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Imaging Spectrum of Duodenal
Emergencies
Babina Gosangi, MD1
Tatiana C. Rocha, MD
Alejandra Duran-Mendicuti, MD
Abbreviations: ERCP = endoscopic retrograde
cholangiopancreatography, IVC = inferior vena
cava, SMA = superior mesenteric artery, VNC =
virtual noncontrast
RadioGraphics 2020; 40:1441–1457
https://doi.org/10.1148/rg.2020200045
Content Codes:
From the Department of Radiology, Divison of
Emergency Radiology, Brigham and Women’s
Hospital, 75 Francis St, Boston, MA 02115.
Presented as an education exhibit at the 2019
RSNA Annual Meeting. Received March 23,
2020; revision requested April 23 and received
June 5; accepted June 13. For this journal-based
SA-CME activity, the authors, editor, and re-
viewers have disclosed no relevant relationships.
Address correspondence to A.D.M. (e-mail:
mduranmendicuti@bwh.harvard.edu).
1
Current address: Department of Radiology,Yale
University, New Haven, Conn.
©
RSNA, 2020
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
„ Describe common emergent conditions
of the duodenum.
Discuss the various imaging modalities
„
used for imaging duodenal emergencies.
Recognize the imaging features of duo-
„
denal emergencies.
See rsna.org/learning-center-rg.
1441
TRAUMA/EMERGENCY RADIOLOGY
The duodenum, the first portion of the small bowel, is divided into
four segments and extends to both retro- and intraperitoneal spac-
es. Some conditions arise primarily from the duodenum, but it can
be secondarily affected by processes that involve neighboring struc-
tures. When duodenal emergencies are not identified and treated
promptly, they may result in high morbidity and mortality. Imaging
plays an important role in the diagnosis of duodenal conditions in
the acute setting. However, the radiologic findings can be subtle,
and awareness of relevant patient history and clinical presentation is
important as it may increase the index of suspicion and one’s ability
to diagnose these conditions. Duodenal peptic disease is common
and can be complicated by bleeding and perforation. The duode-
num can be secondarily involved by pancreatitis and gallbladder
pathologic conditions and may be affected by iatrogenic complica-
tions following endoscopic procedures. Traumatic injuries to the
duodenum are generally uncommon, with penetrating traumatic
injury being the most frequent mechanism of injury. Duodenal
vascular pathologic conditions such as aortoduodenal fistula are
uncommon but can be life threatening. The knowledge of which
pathologic condition can involve which duodenal segment can help
the radiologist establish a differential diagnosis and achieve a more
targeted imaging approach.
The online slide presentation from the RSNA Annual Meeting is avail-
able for this article.
©
RSNA, 2020 • radiographics.rsna.org
Introduction
The duodenum is the first portion of the small bowel and is ana-
tomically divided into four segments. In this article, we illustrate
the anatomy of the duodenum and review the imaging findings of a
wide range of duodenal emergencies, focusing on multidetector CT,
the modality of choice in the acute setting in the adult population.
The added value of dual-energy CT is also considered. Duodenal
emergencies are discussed, from common to uncommon entities,
including peptic ulcer disease, inflammatory and infectious condi-
tions, oncologic and iatrogenic processes, traumatic injuries, vascular
and congenital pathologic conditions, and their complications. Some
conditions such as peptic ulcer disease and tumors arise primar-
ily from the duodenum, but the duodenum can also be secondarily
1442  September-October 2020 radiographics.rsna.org
TEACHING POINTS
„ In the CT angiographic evaluation of bleeding duodenal ul-
cers, initial nonenhanced imaging helps to differentiate pre-
existing hyperattenuating ingested material within the duo-
denal lumen from active hemorrhage. When a dual-energy
CT scanner is used, VNC images can be created with iodine
subtracted from the images, eliminating the need for a non-
enhanced phase.
„ Indirect signs of duodenal ulcers include short segmental mu-
ral enhancement of the duodenum with submucosal edema,
periduodenal fat stranding, and adjacent lymphadenopathy .
The direct signs of duodenal ulcer at cross-sectional imaging
are occasionally visualized and include focal discontinuity of
the mucosal hyperenhancement and luminal outpouching.
„ The CT appearance of groove pancreatitis ranges from ill-
defined fat stranding and inflammation to frank soft tissue in
the groove. Retroperitoneal inflammation is usually absent.
There might be masslike enlargement of the pancreatic head,
making the differential diagnosis with pancreatic cancer im-
portant.
„ Isolated duodenal injuries are rare and, given the intimate re-
lationship of the duodenum and pancreas, they are frequently
injured concomitantly.
„ It is important to know that findings similar to those in ADF
are expected following aortic surgery. Therefore, evaluation
of the timing and evolution of the findings is key. After 3–4
weeks, any ectopic gas is abnormal and should be consid-
ered a sign of perigraft infection and possibly fistulization to
bowel.
affected by pathologic conditions originating
from neighboring organs such as the pancreas,
gallbladder, and aorta. Trauma to the duodenum
is uncommon, and penetrating trauma is the
most frequent mechanism of injury. The duode-
num may be affected by iatrogenic complications
following endoscopic procedures or by vascular
pathologic conditions such as aortoduodenal
fistula or pseudoaneurysm rupture, which can
be life threatening. When duodenal emergencies
are not identified and treated promptly, they may
result in high morbidity and mortality. Imaging
plays a key role in diagnosing these conditions in
the acute setting.
The knowledge of which pathologic condition
can involve which duodenal segment can help
the radiologist establish a differential diagnosis
and achieve a more targeted imaging approach.
Although this article focuses on describing duo-
denal conditions, from the most common to the
least common, we suggest using a segment-wise
approach to evaluating duodenal pathologic con-
ditions. A list of common conditions occurring in
each duodenal segment is provided in Table 1.
Anatomy of the Duodenum
The duodenum is the first segment of the small
intestine, measuring approximately 25 cm in
length. It is a C-shaped structure that lies at the
Table 1: Common Duodenal Conditions by
Duodenal Segment
First segment
Duodenal peptic disease
Gallbladder pathologic conditions
Crohn disease
Second segment
Duodenal peptic disease
Pancreatitis
Groove pancreatitis
Gallbladder pathologic conditions
Bouveret syndrome
Duodenal adenocarcinoma
Trauma
Iatrogenic perforation following ERCP with
sphincterectomy
Duodenal diverticulitis
Annular pancreas
Third segment
Pancreatitis
Trauma
SMA syndrome
Aortoduodenal fistula
Fourth segment
Crohn disease
Malrotation
Note.—ERCP = endoscopic retrograde cholan-
giopancreatography, SMA = superior mesenteric
artery.
level of the L1 to L3 vertebrae and extends from
the gastric pylorus to the ligament of Treitz. This
ligament is not identified at CT, but the term is
broadly used in the medical literature to designate
the duodenojejunal flexure (1,2). The duodenum
is mostly retroperitoneal in location, except for
the first 2.5 cm, which are intraperitoneal.
The duodenum is divided into four segments
and has two flexures, the superior and inferior
duodenal flexures (Fig 1). The first segment or
duodenal bulb passes slightly upward from the
pylorus to the level of the gallbladder neck. The
proximal half is intraperitoneal and is enclosed by
the same peritoneal layers that invest the stomach,
and the distal half becomes retroperitoneal (3).
The second segment or descending duodenum lies
to the right of the midline and extends from the
superior duodenal flexure to the inferior duodenal
flexure and surrounds the pancreatic head. The
minor and major papillae are usually located in the
second segment of the duodenum. The third seg-
ment or horizontal duodenum crosses left of the
midline in front of the inferior vena cava (IVC),
lumbar spine, and aorta. The fourth segment or
ascending duodenum is the shortest segment and
runs to the left of the second lumbar vertebra to
the duodenojejunal flexure (Fig 2).
RG  •  Volume 40  Number 5 Gosangi et al  1443

Figure 1.  Duodenal anatomy. Draw-

ing (a) and coronal CT image (b) show
the anatomic relationships of the duode-
num: stomach (black *), first segment of
the duodenum (green arrow; green area
in a), second segment of the duodenum
(pink arrow; pink area in a), third segment
of the duodenum (yellow arrow; yellow
area in a), fourth segment of the duode-
num (orange arrow; orange area in a),
gallbladder (brown * and brown area in
a), pancreas (brown arrow), aorta (white
* and red area in a), and inferior vena cava
(IVC) (blue * and blue area in a).

Figure 2.  Anatomic relationships of the duodenum at CT. (a) Axial CT image
shows the first segment of the duodenum (dashed outline in a–d) and the gall-
bladder (white arrow) and IVC (green arrow). (b) Coronal CT image shows the
second segment of the duodenum and the liver (*), common bile duct (orange
arrow), portal vein (red arrow), and pancreatic duct (purple arrow). (c) Axial CT
image shows the third segment of the duodenum and the SMA (blue arrow) and
aorta (yellow arrow). (d) Axial CT image shows the fourth segment of the duo-
denum and the duodenojejunal junction (green arrow) and aorta (yellow arrow).

is routinely administered. At our institution,

The main sources of arterial blood supply to
the duodenum are the superior and inferior pan-
creaticoduodenal arteries and the supraduodenal
artery. A segment-wise summary of the anatomic
relationships of the duodenum and blood supply
to the duodenum are provided in Table 2.
Imaging Approach
Multidetector CT has proven to be helpful in
the evaluation of the duodenal wall, intraluminal
content, and periduodenal space and is the mo-
dality of choice for evaluating duodenal patho-
logic conditions in the emergency department
setting. Iodinated intravenous contrast material
when acute gastrointestinal bleeding is suspected,
three-phase multidetector CT angiography is
performed and includes non–contrast material–
enhanced, arterial phase, and portal venous phase
imaging. Arterial phase images are obtained with
bolus tracking at the abdominal aorta (150 HU,
Hounsfield unit threshold), and portal venous
phase images are obtained at 70–90 seconds fol-
lowing contrast material administration. Initial
nonenhanced imaging helps to differentiate
preexisting hyperattenuating ingested material
within the duodenal lumen from active hemor-
rhage. When a dual-energy CT scanner is used,
virtual noncontrast (VNC) images can be created
with iodine subtracted from the images, eliminat-
ing the need for a nonenhanced phase. Iodine
overlay images demonstrate active uptake of
contrast material. Active hemorrhage has uptake
on iodine overlay images, which is suppressed on
VNC images and helps to differentiate it from
1444  September-October 2020 radiographics.rsna.org

Table 2: Anatomic Relationships and Blood Supply of the Four Segments of the Duodenum

Duodenal
Segment Anterior Anatomy Posterior Anatomy Blood Supply
First Quadrate lobe of the liver Common bile duct, portal vein, head Superior pancreaticoduode-
and neck of the pancreas, gastro- nal artery, retroduodenal
duodenal artery artery
Second Gallbladder, right lobe of the Right renal hilum, right renal vessels, Superior pancreaticoduode-
liver IVC, right psoas muscle nal artery, inferior pan-
creaticoduodenal artery
Third Superior mesenteric ves- Aorta, right ureter, right psoas Inferior pancreaticoduode-
sels, root of the mesentery, muscle, right gonadal vessels, IVC nal artery
transverse mesocolon
Fourth Transverse colon, transverse Aorta, left psoas muscle, left kidney, Jejunal branches of the
mesocolon, root of the left ureter, left renal and gonadal SMA
mesentery vessels

ingested material, which remains hyperattenuat-
ing on VNC images. Oral contrast material is
not administered because it would obscure the
intravenous contrast material extravasation into
the bowel lumen (4). The use of oral contrast
material is reserved for postsurgical cases or in
the setting of penetrating trauma.
If the findings at CT angiography are incon-
clusive, radionuclide imaging with technetium
99m–tagged red blood cells can be performed.
However, availability of this modality can be
limited in the acute care setting, particularly
overnight (5). Nonenhanced CT or dual-energy
CT VNC images can confirm the presence of
traumatic or spontaneous intramural duodenal
hematoma. Plain radiography can be useful in
detecting pneumoperitoneum in some cases of
perforation, with images obtained in the upright
position being more sensitive for detection than
those obtained in the supine position. Plain
radiographs can also be obtained to assess for
the presence of foreign bodies and stent position.
Upper gastrointestinal series and/or MRI can
be used to confirm or further evaluate duodenal
pathologic conditions diagnosed at CT but are
not part of the imaging algorithm performed in
the acute setting.
Inflammatory and Infectious
Conditions of the Duodenum
Peptic ulcer disease is a common entity, affecting
about 5%–10% of the world population (6). It
is caused by an acid peptic injury of the gastro-
duodenal mucosal barrier leading to a defect in
the mucosa, which can progressively penetrate
through the muscularis into the deeper layers
(7). The large majority of duodenal and gastric
ulcers are caused by Helicobacter pylori infection
and/or use of nonsteroid anti-inflammatory drugs
(NSAIDs) (7). Duodenal ulcer occurs most com-
monly in the duodenal bulb, which is the first site
of entrance of the acid gastric contents into the
duodenum. Postbulbar ulcers are rare, and when
they occur, suspicion for an underlying cause,
such as Zollinger–Ellison syndrome or Crohn
disease, should be raised (7).
CT is the imaging modality of choice in the
emergency department setting, but diagnosing
uncomplicated ulcers can be challenging. CT
findings of uncomplicated ulcers are subtle, and
high clinical suspicion is required to prompt
closer and attentive review of the duodenum
to reach the correct diagnosis. Indirect signs of
duodenal ulcers include short segmental mural
enhancement of the duodenum with submucosal
edema, periduodenal fat stranding, and adjacent
lymphadenopathy (8). The direct signs of duode-
nal ulcer at cross-sectional imaging are occasion-
ally visualized and include focal discontinuity
of the mucosal hyperenhancement and luminal
outpouching (Fig 3).
The most common complication of peptic
ulcer disease is bleeding, diagnosed in 50–170
per 100 000 cases, followed by perforation, found
in 7–10 per 100 000 cases (9,10). Postbulbar
duodenal ulcers are associated with a higher
incidence of bleeding, with nearly 57% causing
hemorrhage (11). Posterior duodenal ulcers can
erode into the gastroduodenal artery and cause
massive hemorrhage.
The most commonly used imaging modality to
assess for an actively bleeding duodenal ulcer is
three-phase CT angiography. Nonenhanced CT
images may reveal high-attenuating intraluminal
material in the duodenum, with Hounsfield units
ranging between 30 and 45, and the highest-at-
tenuation clot is generally found near the bleed-
ing site (sentinel clot) (8). On the arterial phase
images, an intraluminal focus of high attenuation
(>90 HU) can be seen representing the contrast
RG  •  Volume 40  Number 5 Gosangi et al  1445

Figure 3.  Duodenal ulcer in a 63-year-old man. (a) Axial oral and intravenous contrast-enhanced CT image shows outpouching in
the duodenum, filled with contrast material (arrow). (b) Image from upper gastrointestinal series shows outpouching (arrow) in the
second segment of the duodenum. (c) Endoscopic image shows an ulcer with a small focal bleed (arrow).

Figure 4.  Hemorrhagic duodenal ulcer in a 63-year-old woman. (a) Axial

intravenous contrast-enhanced CT image of the abdomen obtained in the
arterial phase shows contrast material extravasation (arrow) into the second
segment of the duodenum. (b) Axial intravenous contrast-enhanced CT im-
age of the abdomen obtained in the portal venous phase shows an increase
in extravasation (arrow), indicating active hemorrhage. (c) Axial iodine over-
lay dual-energy CT image shows active bleeding (arrow). (d) Endoscopic
image shows a bleeding ulcer (arrow), which was treated with clipping.

is the imaging modality of choice in the assess-

blush. The attenuation of the contrast blush
should be equivalent to the contrast opacifica-
tion of the aorta or other adjacent arterial vessels.
On the portal venous phase images, there is an
increase in the size of the blush or a change in
its shape. If the bleeding is slow or delayed, the
extravasation may only be visualized on the portal
venous phase images. In patients who had bleed-
ing but are not actively bleeding at the time of
imaging, the only finding can be the presence of
the high-attenuation material in the nonenhanced
images.
When dual-energy CT is performed, iodine
maps can be created to depict iodine content,
which makes more evident the presence of the
intraluminal contrast blush (Fig 4). Endoscopy
ment for bleeding duodenal or gastric ulcers to
identify the site and cause of the ulcer and also to
treat it with hemostasis. On CT images, a perfo-
rated duodenal ulcer is suspected when there is
extraluminal intraperitoneal or retroperitoneal
gas, depending on which segment of the duo-
denum is involved. Additional findings include
focal duodenal wall thickening, surrounding fat
stranding, and discontinuity of the duodenal wall.
When oral contrast material is administered,
extraluminal extravasation of oral contrast mate-
rial may be seen (Fig 5) (12). Plain radiography
may detect perforation when free air is depicted
under the diaphragm on upright abdominal (or
chest) radiographs. Complications of perforated
posterior duodenal ulcers to the retroperitoneum
or adjacent organs such as the pancreas, gallblad-
der, common bile duct, and liver include abscess
formation and fistulization to the biliary tree.
Figure 6 demonstrates CT images of an ulcer
1446  September-October 2020 radiographics.rsna.org

Figure 5.  Perforated duodenal ulcer in an 81-year-old woman who underwent oral and intravenous contrast-enhanced CT of the
upper abdomen. (a) Coronal CT image shows small foci of extraluminal gas (arrow) adjacent to the second segment of the duode-
num. (b) Axial CT image shows extraluminal extravasation of oral contrast material (arrow) adjacent to the second segment of the
duodenum. (c) Axial iodine overlay dual-energy CT image shows contrast material extravasation (arrow) in orange owing to iodine
uptake by the oral contrast material.

Figure 6.  Duodenal ulcer complicated by abscess formation in a 58-year-old woman. (a) Axial oral and intravenous contrast-en-
hanced CT image of the abdomen shows a gas-containing fluid collection (dashed oval), contiguous within the second segment
of the duodenum and displacing the pancreatic head (arrow) anteriorly. (b) Image from upper gastrointestinal series obtained
after pigtail catheter placement to drain the abscess shows the pigtail catheter (arrow) terminating in the second segment of the
duodenum. (c) Axial CT image obtained following pigtail catheter placement shows a decrease in the size of the abscess (arrow).

in the second segment of the duodenum, com-
plicated by perforation and abscess formation,
displacing the pancreas anteriorly. At CT when
there is spontaneous pneumobilia in the absence
of recent instrumentation or surgery, suspicion
for a bilioenteric fistula should be raised (8).
Severe duodenal ulcers can result in stricture and
gastric outlet obstruction (13). The CT findings
of peptic ulcer disease are summarized in the
flowchart (Fig 7).
H. pylori is the most common infectious cause
of acute duodenitis (14). CT findings of acute
infectious duodenitis are nonspecific and include
circumferential wall thickening, mucosal hyper-
enhancement, and fat stranding (Fig 8a).
Pancreatitis is the most common inflamma-
tory process to affect the duodenum (13,15).
The duodenum can be directly damaged by the
pancreatic enzymes that cause mural edema and
possible obstruction of the gastric outlet or intra-
mural hematoma from the rupture of intramural
vasculature. The duodenum can also be indirectly
affected by extrinsic compression from a fluid
collection or enlarged pancreatic head (14). The
CT findings will be related to the pancreatic
inflammation associated with secondary wall
thickening and fat stranding of the duodenum.
An uncommon form of chronic pancreatitis af-
fecting the pancreaticoduodenal space is called
groove pancreatitis. The CT appearance of groove
pancreatitis ranges from ill-defined fat strand-
ing and inflammation to frank soft tissue in the
groove (Fig 8b, 8c). Retroperitoneal inflamma-
tion is usually absent. There might be masslike
enlargement of the pancreatic head, making the
differential diagnosis with pancreatic cancer im-
portant. MR cholangiopancreatography can help
make the differentiation (16,17).
Acute cholecystitis can also cause second-
ary inflammation of the duodenum owing to its
RG  •  Volume 40  Number 5 Gosangi et al  1447

Figure 7.  Flowchart shows the CT features of peptic ulcer disease.

Figure 8.  Inflammatory conditions of the duodenum. (a) Duodenitis in a 64-year-old man. Coronal contrast-enhanced CT image
shows diffuse wall thickening of the duodenum with periduodenal fat stranding, suggestive of duodenitis (arrow). (b, c) Groove
pancreatitis in a 36-year-old woman with epigastric pain and elevated lipase levels. Axial (b) and coronal (c) contrast-enhanced CT
images show a bulky pancreatic head (*), with peripancreatic stranding and fluid (arrows in b). Note the thickening of the second
segment of the duodenum, with periduodenal stranding and trace fluid (arrow in c).

proximity to the duodenal first and/or second
segments. CT images show duodenal wall thick-
ening adjacent to the inflamed gallbladder. If the
cholecystitis is severe, recurrent, or chronic, a
gallstone can erode through the gallbladder wall
into the adjacent gastrointestinal tract, most com-
monly the duodenum, and get impacted, usually
in the terminal ileum, causing bowel obstruction.
This entity is rare and is called gallstone ileus.
Bouveret syndrome is a rare variant of gallstone
ileus that occurs as a result of a gallstone eroding
through the gallbladder wall into the duodenum
causing gastric outlet obstruction (18). The Rigler
triad of pneumobilia, small bowel obstruction, and
an ectopic gallstone can be visualized at CT and
less often at plain radiography (19). However, in
some cases conventional CT images might not
depict the ectopic gallstone, which can be indis-
tinguishable from the surrounding fluid in the
bowel lumen. Dual-energy CT has been shown
to demonstrate the impacted gallstone owing to
its ability to differentiate materials on the basis of
their differential energy-dependent x-ray absorp-
tion behaviors (20,21). Also, in the setting of unex-
plained pneumobilia with or without an inflamed
gallbladder and in the absence of a gallstone ileus,
a close look at the bowel is recommended to assess
for a cholecystoenteric fistula (Fig 9) (22).
In patients with Crohn disease, duodenal
involvement is seen in about 0.5%–4.0% of cases
(22). Primary involvement manifests as ulcers
and strictures in the duodenum and secondary
involvement as a fistulous communication from
an adjacent affected loop of small bowel or colon.
CT findings of duodenal Crohn disease include
features such as duodenal wall thickening and
fat stranding. Duodenal stenosis or fistulas can
be seen in some cases. Stenosis is characterized
1448  September-October 2020 radiographics.rsna.org

Figure 9.  Bouveret syndrome in an

82-year-old woman. (a) Axial contrast-
enhanced CT image of the abdomen
shows a 3-cm gallstone (arrow) in the
first segment of the duodenum, with a
choledochoduodenal fistula (arrowhead).
(b) Coronal CT image shows pneumo-
bilia (arrow) and extensive periduodenal
stranding (arrowhead). (Case courtesy of
Daniel Souza, MD, Brigham and Women’s
Hospital, Boston, Mass.)

Figure 10.  Crohn disease stricture

of the third segment of the duo-
denum in a 47-year-old woman.
(a) Coronal iodine overlay dual-
energy CT image shows focal nar-
rowing and wall thickening of the
second and third segments of the
duodenum, with enhancing mu-
cosa (arrow). (b) Axial MR entero-
graphic image shows a distended
stomach with significant luminal
narrowing and stricture (arrow) of
the second and third segments of
the duodenum.

by short segment narrowing and wall thickening
of the duodenum with mucosal enhancement
(Fig 10). Stenosis and duodenal fistula require
prompt surgical treatment. Ulcerlike duodenal
Crohn disease is a chronic condition and medical
treatment is advised (23).
Iatrogenic Complications
Iatrogenic complications involving the duode-
num can occur after ERCP, esophagogastroduo-
denoscopy (EGD), sphincterotomy, endoscopic
polypectomy, and stent placement and include
hemorrhage, perforation, duodenal hematoma,
obstruction, and infection. The risk of bleed-
ing following EGD with biopsy is 0.3% (24),
and estimates of perforation after ERCP and
sphincterotomy range from 0.3% to 0.6% (25).
CT findings of hemorrhage include evidence of
intraluminal bleeding or intramural hematoma
(24). The CT findings of duodenal perforation
include retroperitoneal or intraperitoneal free air
and extraluminal extravasation of oral contrast
material, if administered. Occasionally, a discrete
defect in the duodenal wall may be seen (26).
Different types of stents can migrate into the
duodenum and can cause complications such as
perforation, duodenitis, and obstruction. Several
types of stents have been reported in the litera-
ture including biliary, esophageal, pancreatic, and
ureteral stents (27,28). CT can help in determin-
ing the precise location of the stent and presence
of perforation and obstruction (29).
Certain anatomic characteristics of the duo-
denum make endoscopic resection of lesions
challenging, including (a) a narrow lumen; (b) a
C-loop shape that makes maintaining endoscope
position difficult; (c) a thin deep muscle layer
that results in a higher rate of perforation; and
(d) an extensive vascular network that increases
the risk of bleeding, which can be severe and po-
tentially life threatening (30). The use of cautery
carries a risk of delayed bleeding, perforation,
and postpolypectomy coagulation syndrome
(PPCS) (31). The PPCS is the transmural wall
burn and localized peritonitis caused by electro-
coagulation without evidence of perforation on
radiologic images (32). It is an uncommon com-
plication related to polypectomy in general and
has mostly been described after colonoscopy but
is a potential complication in duodenal polypec-
tomy. CT findings of PPCS include wall thicken-
ing involving a short segment of the duodenum
with extensive periduodenal fat stranding (Fig
11) and mucosal defect at the site of the polyp-
ectomy, with fluid and fat stranding and without
extraluminal gas (33).
RG  •  Volume 40  Number 5 Gosangi et al  1449

Figure 11.  Postpolypectomy syndrome in a 42-year-old man who underwent biopsy of a duodenal
polyp on the previous day. (a) Coronal contrast-enhanced CT image of the abdomen shows extensive fat
stranding and wall thickening (arrow) of the second and third segments of the duodenum. (b) Axial CT
image shows stranding and wall thickening (arrow) of the second segment of the duodenum.

Duodenal Trauma In duodenal intramural hematomas, the thick-

Duodenal trauma is rare, with a reported inci-
dence of 0.5%–5% in abdominal trauma (34,35),
but is associated with high morbidity and mor-
tality, with mortality ranging from 6% to 29%
(36). The duodenum is relatively protected from
traumatic injury given its deep central and mostly
retroperitoneal location. Isolated duodenal inju-
ries are rare and, given the intimate relationship
of the duodenum and pancreas, they are both
frequently injured concomitantly. Penetrating
duodenal injury is the most common cause of du-
odenal trauma. In a literature review encompass-
ing 24 studies, 80% of cases occurred as a result
of penetrating trauma and 20% as a consequence
of blunt trauma (36). Blunt duodenal injuries are
most often seen with deceleration mechanism,
seat belt, or handlebar injuries, with the high
force of impact causing compression of the duo-
denum against the lumbar spine. Blunt injuries
are often more insidious in their manifestation,
making the initial diagnosis difficult (37), and the
injuries are more complex as a consequence of
crushing or compression (38).
In a literature review (38), the second seg-
ment of the duodenum was the most commonly
injured (36%), followed by the third segment
(18%), fourth segment (15%), and first segment
(13%), and multiple sites were found in 18% of
cases. Traumatic injuries of the duodenum can
be minor (contusion and hematoma) or major
(perforation, transmural laceration, or transection
and disruption of the duodeno-biliary-pancreatic
complex) (37,39). Duodenal contusions are
suspected when there is diminished bowel wall
enhancement, focal wall thickening of more than
4 mm in thickness with intramural gas, and peri-
duodenal fat stranding or fluid (Fig 12a).
ened duodenal wall demonstrates high or mixed
attenuation (Fig 12b, 12c). Nonenhanced CT
images or dual-energy VNC images are helpful in
confirming the diagnosis of hematoma. Gastric
outlet obstruction is a common complication of
duodenal hematomas (40). Perforation is diag-
nosed when there is disruption of the duodenal
wall with extravasation of oral contrast material,
adjacent extraluminal gas, and retroperitoneal
fluid collection (Fig 13a, 13b). In complete
duodenal transection, the duodenal wall is totally
disrupted with pneumoperitoneum, pneumoretro-
peritoneum, and retroperitoneal hemorrhage (Fig
13c). When isolated minor CT findings are found,
such as periduodenal fluid or hematoma, cases can
be managed conservatively with serial examination
and follow-up CT in 24 hours (37). When major
CT findings are encountered, patients usually
require surgical management.
Oncologic and Neoplastic
Emergencies
Oncologic duodenal emergencies can occur from
primary duodenal masses or from involvement
by malignancies from adjacent organs. Twenty
percent of small bowel tumors arise in the duode-
num (41). The most common malignant tumor of
the duodenum is adenocarcinoma, and the most
common benign tumor is gastrointestinal stromal
tumor (GIST) (42). Other primary small bowel
tumors include lymphoma and carcinoid (43,44).
Adenocarcinomas represent up to 80%–90% of
all primary malignant duodenal tumors (44).
At CT, adenocarcinoma typically manifests as
a focal area of wall thickening causing luminal
narrowing. However, polypoid and infiltrative
masses have been reported. Occasionally it can
1450  September-October 2020 radiographics.rsna.org

Figure 12.  Duodenal trauma. (a) Duodenal contusion in a 63-year-old man following a motor vehicle collision. Axial
CT angiogram shows diffuse wall thickening of the duodenum with hyperattenuation, likely a duodenal hematoma
(white arrow) with adjacent hemoperitoneum (*). Note the devascularization of the left kidney owing to injury to the
left renal artery (black arrow). (b, c) Duodenal hematoma in a 65-year-old man following blunt trauma to the abdo-
men. Axial (b) and coronal (c) CT angiograms of the abdomen show a high-attenuation collection centered in the
second and third segments of the duodenum, consistent with hematoma (*).

Figure 13.  Duodenal trauma in two patients. (a, b) Duodenal perforation in a 58-year-old man following a deceleration injury.
Axial (a) and coronal (b) oral and intravenous contrast-enhanced abdominal CT images show foci of extraluminal gas (arrow),
with wall thickening of the second segment of the duodenum (arrowhead). (c) Duodenal transection in a 66-year-old man follow-
ing a motor vehicle injury. Coronal contrast-enhanced CT image of the abdomen shows discontinuity of the duodenal wall (arrow)
with extensive periduodenal hemorrhage (*). Note the liver laceration (arrowhead).

manifest as a circumferential apple-core le-
sion. The tumor is often rigid and can result in
early obstruction (44). Features of gastric outlet
obstruction at CT include short segment oblit-
eration of the duodenal lumen with distention of
the stomach (Fig 14). Fewer than 5% of GISTs
affect the duodenum, nearly always in the sec-
ond through fourth segments (45). Benign and
malignant GISTs have a similar CT appearance
unless metastatic disease is present and are seen
as exophytic masses with heterogeneous en-
hancement, central necrosis, or ulceration at CT
(41,46). Lymphomas tend to be circumferential
with homogeneous enhancement, lymph node
enlargement, or both (47).
Duodenal carcinoids represent fewer than 3%
of all carcinoid tumors (45) and are depicted on
contrast-enhanced CT images as intraluminal
masses or focal circumferential wall thickening
with homogeneous hyperenhancement in the
arterial and venous phases. Desmoplastic reac-
tion of the mesentery with stellate soft-tissue
stranding and liver metastasis are accompanying
features of carcinoids.
Patients may present to the emergency depart-
ment with symptoms of gastrointestinal bleeding or
suspected gastric outlet obstruction, and occasion-
ally a duodenal mass will be diagnosed at CT.
Three-phase CT angiography should be performed
when patients are diagnosed with gastrointestinal
bleeding. The CT finding of sentinel clot sign can
help detect and localize the site of bleeding. At CT
angiography, a hemorrhagic tumor has focal con-
trast blush within the mass, a finding that increases
on delayed images (Fig 15), or active contrast
extravasation in the peritumoral region, indicating
ongoing bleeding and the need for embolization or
emergent surgical exploration (43).
Metastatic involvement of the duodenum could
be from local invasion, hematogenous spread,
or spread through the mesentery. Contiguous
tumoral extension to the duodenum can occur
from pancreatic head, gastric, gallbladder, colonic,
and hepatic cancers, which may produce duodenal
RG  •  Volume 40  Number 5 Gosangi et al  1451
displacement, obstruction, or fistulization. Malig-
nant tumors that typically spread hematogenously
are lung cancer and melanoma (45).
Another possible complication of duodenal tu-
mors is invagination or intussusception. Intestinal
invagination is rare in adults. About 90% of oc-
currences in adults have a well-defined pathologic
lead point that may be benign or malignant (48).
Intussusceptions originating in the duodenum are
rare. They can be divided into duodenoduodenal
and duodenojejunal. The clinical presentation can
be related to gastric outlet obstruction or biliary
and pancreatic drainage obstruction. CT images
demonstrate a bowel-within-bowel configuration,
with or without contained fat or mesenteric ves-
sels (Fig 16) (48).
Vascular Abnormalities of the
Duodenum
Spontaneous intramural small bowel hematoma
is associated with bleeding disorders and the
administration of anticoagulation therapy and
usually involves a longer segment of bowel com-
pared to traumatic hematomas (49). Although
uncommon, spontaneous duodenal hematomas
can cause upper gastrointestinal tract obstruction
and hemorrhage, jaundice, and pancreatitis (50).
Nonenhanced CT findings include homogeneous
and circumferential intramural thickening with
hyperattenuating material (30–80 HU) in the
Figure 14.  Gastric outlet obstruction from a
biopsy-proven duodenal adenocarcinoma in a
62-year-old man. (a) Coronal intravenous and
oral contrast-enhanced CT image shows an infil-
trative mass in the third segment of the duode-
num causing near-complete obliteration of the
duodenal lumen (arrow) with dilatation of the
stomach (*). (b) Image from upper gastrointesti-
nal series shows a long nonopacified segment of
the third segment of the duodenum (arrow) with
dilatation of the stomach (*).
Figure 15.  Duodenal metastatic disease in a
72-year-old woman with known lung cancer.
(a) Axial contrast-enhanced CT image shows a
small focus of hemorrhage (arrow) in the sec-
ond segment of the duodenum. (b) Axial CT
image obtained in the delayed phase shows
change in the shape and mild increase in the
size of the hemorrhage (arrow), findings consis-
tent with active hemorrhage.
bowel wall. As the hematoma ages, it reduces
in size and its attenuation decreases, and it can
evolve into a hypoattenuating area that can mimic
an intramural cystic lesion (Fig 17) (51,52).
When dual-energy CT is performed, VNC images
are helpful in confirming the lack of enhance-
ment, as well as the high attenuation of blood
products in the hyperacute phase.
Aortoenteric fistula (AEF) is the abnormal
communication between the aorta and bowel.
The duodenum is the most commonly affected
bowel segment, mostly the second and third
segments, and this condition is referred to as aor-
toduodenal fistula (ADF). It is a life-threatening
condition and without prompt surgical interven-
tion the associated mortality approaches 100%.
AEF may be primary or secondary in cause.
Primary AEF is rare and almost always associated
with a preexisting aortic aneurysm. It is a direct
communication between the native aorta and the
adjacent bowel, with no history of prior aortic
surgery or trauma. Secondary AEF is far more
common but still relatively rare (53). It occurs as
a complication of aortic reconstructive surgery
with or without the placement of an aortic stent
graft. Secondary fistulas that result from perigraft
infection may occur between 2 weeks and 10
years after surgery (54).
Three-phase CT angiography is the imag-
ing modality of choice for the diagnosis of ADF.
1452  September-October 2020 radiographics.rsna.org

Figure 16.  Duodenoduodenal

intussusception in an 89-year-old
woman. Coronal (a) and axial (b)
CT images of the abdomen show
a bowel-within-bowel appearance
(arrow) owing to telescoping of
one segment of the duodenum
into another segment of the duo-
denum. Follow-up endoscopy
(not shown) helped to confirm
a duodenal mass, which was the
lead point for the intussusception.
The results of a biopsy confirmed
adenocarcinoma.

Figure 17.  Spontaneous duodenal he-

matoma in a 56-year-old man undergo-
ing anticoagulant therapy who experi-
enced sudden onset of abdominal pain.
(a) Axial CT image of the abdomen shows
high-attenuation material with focal areas
of low attenuation within the second
segment of the duodenum, consistent
with duodenal hemorrhage (arrow).
(b) Axial CT image obtained at follow-
up 2 weeks later shows evolution of the
hematoma (white arrow), which has de-
creased in size, and improved periduode-
nal hemorrhage (yellow arrow).

The presence of intraluminal gas in the aorta or
adjacent to it, breach of the aortic wall, and active
extravasation of contrast material into the duode-
nal lumen are specific CT findings for the diag-
nosis of an ADF (54). Less specific CT imaging
findings are periaortic fat stranding or soft-tissue
attenuation surrounding the aorta, with oblitera-
tion of the fat planes between the aorta and the
duodenum, thickening of the duodenal loop lying
adjacent to the aorta, and pseudoaneurysm (Fig
18). It is important to know that similar findings
are expected following aortic surgery. Therefore,
evaluation of the timing and evolution of the
findings is key. After 3–4 weeks, any ectopic gas
is abnormal and should be considered a sign
of perigraft infection and possibly fistulization
to bowel. Periaortic soft tissue and fluid should
resolve in 2–3 months (54,55).
Superior mesenteric artery (SMA) syndrome is
an uncommon condition (incidence, 0.1%–0.3%)
characterized by compression of the third segment
of the duodenum between the aorta and the SMA
(14). It is caused by loss of retroperitoneal fatty
tissue, which leads to narrowing of the distance
and angle between the aorta and the SMA (14).
The angle and distance between the aorta and
SMA can be measured on sagittal CT reforma-
tions. A normal aortomesenteric angle measures
38°–56° and a normal aortomesenteric distance
measures 10–28 mm (56). CT images show nar-
rowing of the aortomesenteric angle to less than
22° and narrowing of aortomesenteric distance to
less than 8–10 mm (Fig 19) (14). The diagnosis of
SMA syndrome must be based on clinical symp-
toms correlated with radiologic findings (57).
Gastroduodenal and pancreaticoduodenal ar-
tery pseudoaneurysms are rare, with an incidence
rate of 1.5% and 1.3% of all visceral artery an-
eurysms, respectively. They can be secondary to
complications of pancreatitis or occur following
intervention. Gastroduodenal pseudoaneurysms
are associated with duodenal ulcers. Rupture
of an arterial pseudoaneurysm is an emergency
(58–60). CT angiography is the best imaging
modality to aid in diagnosing a pseudoaneu-
rysm, showing focal arterial dilatation. If there is
pseudoaneurysmal rupture, CT angiography will
show contour irregularity of the pseudoaneurysm
and the presence of intraluminal contrast mate-
rial extravasation in the arterial phase, indicating
acute hemorrhage, which increases in delayed
phases (Fig 20). Periduodenal hematoma can be
RG  •  Volume 40  Number 5 Gosangi et al  1453

Figure 18.  ADF in a 61-year-old woman after aortoiliac stent placement. (a) Axial CT angiogram in the arterial phase
shows extensive periaortic stranding and soft-tissue thickening (white arrow), with a small focus of intravenous contrast
material in the third segment of the duodenum (yellow arrow). (b, c) Coronal CT angiograms obtained in the arterial
phase show periaortic stranding and soft-tissue thickening (arrow in b) and a small amount of contrast material in the
duodenum (arrow in c). The constellation of findings is consistent for ADF. The patient died less than 24 hours later.

Figure 19.  SMA syndrome in a

37-year-old woman. (a) Axial con-
trast-enhanced CT image shows
significant decrease in the distance
between the aorta and the SMA
(aortomesenteric distance), mea-
suring 4 mm (arrow). (b) Sagit-
tal contrast-enhanced CT image
shows a decrease in the angle be-
tween the aorta and the SMA (aor-
tomesenteric angle) (circle) to 12°.

Figure 20.  Duodenal hemorrhage secondary

to rupture of an inferior pancreaticoduodenal
artery aneurysm in a 65-year-old man. (a) Axial
CT angiogram of the abdomen shows a 7-mm
aneurysm (dashed circle) with surrounding he-
matoma (*). (b) Angiogram shows a 7-mm an-
eurysm in the inferior pancreaticoduodenal ar-
tery (arrow), which was coiled. (Case courtesy of
Jennifer W. Uyeda, MD, Brigham and Women’s
Hospital, Boston, Mass.)

seen when the bleeding is extensive. The diag-
nosis of pseudoaneurysm can be confirmed and
treated at angiography.
Ischemic duodenitis is caused by splanchnic
arterial insufficiency and is rare because the
duodenum has a rich collateral blood supply. At
least two or three vessels must be occluded or
severely stenosed owing to atheromatous disease
for ischemia to occur. CT images show segmen-
tal wall thickening of the duodenum and lack of
mucosal enhancement, submucosal hemorrhage,
or hyperemia. Other typical findings are pneu-
matosis intestinalis and gas in the mesenteric or
portal vein (61). Duodenal ischemia can be a
complication from midgut volvulus in the pres-
ence of malrotation.
Congenital Anomalies
Annular pancreas is an uncommon congeni-
tal migratory anomaly that leads to a segment
of the pancreas encircling the duodenum. The
reported prevalence varied between five and 15
per 100 000 in adults in a cadaveric case series to
one in 250 in an ERCP study (62). The second
segment of the duodenum is affected in 85% of
cases. The diagnosis is made when pancreatic tis-
sue and an annular duct are depicted encircling
the descending duodenum on CT or MR images.
1454  September-October 2020 radiographics.rsna.org
Figure 21.  Duodenal diverticulitis in a 45-year-
old woman. (a) Coronal enhanced CT image
shows an outpouching from the medial wall of
the second segment of the duodenum, repre-
senting a noninflamed diverticulum (arrow) as
an incidental finding. (b) Coronal enhanced
CT image obtained after the patient presented
with abdominal pain months later shows fluid
in the diverticulum, with extensive surrounding
fat stranding (dashed oval) and wall thickening,
consistent with acute duodenal diverticulitis.
If the encircling of the duodenum is incomplete, a
crocodile jaw–like configuration is depicted, with
pancreatic tissue anterior and posterior to the
duodenum (incomplete annular pancreas) (62).
Annular pancreas may be an incidental finding or
may manifest with duodenal obstruction early in
life or with pancreatitis in adults (63,64). In the
emergency department setting, annular pancreas
should be considered in patients presenting with
acute or recurrent pancreatitis when common
causes have been ruled out (65).
Malrotation refers to an abnormal position of
the intestine within the peritoneal cavity owing to
the failure of the bowel to complete its rotational
sweep during embryologic development (14).
Malrotation occurs in 0.2%–1% of the normal
population (66), and although complications
are most commonly seen in childhood, approxi-
mately 40% of cases manifest in adulthood (67).
The most common result of malrotation is the
duodenum not crossing the midline and remain-
ing in the right side of the abdomen, the cecum
lying to the left of the midline, the short mesen-
tery lacking fixation, and peritoneal (Ladd) bands
passing from the cecum to the right side across
the duodenum (14).
At CT, the duodenum is not visible between
the aorta and the SMA, the expected normal
anatomic relationship. Secondary findings of mal-
rotation include reversed location of the superior
mesenteric artery and vein and presence of the
colon in the left side of the abdomen and the
small bowel in the right side (13). Midgut volvu-
lus may occur if there is twisting of the narrow
mesentery, with compromise of the venous drain-
age and subsequently of the arterial supply to the
intestine and possible bowel ischemia (66,68).
Duodenal obstruction can also occur owing to
compression from the peritoneal bands.
Miscellaneous Conditions
Duodenal diverticulosis is a common entity and
has a prevalence of up to 23% (69) and is the
second most common location of diverticulosis
after the colon. Duodenal diverticula may be con-
genital or acquired (with the latter being more
common) and, like pulsion diverticula manifest-
ing elsewhere in the gastrointestinal tract, are
formed by protrusion of the mucosa, muscularis
mucosa, or submucosa through a focal weakness
in the duodenal wall (69). They occur in the sec-
ond through fourth segments of the duodenum,
usually along its medial aspect, with 62% arising
from the second segment (70). Duodenal diver-
ticulum is usually incidentally found on CT im-
ages, depicted as a focal duodenal outpouching,
and may resemble a masslike structure between
the duodenum and pancreas containing air, an
air-fluid level, fluid, contrast material, or debris
(71,72). It is important to recognize this entity,
as its radiologic features can mimic other intra-
abdominal processes such as cystic pancreatic
neoplasms or complications from pancreatitis.
Duodenal diverticula are usually asymptom-
atic, with less than 10% causing symptoms (73).
Bleeding and perforation are the most frequently
reported complications (74). CT angiography may
detect high-attenuation intraluminal material and/
or active extravasation of contrast material into
the duodenal lumen in cases of bleeding duodenal
diverticulosis. CT findings of perforated duodenal
diverticulosis include extraluminal gas and mes-
enteric fat stranding, with or without fluid. Unlike
colonic and jejunoileal diverticula, duodenal di-
verticula are less likely to become infected. This is
probably because of their larger size and relatively
sterile liquid duodenal contents (72). CT findings
of duodenal diverticulitis are similar to those of
diverticulitis in other locations, with fat strand-
ing adjacent to the duodenal diverticulum and
focal wall thickening (Fig 21) (75). Periampullary
diverticulum can cause obstructive jaundice by
mechanical compression of the common bile duct
(Lemmel syndrome).
Bezoars result from the accumulation of undi-
gested or partially digested material in the form
RG  •  Volume 40  Number 5 Gosangi et al  1455
Figure 22.  Bezoar in the duodenum. (a) Coronal contrast-enhanced CT image shows low attenuation and heterogenous material
filling and distending the stomach and the second and third segments of the duodenum (arrows). (b) Endoscopic image shows a
large hair-containing mass, consistent with a trichobezoar. (c) Photograph shows a large trichobezoar that was surgically removed.
(Case courtesy of Jennifer W. Uyeda, MD, Brigham and Women’s Hospital, Boston, Mass.)
of concretions in the gastrointestinal tract. The
true incidence of bezoars is unknown. However,
the reported incidence was found in less than
1% of patients undergoing upper gastrointestinal
endoscopy. They are classified on the basis of their
content (76). The major types are phytobezoars
(fruit or vegetable matter), trichobezoars (hair),
pharmacobezoars (medication such as tablets or
semiliquid drugs), and lactobezoars (concentrated
milk formulas) (77). When present in the duode-
num, they can cause gastric outlet obstruction.
Bezoars appear as low-attenuation intraluminal
objects in the gastrointestinal tract at CT (Fig
22). Endoscopy helps in identifying and retrieving
the bezoar. Surgery may be needed if endoscopic
therapy fails or if there is a complication related to
the bezoar, such as obstruction or bleeding.
Foreign body ingestion occurs primarily in chil-
dren and in adult patients with psychiatric disor-
ders. Not having a clear history about the ingestion
of a foreign body makes this a diagnostic challenge.
Abdominal radiography is useful in identifying
the presence of a radiopaque foreign body and its
approximate location. CT can aid in the deter-
mination of its precise location and identifying
the presence of complications such as duodenitis,
obstruction, and perforation (78). Various types
of stents can migrate into the duodenum and can
cause complications such as perforation, duode-
nitis, and obstruction. Several types of stents have
been reported in the literature, including biliary,
esophageal, pancreatic, and ureteral stents (27,28).
Conclusion
The anatomic location of the duodenum, with
both intraperitoneal and retroperitoneal seg-
ments, and its close relationship with adjacent
structures result in its involvement by a multitude
of pathologic entities. CT plays an important role
in the diagnosis of emergent duodenal processes
and their complications. Knowledge of the imag-
ing findings of these entities and which segments
of the duodenum are more commonly involved
is important to make an accurate diagnosis and
prompt adequate treatment and management.
The radiologist should be aware that some find-
ings are subtle and that correlation with the clini-
cal presentation and relevant patient history are
important to reach the correct diagnosis.
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