What are the normal findings and common disease findings on an oesophagogastroduodenoscopy (OGD) of the proximal small intestine?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: March 12, 2026 • View editorial policy

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question

OGD Findings in the Small Intestine (Duodenum)

Normal Endoscopic Findings

The normal duodenum on OGD should demonstrate smooth, pink mucosa with visible circular folds (plicae circulares), no ulcerations, erosions, or masses, and adequate visualization of the duodenal bulb and second portion of the duodenum. 1

Key normal anatomical features include:

  • Intact mucosal surface with regular fold pattern throughout the duodenal bulb and descending duodenum 2
  • Pink to salmon-colored mucosa without erythema, pallor, or nodularity 1
  • Smooth transition from gastric to duodenal mucosa at the pylorus 1
  • Visible ampulla of Vater in the second portion when adequately visualized 1

Common Pathological Findings

Peptic Ulcer Disease

Duodenal ulcers are among the most common abnormal findings, occurring in approximately 20% of patients with pathology. 3

  • All duodenal ulcers must be tested for H. pylori with eradication if positive (>90% compliance recommended) 1
  • Ulcers should be photo-documented and biopsied to exclude malignancy, though duodenal ulcers are less commonly malignant than gastric ulcers 1
  • Re-evaluation after appropriate treatment is recommended within 6-8 weeks 1

Duodenitis

Duodenitis presents as erythematous, inflamed mucosa and occurs in approximately 8.6% of patients undergoing OGD. 4

  • Often associated with H. pylori infection requiring testing and treatment 1
  • May be patchy or diffuse in distribution 4
  • Biopsies should be obtained if appearance is atypical or severe 1

Coeliac Disease

When coeliac disease is suspected, a minimum of four biopsies must be taken from different duodenal locations, including at least one from the duodenal bulb. 1 This is a strong evidence, strong recommendation 1

Classic endoscopic features include:

  • Flattened mucosal appearance with loss of normal fold pattern 1
  • Scalloping of duodenal folds 1
  • Nodularity of the mucosa 1
  • Reduction or absence of duodenal folds 1

Critical caveat: Coeliac disease may be present with completely normal endoscopic appearance, making biopsies mandatory when clinically suspected 1. Villous atrophy occurs in a patchy distribution, necessitating multiple biopsy sites 1.

Adenomas and Polyps

In patients with familial adenomatous polyposis, up to 90% have duodenal adenomas, making careful inspection essential 1

  • Duodenal adenomas carry malignancy risk and require surveillance 1
  • Representative biopsies should be taken from any identified polyps 1
  • The ampullary region requires particular attention as it is a common site for adenoma development 1

Malignant Lesions

Any malignant-appearing duodenal lesion requires photo-documentation and a minimum of six biopsies. 1

  • Location should be documented with distance from a fixed landmark (e.g., incisors) 1
  • Number, size, and morphology must be described using standardized classifications 1
  • Sufficient tissue should be obtained for additional molecular testing if needed 1

Iron Deficiency Anemia Investigation

When investigating iron deficiency anemia, duodenal biopsies should be obtained if coeliac serology is positive or has not been previously measured. 1

  • This should be performed in addition to gastric biopsies from antrum and body 1
  • Minimum of four duodenal biopsies including the bulb 1

Quality Standards for Duodenal Examination

Adequate mucosal visualization must be achieved through aspiration and mucosal cleansing techniques (75% minimal standard, 100% aspirational) 1

Key quality metrics include:

  • Photo-documentation of anatomical landmarks (>90% aspirational standard) 1
  • Photo-documentation of all detected lesions (>90% minimal, 100% aspirational) 1
  • Sufficient inspection time during diagnostic procedures, particularly for surveillance 1
  • Standardized biopsy protocols when pathology is suspected 2, 1

Common Pitfalls to Avoid

The duodenojejunal flexure represents a diagnostic blind spot that may be missed by standard OGD, potentially leading to missed bleeding sources 5. If standard OGD and colonoscopy are unremarkable in gastrointestinal bleeding, consider additional imaging or enteroscopy 5.

Normal endoscopic appearance does not exclude coeliac disease - biopsies are mandatory when clinical suspicion exists 1. Patients must maintain a gluten-rich diet (gluten in more than one meal daily for at least 6 weeks) before diagnostic endoscopy to avoid false-negative results 1.

Approximately 50% of first diagnostic OGDs show neither macroscopic nor histological abnormalities 6, emphasizing the importance of appropriate patient selection and clinical indication 2, 7.

References

2
Guideline

aga clinical practice update on high-quality upper endoscopy: expert review.

Clinical Gastroenterology and Hepatology, 2024

Related Questions

A 68-year-old white male, 21 days post total hip arthroplasty, has itching at the clean, dry surgical site without drainage; what measures can be taken to resolve or minimize the itching?
In a 79-year-old patient receiving enteral tube feeding who presents with diarrhea, which stool test should be ordered first?
In a 55‑year‑old man with a recent electrocardiogram showing sinus rhythm, a QS complex in V1, poor R‑wave progression in V2, left‑atrial enlargement, and a prolonged QT interval, what is the most likely diagnosis and appropriate treatment?
How do I convert an infusion rate of 60 cc per hour to drops per minute using a microdrip set?
What is the appropriate evaluation and management for an 82‑year‑old male presenting with lower abdominal pain and a burning sensation on urination?
What are the common postoperative complications of abdominoplasty (tummy tuck) and how should they be managed?
What is the appropriate treatment for acute prostatitis caused by Enterococcus species?
Can you write the prescription directions (sig) for a 100 mg intramuscular injection every two weeks, including the appropriate syringes for drawing up and administering the dose?
Which laboratory tests are recommended to evaluate a patient with suspected ketone‑prone diabetes?
How should an isolated low complement component 3 (C3) level be evaluated and managed?
Can Lantus (insulin glargine) be used as the only insulin while continuing oral hypoglycemic agents in an adult with type 2 diabetes?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.