What is the workup after identifying duodenitis during an Esophagogastroduodenoscopy (EGD)?

Diagnostic Workup for Duodenitis Identified During EGD

When duodenitis is identified during an esophagogastroduodenoscopy (EGD), the workup should include testing for H. pylori infection, obtaining biopsies from the duodenum for histopathological examination, and assessing for potential etiologies such as medications, celiac disease, and other inflammatory conditions. 1

Initial Evaluation and Biopsy Protocol

• Biopsies should be obtained from the duodenum during the EGD when duodenitis is identified to confirm the diagnosis histologically and assess for potential causes 1
• Histopathological review should be performed by a gastrointestinal pathologist to determine the presence and severity of inflammation 1
• When obtaining biopsies from the duodenum, a minimum of four biopsies from the second part of the duodenum including a specimen from the duodenal bulb should be taken if celiac disease is suspected 1
• Testing for H. pylori infection should be performed in all patients with duodenitis, as it is a common cause that requires specific treatment 1, 2

Specific Testing Based on Clinical Presentation

• Universal testing for H. pylori should be performed through biopsy-based methods (histology, rapid urease test) or non-invasive tests (urea breath test, stool antigen) 1, 2
• If seronegative enteropathy is suspected, HLA typing may be useful to assess for celiac disease 1
• A detailed medication history should be obtained to identify potential causative agents (NSAIDs, potassium supplements, bisphosphonates) 1
• Travel history should be assessed for risk factors associated with tropical sprue or parasitic infections like Giardia 1
• Assess for symptoms such as fever, bloody diarrhea, and weight loss which might suggest Crohn's disease or lymphoproliferative disorders 1

Additional Testing When Indicated

• If erosive duodenitis is identified, consider the increased risk for peptic ulcer disease and follow accordingly 3
• In cases where gastric cancer is a concern (based on risk factors or endoscopic appearance), additional workup should include:
  • Chest/abdomen/pelvis CT with oral and IV contrast 1
  • Testing for microsatellite instability (MSI) by PCR/NGS or mismatch repair (MMR) by immunohistochemistry 1
  • Endoscopic ultrasound if early-stage disease is suspected 1

Follow-up Recommendations

• For patients with duodenitis where H. pylori is identified, eradication therapy should be initiated and confirmed with follow-up testing 2
• In cases where an underlying cause was identified and treated, a follow-up EGD with biopsy might not be necessary depending on clinical response 1
• For patients with idiopathic duodenitis (no identified cause), consider repeating endoscopy after a period of time (approximately 9-12 months) to assess for resolution 1
• If seronegative celiac disease is suspected, follow-up endoscopy with biopsy should be performed after approximately 12 months on a gluten-free diet to confirm mucosal improvement 1

Common Pitfalls and Caveats

• Radiographic diagnosis of erosive duodenitis has poor sensitivity and is only reliable in advanced disease; endoscopic evaluation with biopsy remains the gold standard 4
• Endoscopic appearance alone may not reliably distinguish between different types of duodenitis (granular, multi-polypoid, reddened, erosive) and histological confirmation is essential 5
• Erosive-hemorrhagic duodenitis has been associated with a higher incidence of progression to peptic ulcer disease and should be managed similarly to duodenal ulcers 3
• The presence of duodenitis does not confirm GERD as a cause of extraesophageal symptoms, and additional testing may be needed to establish this connection 1
• Eosinophilic gastroenteritis should be considered in the differential diagnosis when eosinophilic infiltration is found on biopsy, requiring exclusion of other causes of eosinophilia 6

By following this systematic approach to the workup of duodenitis identified during EGD, clinicians can effectively diagnose the underlying cause and implement appropriate management strategies to improve patient outcomes.