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Involvement of the gastrointestinal (GI) tract is an infrequent extrathoracic presentation of sarcoidosis. We reviewed 305 cases of GI involvement reported in 238 patients, in whom GI sarcoidosis was the first sign of the disease in half the cases. The disease does not affect the GI tract uniformly, with a clear oral-anal gradient (80% of reported cases involved the esophagus, stomach, and duodenum). Clinicopathological mechanisms of damage may include diffuse mucosal infiltration, endoluminal exophytic lesions, involvement of the myenteric plexus, and extrinsic compressions. Ten percent of patients presented with asymptomatic or subclinical disease found on endoscopy. The diagnosis is relevant clinically because 22% of cases reviewed presented as life threatening. In addition, initial clinical/endoscopic findings may be highly suggestive of GI cancer. The therapeutic approach is heterogeneous and included wait-and-see or symptomatic approaches, glucocorticoid/immunosuppressive therapy, and surgery. Sarcoidosis of the gut is a heterogeneous, potentially life-threatening condition that requires a multidisciplinary approach and early clinical suspicion to institute personalized therapeutic management and follow-up.

A 57-year-old female was referred to our department for treatment of a duodenal submucosal tumor (SMT), which had been growing over the last five years. Computed tomography demonstrated a marginally enhanced mass, measuring 36 mm in diameter, containing internal multiple hypovascular areas. Endoscopic ultrasonography-guided fine needle biopsy was performed using a 20-gauge core trap needle, and the specimens showed benign Brunner's glands. She underwent laparoscopic endoscopic cooperative surgery and the SMT was completely removed without any adverse events. Histology of the resected tumor showed Brunner's gland hyperplasia (BGH). BGH is generally a benign lesion. However, an accurate diagnosis is required to avoid overtreatment when it mimics malignancy.

Duodenal perforation is a rare and severe acute surgical condition which commonly follows the complications of endoscopic and laparoscopic procedures. Small degree of damage in this mechanism and an early diagnosis allow for an effective primary management. The most difficult surgical challenge is an effective management of retroperitoneal duodenal perforation together with coexisting pathological changes of its wall. In this work we present a case of duodenal necrosis with excessive necrosis of a fragment of its wall due to perinephric abscess, with an effective method of management of a defect in an isolated free small intestinal loop in association with gastroduodenal passage exclusion.

Background and Study Aims: Functional dyspepsia is an exclusion diagnosis requiring different tests, including endoscopy, often repeated over time. Duodenal biopsies are frequently resorted to, not rarely revealing duodenal microscopic inflammation. Aim of the study is to confirm a previously supposed role of antro-duodenal low-grade inflammation in functional dyspepsia, evaluating the frequency of duodenal lymphocytosis, H. pylori infection and their association in a group of patients with functional dyspepsia compared to asymptomatic control subjects., Patients and Methods: A cross-sectional, observational study has been conducted screening all the patients who underwent duodenal biopsies during upper endoscopy, in a 30 months period. All the patients without endoscopic lesions were analysed. The study group consisted of patients compatible with the diagnosis of functional dyspepsia (Rome III criteria). The control group consisted of healthy asymptomatic subjects in the population subjected to endoscopy. The presence of duodenal lymphocytosis and of H. pylori infection in the two groups was evaluated., Results: 216 patients were enrolled: 161 in the functional dyspepsia group and 55 as asymptomatic control group. The frequency of duodenal lymphocytosis was similar between cases and control groups (25.47% vs 25.45%; p = 0.99), as well as H. pylori infection (26.71% vs 23.64%; p = 0.78). Duodenal lymphocytosis was significantly associated with functional dyspepsia only in H. pylori positive dyspeptic patients (p = 0.047). 94% of the subjects with both lymphocytosis and H. pylori infection suffer from dyspepsia. Duodenal intraepithelial lymphocytosis is significantly associated with bloating (p = 0.0082)., Conclusions: In our cohort of dyspeptic patients, duodenal lymphocytosis is significantly associated with bloating and the simultaneous presence of duodenal lymphocytosis and H. pylori infection is significantly more prevalent than in control subjects., (Copyright © 2019 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.)

A biliary fistula which may occur spontaneously or after surgery, is an abnormal communication from the biliary system to an organ, cavity or free surface. Spontaneous biliary-enteric fistula is a rare complication of gallbladder pathology, with over 90% of them secondary to cholelithiasis. Approximately 6% are due to perforating peptic ulcers. Symptoms of biliary-enteric fistula varies widely and usually non-specific, mimicking any chronic biliary disease. Cholecystoduodenal fistula causing severe upper gastrointestinal (UGI) bleed is very rare. Bleeding cholecystoduodenal fistula commonly requires surgical resection of the fistula and repair of the duodenal perforation. We describe the case of a previously healthy older patient who initially presented with symptoms suggestive of UGI bleeding. Bleeding could not be controlled endoscopically. When a laparotomy was performed, a cholecystoduodenal fistula was discovered and bleeding was noted to originate from the superficial branch of cystic artery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The proliferative lesions of the Brunner's glands (BGs) are hyperplasia and hamartomas, and they are usually asymptomatic and very rarely diagnosed. The aetiology of these lesions is not yet clear. The aim of this study is to evaluate the clinical presentations of patients with BG hyperplasia and hamartomas and to assess the pathological features of these lesions in association with Helicobacter pylori ( H. pylori )., Methods: Our retrospective study included patients who underwent upper gastrointestinal system endoscopy between 2010 and 2015. The hospital records of 18 patients diagnosed with hyperplasia or hamartoma of BG were reviewed for the clinical and pathological findings. Data from patients with BG lesion were compared with 37 patients who had nonspecific duodenitis as the control group., Results: Female/male ratio in our study sample was 1/1. The age range was between 16 and 85 years with a mean age of 48.61. BG hyperplasia and hamartomas were found in 72.22 and 27.78% of the patients, respectively. The rate of H. pylori in gastric mucosa was 43.2% in the control group and 66.7% in the BG lesion group. In the BG lesion group, the rate of H . pylori was higher. H. pylori was identified in 60% of BG hamartomas and in 69.2% of hyperplastic BGs., Conclusion: Our study demonstrated that H. pylori may play an important role in the development of BG hyperplasia and hamartomas in association with chronic gastritis and duodenitis. This is probably due to chronic irritation.

Background: Seronegative celiac disease (CD) poses a diagnostic challenge. Aims: Characterize and identify differences between seronegative and seropositive CD. Patients and methods: Retrospective cohort study examining adult patients diagnosed with CD (1980-2017). Clinical, analytical, histological, genetic and immunophenotypic data were compiled. Seronegative CD was defined as a anti-tissue transglutaminase type 2 IgA and endomysial antibodies (EMA) negative and HLA-DQ2 and/or DQ8 positive, showing clinical signs of CD plus an abnormal duodenal biopsy, and responding to a gluten-free diet (GFD). Factors associated with seronegative CD were identified through binomial logistic regression. Results: Of 315 CD patients, 289 were seropositive (91.7%) and 26 seronegative (8.3%). Among the seronegative patients, higher prevalence was observed for autoimmune thyroiditis (26.9% vs. 9.7%, p  = .016), HLA-DQ8 heterozygosity (23.1% vs. 2.5%, p  ˂ .001) and Marsh I lesion (34.6% vs. 3.7%, p  ˂ .001). The two groups showed similar flow cytometry-determined duodenal immunophenotypes and rates of refractory CD. Conclusions: Seronegative CD differs mostly in genetic (more HLA-DQ8) and histologic (milder atrophy) features as compared with seropositive. Intestinal intraepithelial immunophenotype by flow cytometry, similar in both modalities, is a useful tool to diagnose seronegative CD.

Background: Methotrexate-associated lymphoproliferative disorder (MTX-LPD) can present as a benign lymphoid proliferation or a malignant lymphoma in patients taking MTX. Almost 50% of MTX-LPD cases show spontaneous remission after withdrawal of MTX treatment. Studies have suggested that the hyper-immune state of rheumatoid arthritis, the immunosuppressive state associated with MTX, and the carcinogenicity of the Epstein-Barr virus might contribute to MTX-LPD development. Although most cases of MTX-LPD occur at extranodal sites, few cases of MTX-LPD affecting the stomach and duodenum have been reported. To our knowledge, no other study has reported on the endoscopic observations of dramatic withdrawal and appearance of multiple digestive tract lesions in a short period of time. Herein, we report the clinical course and imaging findings of our case, which may be useful for understanding the pathological condition of MTX-LPD., Case Presentation: We describe the case of a 70-year-old woman with MTX-LPD of the stomach and duodenum. Disease regression was temporarily achieved after cessation of MTX treatment; however, it subsequently recurred, and complete response was only achieved after six cycles of rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisolone (R-CHOP) chemotherapy., Conclusions: The first-choice therapy for patients taking MTX who develop suspected MTX-LPD should be the withdrawal of MTX treatment. Even after remission is achieved, patients should be kept under careful observation, and if the disease recurs, chemotherapy should be commenced promptly.

We describe the case of an 82-year-old Caucasian woman who presented to our institution as a transfer from an outside hospital with nausea, vomiting and abdominal pain with CT imaging concerning for a duodenal mass or abscess in the juxtapapillary region of the second part of the duodenum. Upper endoscopy showed a non-bleeding duodenal diverticulum with purulent discharge consistent with diverticulitis. She underwent endoscopic disimpaction with irrigation and received a 14 day course of antibiotics, after which she presented for follow-up 1 month after discharge without complications. This case highlights the rarity of juxtapapillary duodenal diverticulitis, its nonspecific clinical presentation and imaging findings and the importance of early diagnosis and management to prevent severe complications including perforation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Intramural small bowel haematoma is a rare cause of intestinal obstruction in children. Coagulation disorders or anticoagulant therapy are the most common cause followed by blunt trauma. A one and half-year-old boy, with known case of gastro-oesophageal reflux disease had undergone upper gastrointestinal endoscopy and biopsy. Four days later, he presented to us with clinical features of small bowel obstruction. CT of the abdomen showed features suggestive of haemorrhagic duplication cyst. Explorative laparotomy revealed 15-20 cm of bowel from the third part of the duodenum to proximal jejunum filled with clotted blood and thinned out serosa. There was no evidence of intraluminal blood in the distal bowel loops. Resection of the involved bowel with primary anastomoses was done. Histopathological examination of bowel revealed intramural haematoma associated with prolapse of the mucosa. There was no evidence of duplication cyst or vascular malformations. Postoperative period was uneventful., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

It has recently been shown that duodenal foveolar gastric metaplasia (FGM) sometimes presents as a polyp. The mechanism by which FGM develops into a polypoid lesion is unknown and it is unclear whether this form of FGM is indistinguishable from other polypoid lesions or whether endoscopists do not recognize it because they are unfamiliar with it. We identified and retrieved archival cases of FGM endoscopically suspicious for adenomatous polyp and examined their pathological, clinical and endoscopic features. Endoscopic features of the 13 identified FGMs presenting as polyps were heterogeneous and overlapping with those of adenomatous polyps. FGM was frequently associated with mucosal and submucosal Brunner's glands, but defining and recognizing hyperplasia of these glands remains difficult. Other pathological features could not explain the development of a polypoid lesion. The endoscopic features of FGM polyps are non-specific, overlapping with those of adenomatous polyps. FGM polyps probably acquire their polypoid aspect due to association with Brunner's gland hyperplasia (BGH), which also arises due to chronic inflammation and damage. Because BGH is ill-defined and difficult to recognize, while FGM is diagnosed easily, this type of polypoid lesions has until now only been recognized based on the presence of FGM, although FGM is most likely a secondary phenomenon and not the primary cause of the polyp., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

Background: Rumination syndrome is a functional gastrointestinal disorder characterized by effortless, postprandial regurgitation. Duodenal eosinophilia has been described in patients with functional dyspepsia. Because of the significant symptomatic overlap between functional dyspepsia and rumination syndrome, we hypothesized that histological changes might exist among patients with rumination syndrome., Methods: We included patients with rumination syndrome in whom we had obtained duodenal biopsies and compared these with controls. Digital images of biopsy specimens were analyzed for routine pathology and eosinophil counts by a pathologist blinded to the case-control status., Results: The 22 patients with rumination syndrome had a mean age of 39.2 years (range 21-71) and 77% were female. The 10 controls had a mean age of 34.3 (range 27-69) and 80% were female. There was a significant increase in the mean eosinophil count among the patients with rumination syndrome compared to controls, 26 per mm 2 (range 16-42) versus 18 per mm 2 (range 10-28), p = 0.006. Intraepithelial lymphocyte counts were significantly higher in rumination patients (mean 15/100 enterocytes, range 8-29) versus controls (mean 11/100 enterocytes, range 11-18), p = 0.02., Conclusion: Patients with rumination syndrome have subtle duodenal pathology with eosinophilia and increased intraepithelial lymphocyte counts compared to controls.

A 30-year-old woman presented with severe abdominal pain and abdominal distension. CT demonstrated two intra-abdominal masses, one involving the left lateral segment of the liver and the other adjacent to the duodenum. Initial biopsies were consistent with focal nodular hyperplasia of the liver and non-specific lymphocytic infiltrate in the paraduodenal mass. Due to persistent symptoms, the patient underwent laparoscopic resection of the paraduodenal mass. Final pathology was consistent with an inflammatory pseudotumour and the patient's symptoms subsequently resolved., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To demonstrate the prevalence, accompanying pathologies, imaging and follow up findings of Duodenal Diverticula (DD) with Multidetector Computed Tomography (MDCT)., Materials and Methods: Consecutive 2910 abdominal MDCTs were retrospectively reviewed on axial, coronal and sagittal planes. DD were evaluated for prevalence, location, number, size, contents, diverticular neck, accompanying pancreaticobiliary pathologies, jejunal and colonic diverticula, respectively., Results: DD were diagnosed in 157 cases (5.4%) and found mostly in the second part of the duodenum. Juxta-ampullary DD was the most common type (78.3%) and mostly located ventral (n:86, 69.9%) to the ampulla of Vater. DD was solitary in 123 patients (78.3%) and more than one in 34 patients (21.7%). The median diameter of DD was 2.5 cm (range 1.5-3.6 cm) in the long-axis. The lumen of DD contains air and contrast agent (n:96, 61.1%); air, contrast agent and debris (n:42, 26.7%) in most cases. Colonic diverticula (n:36, 22.9%), cholelithiasis (n:32, 20.4%), choledocholithiasis (n:7, 4.4%), and biliary dilatation (n:8, 5.1%) were the most common additional findings. Median follow-up time was 23 months (range 11 to 41 months). In three cases, new findings (cholelithiasis, n:3, choledocholithiasis, n:1) were detected., Conclusion: Accompanying pathologies with DD diagnosis are valuable for physicians in order to manage the patients. Following clinical and radiological features of well-diagnosed DD might reduce the possible complications., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Introduction: Functional dyspepsia (FD) is a complex symptom. Currently there are multiple therapeutic options that are used for the management of these patients; however, FD therapies are based on symptomatic control and do not address the pathophysiological pathways involved in its development. The duodenum has been proposed as a key site to understand the complex pathophysiology involved in FD., Objective: The aim of the study is to determine duodenal eosinophilia in patients with FD and establish the clinical-pathological correlation with the cardinal symptoms of dyspepsia., Material and Methods: Case-control study. Patients older than 18 years with dyspepsia according to the Rome IV criteria, and upper gastrointestinal endoscopy normal (FD group).Patients with iron deficiency anemia and chronic diarrhea (control group). Biopsies were taken in the stomach, duodenal bulb and second portion of duodenum. A sample size of 140 patients (70 patients in the FD group and 70 patients in the control group) was calculated. The collected information was described and analyzed by conventional statistical techniques., Results: 243 patients were recruited. 84 patients were included in the FD group and 84 patients in the control group. 135 patients were women (80.3%). The mean age was 53.6 years (SD 14.9). Duodenal eosinophilia was found with significant difference in patients with early satiety (p=0.01). There was no difference in patients with postprandial fullness (p=0.63), epigastric pain or burning (p=0.26), gastroesophageal reflux symptoms (p=0.13), allergy and food intolerance (p=0.42) and smoking (p=0.28). There was no relationship between duodenal mastocytosis and early satiety (p=0.98), postprandial fullness (p=0.78), and epigastric pain or burning (p=0.82)., Conclusions: Duodenal eosinophilia was similar in FD and controls. In subgroup analysis, duodenal eosinophilia occurs in patients with early satiety.

Competing Interests: Competing interests: None declared.

Internal hernias are defined as the protrusion of abdominal viscera through an aperture in the intraperitoneal recesses, they are considered as a rare cause of intestinal obstruction. The paraduodenal hernias are the most common type of congenital hernia especially the left-sided ones. We report a case of a 46 year-old man presenting a left paraduodenal hernia with acute small bowel obstruction, which was firstly (preoperatively) assigned to a tumoral cause., Competing Interests: The authors declare no conflict of interests.

We describe a patient with a giant Brunner's gland hamartoma in the duodenum who was safely treated by endoscopic mucosal resection (EMR). A 64-year-old woman visited our hospital for a workup of severe anaemia (haemoglobin level: 5 g/dL). Oesophagogastroduodenoscopy revealed a large pedunculated and elongated polypoid lesion measuring approximately 70 mm in longitudinal diameter, located at the anterior wall of the duodenal bulb. We diagnosed her as having gastrointestinal bleeding originating from this lesion. Although we considered surgical intervention initially, en bloc EMR, a less invasive treatment, was finally accomplished safely by placing endoclips before resection. The histological examination of the specimen revealed a hamartomatous lesion consisting of Brunner's glands with cystic change and adipose tissue separated by the septa of smooth muscle fibers. Ultimately, we diagnosed her as having Brunner's gland hamartoma. Notably, there were tiny foci of heterotopic pancreatic tissue containing islets and duct epithelium. Although this type of lesion is benign, a larger one may cause clinical symptoms such as obstruction or bleeding, and thus, local resection is preferable., (Copyright © 2018 Pan-Arab Association of Gastroenterology. Published by Elsevier B.V. All rights reserved.)

Background: Portal hypertension is a serious complication of liver cirrhosis., Objective: To identify relevant endoscopic findings in patients with advanced cirrhosis and consecutive portal hypertension., Methods: This was a retrospective study of liver transplant candidates who underwent upper gastrointestinal endoscopy between April 2011 and November 2015., Results: A total of 1,045 upper endoscopies were analyzed. Portal hypertensive gastric and duodenal polyps were frequently observed and were associated with thrombocytopenia (p = 0.040; OR: 2.4, 95% CI 1.04-5.50), Child-Pugh score > 6 (p = 0.033; OR: 2.3, 95% CI 1.07-4.92), Model for End Stage Liver Disease score > 16 (p = 0.030; OR: 4.1, 95% CI 1.14-15.00), and previous rubber band ligation (p < 0.001; OR = 5.2, 95% CI 2.5-10.7). These polyps often recurred after polypectomy; however, no malignant transformation occurred during the observational time until October 2017. The most common endoscopic finding was esophageal varices, observed in more than 90% of patients., Conclusion: Portal hypertensive polyposis is common in patients with advanced cirrhosis. Our data suggest that these polyps have benign characteristics.

Background and Aims: Familial adenomatous polyposis (FAP) is a hereditary syndrome that can affect the entire GI tract. Current screening recommendations include EGD starting at age 25 to 30 years or earlier in symptomatic patients. However, few reports describe upper GI tract involvement in children with FAP that support the notion of early screening. The aim of our study is to understand the prevalence and severity of upper GI involvement in children with FAP., Methods: We performed a retrospective review of the Mayo Clinic records, between 1992 and 2016, to identify children with the diagnosis of FAP who underwent EGD examinations. A systematic review of the literature was performed to include published studies reporting children with FAP and upper GI findings., Results: The retrospective study included 69 children with a mean age of 13.5 years (range, 3-18). Thirty-six children (52%) had duodenal adenoma with low-grade dysplasia. Five children required an ampullectomy secondary to enlarged and polypoid ampullas. Combined with published studies, a total of 206 children with upper GI findings were identified, of which 87 (42%) had duodenal adenoma (1 had high-grade dysplasia). Meta-analysis of 5 series demonstrated duodenal adenoma detection rate of 39% (95% confidence interval, 21%-57%; I 2  = 85%)., Conclusions: The available data to date show that children with FAP can have clinically relevant lesions in the upper GI tract earlier than previously foreseen, suggesting that earlier screening may be indicated. Larger multicenter prospective studies are needed to determine the best approach and optimal age for EGD screening in children with FAP., (Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Amyloid tends to deposit in the gastrointestinal tract, which, being easily accessible, is often the target organ for a pathological diagnostic examination. Although a mucosal biopsy is necessary for a definitive diagnosis and several studies have reported positive results for each possible biopsy site, there remain many unclear features in various aspects. This review focuses on the current literature to determine a better understanding of the diagnosis from endoscopic and histological views in patients with systemic amyloidosis with gastrointestinal involvement. A literature search was performed using PubMed to identify relevant studies; linked references were also reviewed. Endoscopic findings vary based on the organ and the depositing amyloids. A fine granular appearance or polypoid protrusions are likely to occur in the duodenum. AL, Aβ2M, and ATTR amyloids are likely to deposit submucosally, while AA amyloid is easily deposited in the superficial layer of the mucous membrane. Furthermore, it is necessary to consider the collection of biopsy specimens from the duodenum, which has high positive biopsy rates. However, the difference in the positive biopsy rates depends on whether endoscopic findings are available or whether the appropriate number has not been fully elucidated. A duodenal biopsy is strongly recommended to confirm the deposition of amyloid in patients with systemic amyloidosis having gastrointestinal involvement. Because amyloidosis is a disease with a poor prognosis, early diagnosis and treatment are required; gastroenterologists and endoscopists play important roles., (© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

We present an obese patient who underwent high digestive endoscopy due to dysphagia after accidental ingestion of chicken bone. There is mild reflux oesophagitis and duodenal atrophy. Intestinal biopsy reports severe villous atrophy with lymphoplasmocytic infiltrate. Autoantibodies for celiac disease return positive. The patient never presented digestive symptoms.

We here report two cases of acute bowel obstruction. Emergency intervention showed left obstructive paraduodenal hernia causing volvulus with necrosis of the incarcerated intestinal loops in one patient who underwent one-time anastomosis resection and suffering but viable small bowel in the second patient treated by incarcerated intestinal loop reduction and obturation of the orifice of the hernial canal. We here highlight the diagnostic and therapeutic features of this rare condition.

Brunner's gland cysts are rare, benign lesions of the duodenum usually seen as incidental, polypoid or cystic lesions of the duodenum. We present a series of 25 cases of Brunner's gland cyst, the largest case series to date. All the cases were identified during endoscopic assessment for unrelated causes. The mean age of the patients was 66.2 years and the sex ratio was approximately equal. Most were detected as a small (3-10 mm) polypoid lesion in the second part of the duodenum, away from the ampulla. Most of the cysts were unilocular and all were lined by undulating, cytologically bland cuboidal to columnar cells with clear cytoplasm and small, basal nuclei. No mitotic activity or proliferative activity was seen. No recurrence was noted, despite incomplete removal in many cases. We agree with the hypothesis that Brunner's gland cysts are likely to be caused by local obstruction to the draining duct of Brunner's glands., (Copyright © 2017 Royal College of Pathologists of Australasia. Published by Elsevier B.V. All rights reserved.)

Crohn's disease (CD) is a type of chronic inflammatory bowel disease (IBD) associated with ulceration, and the main foci of the inflammation in CD patients are typically the terminal ileum and colon. However, in the upper gastrointestinal tract (GIT), including the esophagus, stomach and duodenum, inflammatory lesions are also detected as well, with a relatively high frequency (30-75%). Recent advances in imaging modalities, including endoscopy, have aided in the diagnosis of CD. Various lesions, including aphtha, erosion, ulcers, bamboo-joint-like appearance and notch-like appearance, are detected in the upper GI of CD patients. Of these lesions, the bamboo-joint-like appearance in the gastric cardiac region and notch-like appearance in the second portion of the duodenum are highly specific for CD, regardless of the disease activity at other sites. These two findings, particularly a bamboo-joint-like appearance, have therefore been considered as potential biomarkers for CD. Although proton pump inhibitors (PPIs) are administered as an initial treatment for upper GIT lesions of CD, the efficacy of this treatment remains controversial. The administration of mesalazine, steroids, immunosuppressant and biologic agents is expected to be effective for treating such lesions.

Duodenal adenomas are the most common type of polyp arising from the duodenum. These adenomas can occur within and outside of genetic syndromes, and are broadly classified as non-ampullary or ampullary depending on their location. All adenomas have malignant potential and are therefore appropriately treated by endoscopic resection. However, the unique anatomical properties of the duodenum, namely its relatively thin and vascular walls, narrow luminal diameter and relationship to the ampulla and its associated pancreatic and biliary drainage, pose an increased degree of complexity for any endoscopic interventions in this area. This review will discuss the epidemiology of duodenal adenomas, their endoscopic detection and diagnosis, and techniques for safe and effective endoscopic resection of ampullary and non-ampullary lesions., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: The aim of our study is to evaluate if in children with highly positive serology and HLA-DQ2/DQ8 (triple test, TT) and only extra-intestinal symptoms, it is possible to omit performing an intestinal biopsy for celiac disease (CD) diagnosis, as suggested by the new European Society for Pediatric Gastroenterology, Hepatology and Nutrition ESPGHAN guidelines., Methods: In this retrospective study a total of 105 patients, suspected of having CD because of extra-intestinal symptoms and showing serum tissue transglutaminase antibody (anti-tTG) and anti-endomysial antibody (EMA) measurements and HLA genotyping, were considered for the final analysis (33 boys and 72 girls; age range 1.5-17.6 years)., Results: Histological findings confirmed diagnosis of CD in 97 (92.4%) patients. Forty-one patients (39%) showed anti-tTG >10 times normal values, positive EMA and positive HLA-DQ2/DQ8 (positive TT). All of them had a diagnosis of CD, therefore there were no false positive cases. Sixty-four patients were negative for the TT. In eight cases, CD was ruled out and these were considered true negative cases. In the remaining 56 negative TT patients, intestinal biopsy confirmed CD diagnosis and they were considered false negatives. Based on these results, specificity for the TT was 100% and sensitivity was 42.3%., Conclusions: On the basis of the present study, diagnosis of CD can be reliably performed without a duodenal biopsy in children with only extra-intestinal symptoms.

Objective: The aim of this study was characterized sin duodenum the heterotopic gastric mucosa., Materials and Methods: The slides with the diagnosis of heterotopic gastric mucosa during 2014-2015, were reviewed, and clinical, histological and endoscopic data was to collected for every case., Results: 45 cases of heterotopic gastric mucosa in duodenum were found, 91.1% were located in duodenum bulb and 73.2%, presenting as polyps in 73.2% of cases. In all cases, parietal cell was identified as main criteria for the diagnosis. Neither Helicobacter pylori nor dysplasia were identified., Conclusions: Our data confirm its non neoplastic nature. Heterotopic gastric mucosa should be taken into account in diagnosis of duodenal polyps. Parietal cells identification in duodenal mucosa is essential in differential diagnosis with peptic duodenitis.

Enteroenteric intussusception is a condition in which the full-thickness bowel wall becomes telescoped into the lumen of distal bowel. Intussusception in adult occurs infrequently and varies from childhood intussusception, particularly in its presentation, aetiology and treatment. Duodenoduodenal intussusception is rare because the duodenum is fixed in the retroperitoneal position. It usually occurs secondary to tumour, lipoma, Brunner's gland hamartomatous polyp or adenoma. The diagnosis in adults is usually made at laparotomy, where presentation is with intestinal obstruction. In non-emergency presentation, it may be difficult to arrive at an accurate diagnosis as symptoms may be vague, self-limiting intermittent abdominal pain. Clinical examinations and investigations may not be conclusive and another working diagnosis such as irritable bowel syndrome would be made. We describe a case where a patient initially presented with symptoms mimicking pancreatitis but his symptoms persisted over the course of 2 weeks. When a laparotomy was performed, duodenoduodenal intussusception was discovered and confirmed with histopathology. In this case, a discernible leading point could not be identified.

Competing Interests: Competing interests: None

Iatrogenic duodenal injury occurring during laparoscopic cholecystectomy (LC) is managed surgically, though rarely a large, persistent fistula is refractory to surgical interventions. We present the case of a 40-year-old woman transferred to our centre following elective LC for a reported perforated duodenal ulcer. An uncontained leak was found to originate from a 1.5 cm duodenal defect, with no evidence of ulceration. A duodenostomy tube was placed. One month after abdominal closure, the patient continued to have a persistent, large duodenal fistula. A through-the-scope covered oesophageal stent was placed under endoscopic and fluoroscopic guidance. Five weeks later, it was successfully retrieved and no subsequent extravasation of contrast from the duodenum was noted. Unrecognised iatrogenic duodenal injuries sustained during LC can be catastrophic. In cases of massive duodenal defects and high-output biliary fistula uncontrolled after surgical intervention, endoscopic-guided and fluoroscopic-guided placement of a fully covered oesophageal stent may be lifesaving., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background and Aims: Endoscopic full-thickness resection (EFTR) allows for definitive diagnosis and treatment of select subepithelial and epithelial lesions unsuitable to conventional resection techniques. Our aim was to evaluate the efficacy and safety of over-the-scope (OTS) clip-assisted EFTR for these lesions., Methods: Patients who underwent OTS clip-assisted EFTR between June 2014 and October 2015 were analyzed. The procedure involved (1) thermal marking of the periphery of the lesion; (2) lesion suction into the cap of either an OTSC (Ovesco Endoscopy AG, Tübingen, Germany) or Padlock clip (Aponos Medical Corp, Kingston, NH, USA) with or without triprong anchor retraction of the lesion; (3) clip deployment; and (4) en bloc resection of the lesion above the clip using an electrosurgical snare and/or knife. Data were abstracted for demographics, lesion features, histopathologic diagnoses, R0 resection (negative margins) status, and adverse events., Results: Nine patients (7 men) with a mean age of 63 ± 9.6 years were identified. The endoscopic findings included subepithelial lesions in the duodenum (n = 4), rectosigmoid colon (n = 2), stomach (n = 1), and postappendectomy appendiceal orifice polyps (n = 2). The mean lesion size was 8 ± 3 mm and the mean procedure time 53 ± 21 minutes. R0 resection was confirmed in all cases. The histopathologic diagnoses included neuroendocrine tumors (n = 6), sessile serrated adenomas (n = 2), and pancreatic heterotopia (n = 1). No adverse events were noted., Conclusions: OTS clip-assisted EFTR is an effective and safe technique for the removal of select subepithelial and epithelial lesions that are not amenable to conventional resection techniques., (Copyright © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)