential wall thickening, mucosal hyperenhancement,
and fat stranding
 15
BOUVERET SYNDROME

In some cases conventional CT images

might not depict the ectopic gallstone,
which can be indistinguishable from the
surrounding fluid in the bowel lumen.
Dual-energy CT has been shown to
demonstrate the impacted gallstone owing
to its ability to differentiate materials on
the basis of their differential energy-
dependent x-ray absorption behaviors.
Also, in the setting of unexplained
pneumobilia with or without an inflamed
gallbladder and in the absence of a
gallstone ileus, a close look at the bowel is
recommended to assess for a
cholecystoenteric fistula
 16
CROHN DISEASE

Primary involvement manifests as ulcers and strictures in the duodenum and secondary
involvement as a fistulous communication from an adjacent affected loop of small bowel or colon.
CT findings of duodenal Crohn disease include features such as duodenal wall thickening and fat
stranding. Duodenal stenosis or fistulas can be seen in some cases
CT FEATURES OF PEPTIC ULCER DISEASE
 IATROGENIC
COMPLICATIONS
 19

Iatrogenic complications involving the duodenum can occur after ERCP,

esophagogastroduodenoscopy (EGD), sphincterotomy, endoscopic polypectomy, and
stent placement and include hemorrhage, perforation, duodenal hematoma, obstruction,
and infection

Certain anatomic characteristics of the duodenum make endoscopic resection of lesions

challenging, including
(a) a narrow lumen;
(b) a C-loop shape that makes maintaining endoscope position difficult;
(c) a thin deep muscle layer that results in a higher rate of perforation;
(d) an extensive vascular network that increases the risk of bleeding, which can be
severe and potentially life threatening
 20

Postpolypectomy syndrome in a 42-year-old man who underwent biopsy of a

duodenal polyp on the previous day
DUODENAL
TRAUMA
 22

Duodenal trauma is rare, with a reported incidence of 0.5%–5% in

abdominal trauma, but is associated with high morbidity and mortality,
with mortality ranging from 6% to 29% The duodenum is relatively
protected from traumatic injury given its deep central and mostly
retroperitoneal location. Isolated duodenal injuries are rare and, given the
intimate relationship of the duodenum and pancreas, they are both
frequently injured concomitantly. Penetrating duodenal injury is the most
common cause of duodenal trauma.
 23

Duodenal contusion in a 63-year-old man following a motor vehicle collision

 24

(a, b) Duodenal perforation in a 58-year-old man following a deceleration injury. (c)

Duodenal transection in a 66-year-old man following a motor vehicle injury.
ONCOLOGIC AND
NEOPLASTIC
EMERGENCIES
 26

Oncologic duodenal emergencies can occur from primary duodenal masses

or from involvement by malignancies from adjacent organs. Twenty
percent of small bowel tumors arise in the duodenum (41). The most
common malignant tumor of the duodenum is adenocarcinoma, and the
most common benign tumor is gastrointestinal stromal tumor (GIST).
Other primary small bowel tumors include lymphoma and carcinoid.
Adenocarcinomas represent up to 80%–90% of all primary malignant
duodenal tumors
 27

Gastric outlet obstruction from a biopsy-proven duodenal adenocarcinoma in a 62-

year-old man.
 28

Duodenal metastatic disease in a 72-year-old woman with known lung cancer

 VASCULAR
ABNORMALITIES
OF THE DUODENUM
 30

Spontaneous intramural small bowel hematoma is associated with bleeding

disorders and the administration of anticoagulation therapy and usually
involves a longer segment of bowel compared to traumatic hematomas.
When dual-energy CT is performed, VNC images are helpful in confirming
the lack of enhancement, as well as the high attenuation of blood products
in the hyperacute phase. Three-phase CT angiography is the imaging
modality of choice for the diagnosis of ADF (aortoduodenal fistula)
 31

Duodenoduodenal intussusception in an 89-year-old woman

 32

Spontaneous duodenal hematoma in a 56-year-old man undergoing anticoagulant

therapy who experienced sudden onset of abdominal pain
 33

ADF in a 61-year-old woman after aortoiliac stent placement.

 34

Superior Mesenteric Artery (SMA) syndrome in a 37-year-old woman.

 35

Duodenal hemorrhage secondary to rupture of an inferior pancreaticoduodenal artery

aneurysm in a 65-year-old man
CONGENITAL
ANOMALIES
 37

Annular pancreas is an uncommon congenital migratory anomaly that

leads to a segment of the pancreas encircling the duodenum. The reported
prevalence varied between five and 15 per 100000 in adults in a cadaveric
case series to one in 250 in an ERCP study. The second segment of the
duodenum is affected in 85% of cases. The diagnosis is made when
pancreatic tissue and an annular duct are depicted encircling the
descending duodenum on CT or MR images
 38

Duodenal diverticulitis in a 45-yearold woman.

MISCELLANEOUS
CONDITIONS
 40

Duodenal diverticulosis is a common entity and has a prevalence of up to

23% and is the second most common location of diverticulosis after the
colon. Duodenal diverticula may be congenital or acquired (with the latter
being more common) and, like pulsion diverticula manifesting elsewhere
in the gastrointestinal tract, are formed by protrusion of the mucosa,
muscularis mucosa, or submucosa through a focal weakness in the
duodenal wall
 Bezoar in the duodenum 41

Foreign body ingestion occurs primarily in children and in adult patients with
psychiatric disorders. Abdominal radiography is useful in identifying the presence of a
radiopaque foreign body and its approximate location. CT can aid in the determination
of its precise location and identifying the presence of complications such as
duodenitis, obstruction, and perforation
 42

CONCLUSION
The anatomic location of the duodenum, with both
intraperitoneal and retroperitoneal segments, and its close
relationship with adjacent structures result in its involvement
by a multitude of pathologic entities. CT plays an important
role in the diagnosis of emergent duodenal processes and their
complications.
 43

CONCLUSION
Knowledge of the imaging findings of these entities and
which segments of the duodenum are more commonly
involved is important to make an accurate diagnosis and
prompt adequate treatment and management. The radiologist
should be aware that some findings are subtle and that
correlation with the clinical presentation and relevant patient
history
THANK YOU