Nonceliac diaphragm disease of the duodenum: CASE PRESENTATION
A 58-year-old, Indo-Canadian male was evaluated for recurrent bouts of upper epigastric pain and distension that was exacerbated by meals. There was no nausea, vomiting, change in appetite or weight loss. A barium study of the stomach and duodenum showed a dilated duodenum without ulceration (Figure 1). Radiographic studies of the jejunum and ileum were normal. Retained food debris was also reported, possibly from delayed emptying of the duodenum. A chest radiograph was normal. Serological studies for Helicobacter pylori were negative. There was no history of potassium chloride, ASA or other nonsteroidal anti- inflammatory drug use. There was no history of abdominal trauma, rheumatological disorder or familial history of gastrointestinal diseases such as Crohn’s disease or celiac disease. An initial endoscopic examination revealed a normal esophagus and stomach, but there was retained food debris. Endoscopic examination was repeated after a 24 h fluid diet. The mucosa was normal except for two distinct membranous strictures or webs of the descending duodenum (Figure 2). Mucosal biopsies from mucosa of the descending duodenum beyond the second stricture and between strictures, and from the duodenal bulb were normal. Biopsies from the margin of the web-like membranous strictures revealed reactive epithelial cellular changes with mucin depletion. No erosive change was evident. Fibrosis in the submucosal region was present, but there were no iron-laden macrophages or granu- lomas. Gastric biopsies were normal, while silver stains for H pylori were negative. Clinical improvement and resolution of his abdominal pain followed endoscopic balloon dilation and empirical omeprazole therapy.
Figure 1) Barium radiographic study showing diaphragm strictures in the descending duodenum (arrows) with retained food debris. The food debris appears as filling defects in the dilated duodenum between the strictures
Figure 2) Two circumferential stenoses in the descending duodenum without erosion or ulceration
When you can’t afford your medication Purchase Cialis online