Can Duodenal Ulcers Be Missed on EGD?
Yes, duodenal ulcers can be missed on EGD, with studies documenting a 3% to 25% miss rate for upper GI bleeding lesions, including duodenal pathology. 1
Evidence for Missed Lesions
The most recent and highest-quality guideline evidence directly addresses this concern:
Studies evaluating upper endoscopy in patients with obscure bleeding demonstrate a 3% to 25% miss rate for putative bleeding lesions in the upper GI tract. 1 While this miss rate encompasses all upper GI lesions, it definitively establishes that duodenal ulcers can be overlooked during EGD.
In a retrospective review of 300 consecutive patients undergoing capsule endoscopy for obscure bleeding, duodenal masses were missed in 3 patients (1%) on previous endoscopy. 1 This confirms that even with direct visualization, duodenal pathology can escape detection.
Key Factors Contributing to Missed Duodenal Ulcers
Inadequate Inspection Time
Total EGD duration of longer than 7 minutes is associated with increased detection of significant upper GI pathology, including ulcers. 1 Rushed examinations directly increase the risk of missing lesions.
Endoscopists who spent at least 5 to 7 minutes of inspection time during EGD had higher odds of detecting pathology (OR, 1.90; 95% CI, 1.06–3.40) compared with those performing shorter examinations. 1
Poor Mucosal Visualization
Adequate mucosal visualization requires both aspiration and mucosal cleansing techniques, with quality of visualization documented in >90% of procedures. 1 Retained food, blood, or bile in the duodenum can obscure ulcers.
The duodenal bulb is particularly challenging to examine thoroughly, as incomplete examinations can occur when this area is not adequately visualized. 1
Technical and Anatomical Challenges
Duodenal ulcers in the bulb may be obscured by overlying blood clots, edematous mucosa, or unusual presentations such as intussusception. 2 These factors can mask the underlying ulcer crater.
Small or shallow ulcers may be difficult to distinguish from normal mucosal folds or minor erosions without careful inspection and optimal distension. 3, 4
Clinical Implications and Risk Mitigation
When to Suspect a Missed Ulcer
If symptoms persist despite negative initial EGD, particularly in patients with occult GI bleeding, recurrent epigastric pain, or alarm features, repeat endoscopy with meticulous duodenal examination is warranted. 3
The presence of melena, anemia, or positive fecal occult blood testing with a reportedly normal EGD should prompt consideration of repeat examination or alternative imaging. 3, 5
Strategies to Reduce Miss Rates
Use image-enhanced endoscopy (IET) techniques such as narrow-band imaging (NBI) or linked color imaging (LCI), which reduce missed upper GI lesions (0.67% vs 3.5% with standard white-light endoscopy; relative risk, 0.19; 95% CI, 0.07–0.50). 1
Ensure adequate inspection time with systematic examination of all duodenal surfaces, including retroflexion in the duodenal bulb when feasible. 1
Document photo evidence of normal-appearing duodenal mucosa in all quadrants to confirm complete examination. 1
Critical Pitfalls to Avoid
Never assume a negative EGD definitively excludes duodenal ulcer disease when clinical suspicion remains high based on symptoms, laboratory findings, or risk factors (H. pylori, NSAID use). 3, 4
Do not overlook atypical presentations such as ulcers with overlying clots, edematous changes mimicking mass lesions, or ulcers in unusual locations beyond the duodenal bulb. 4, 2
Recognize that complications such as perforation can occur even when ulcers were not identified on prior endoscopy, emphasizing the importance of clinical correlation over endoscopic findings alone. 6, 5
Special Considerations
In patients with alarm features (bleeding, anemia, weight loss, family history of GI malignancy), repeat endoscopy by an experienced endoscopist should be performed if initial examination is negative but clinical suspicion persists. 1, 3
Capsule endoscopy may identify duodenal lesions missed on conventional EGD, though it has its own limitations including inability to obtain biopsies and risk of retention. 1
Informed consent for EGD should include disclosure of the potential for missed lesions, as this is an inherent limitation of the procedure. 1