What is the diagnosis and management of small pearly white pits in the duodenal bulb seen on upper endoscopy?

Small Pearly White Pits in the Duodenal Bulb

Small pearly white pits or scattered white spots in the duodenal bulb require biopsy to establish a histopathological diagnosis, as they can represent multiple distinct pathologies including intestinal lymphangiectasia (most common at 36%), chronic non-specific duodenitis (28%), giardiasis (14%), or less commonly, benign polyps such as ectopic gastric mucosa or inflammatory polyps.

Differential Diagnosis

The appearance of small pearly white pits or scattered white spots (SWS) in the duodenal bulb is a non-specific endoscopic finding that requires histopathological correlation:

• Intestinal lymphangiectasia is the most common cause, accounting for 36.4% of cases with this endoscopic appearance 1
• Chronic non-specific duodenitis represents 28.1% of cases 1
• Giardiasis accounts for 14% of cases 1
• Benign polyps including ectopic gastric mucosa and inflammatory polyps are common in the duodenal bulb and typically present as multiple, small, sessile lesions 2

Diagnostic Approach

At endoscopy, when small pearly white pits are identified in the duodenal bulb, obtain at least 3-4 biopsy specimens from different locations to establish the diagnosis 3, 1. This is critical because:

• Multiple small polyps in the duodenal bulb are practically always benign (inflammatory polyps or ectopic gastric mucosa) and are typically non-solitary, sessile, and small 2
• Histopathological examination is mandatory to differentiate between the various etiologies, as there is no significant relationship with other upper endoscopic findings that would allow clinical diagnosis 1
• The British Society of Gastroenterology recommends at least four biopsy specimens when there is suspicion of duodenal pathology, including at least one from the duodenal bulb 3

Important Clinical Considerations

When Celiac Disease is in the Differential

If the appearance could represent celiac disease (which typically shows scalloped folds, nodularity, or mucosal fissuring rather than white pits), ensure:

• The patient is on a gluten-containing diet (gluten in more than one meal daily for at least 6 weeks) 3
• Obtain at least four biopsies from different duodenal locations, including the bulb 3
• Note that approximately one-third of celiac disease patients have normal endoscopic appearance 3

Location-Specific Risk Stratification

Multiple small polyps confined to the duodenal bulb do not require biopsy or treatment in routine cases, as they are always benign 2. However:

• Polyps in the descending duodenum (D2) have a substantially higher risk of being adenomas (7% of duodenal polyps) and biopsy is mandatory in this location 2
• Adenomas carry significant malignant potential, with up to 20% progressing to high-grade dysplasia and approximately 5% to cancer 4

Management Algorithm

1. Document the characteristics: Number, size, location, and morphology of the lesions 3

2. Obtain biopsies: At least 3-4 specimens from the affected areas 3, 1

3. Based on histopathology:

   • Intestinal lymphangiectasia: No specific treatment required; consider evaluation for underlying causes if symptomatic
   • Giardiasis: Treat with appropriate antiparasitic therapy
   • Chronic duodenitis: Manage underlying cause (H. pylori if present, NSAIDs, etc.)
   • Benign polyps in bulb: No further intervention needed 2
   • Adenomas: Complete endoscopic resection with 6-month surveillance 4

Critical Pitfalls to Avoid

• Do not assume all small white lesions in the duodenal bulb are benign without histological confirmation, as the differential includes infectious, inflammatory, and structural pathologies that require different management 1
• Do not overlook the second portion of the duodenum (D2), where adenomas are more common and carry malignant potential 2
• Ensure proper biopsy orientation by experienced laboratory technicians, as correct orientation is necessary for accurate histopathological assessment 3