Assessment of the Duodenum

The Duodenal biopsy

  • Adequacy- 4 biopsies to assess for coeliac disease
  • Presence of Brunners’ glands for definite confirmation of duodenum
  • Architecture – Villi, Crypt Hyperplasia, Villous: Crypt ratio (Normal 3:1 – 5:1)
  • Inflammatory infiltrate of the Lamina propria – Increased chronic inflammation, macrophages
  • Intraepithelial lymphocytosis (Normal not more than 20/100 epithelial cells)
  • Dysplasia or malignancy
  • Giardia

Specific Conditions

Coeliac disease – Villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis (>40/100), Serology for – IgA antiendomysial, anti-tissue transglutaminase. May develop enteropathy associated T-cell lymphoma. Assoc with dermatitis herpetiformis

Tropical Sprue – Post travel to tropical locations treated with antibiotics

Refractory Sprue – Refractory to gluten withdrawal

Crohn’s disease -Active chronic inflammation and granulomas

Whipples’s disease – Foamy macrophages in the lamina propria with DPAS positive granules – stain for Tropheryma whippeli.

Mycobacterium avium intracellulare – Foamy macrophages with ZN positivity in a patient with AIDS

Agammaglobinaemia/ Combined variable immunodeficiency – Absence of plasma cells in the lamina propria. Nodular lymphoid hyperplasia. May be assoc with co-morbid Giardia. Patient presents with diarrhoea and repeat infections. Usually bacterial.

Microsporidiosis – Intracellular parasites esp in the immunocompromised. Meronts &Sporonts.

Giardia – Kite shaped trophzoites with 2 symmetrical nuclei found along the luminal border

CMV – Discrete ulcers, with intranuclear and intracytoplasmic inclusions

NSAID induced enteropathy – Solitary ulcer of the small intestine. Non-specific ulceration & perforation. May be associated with increased apoptosis or mucosal eosinophilia.

Differential Diagnoses

Macrophages – Whipples, Mycobacterium, Leishmaniasis, other noninfective granulomatous disease eg: Crohn’s

IEL & Villous atrophy – Coeliac, Tropical Sprue, Refractory Sprue

Ulceration – Crohn’s, NSAID, H.Pylori duodenitis, Peptic Ulcer Disease, Behcet’s, ischaemia, vasculitis, malignant lymphoma, Zolligner Ellison syndrome

Tumours- Adenomas, Adenocarcinoma, Carcinoid, Gangliocytic Paraganglioma

References:

Gattuso at al. Differential Diagnosis in Surgical Pathology.

Rosai & Ackerman. Surgical Pathology.

Morson & Dawson’s. Gastro-intestinal Pathology.

Wilson et al. How many duodenal biopsy specimens are required to make a diagnosis of coeliac disease?. Gastointestinal endoscopy. Vol67. Issue 7. June 2008, 1082-1087.

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