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Duodenum

The duodenum is the first and shortest segment of the small intestine, measuring approximately 25 to 30 cm in length and named for its approximate span of twelve fingers' breadth (from the Latin duodenum digitorum).^[1] It forms a C-shaped structure that encircles the head of the pancreas, connecting the pylorus of the stomach to the jejunum, and with most of it (parts 2–4) positioned retroperitoneally in the upper abdomen, inferior to the liver and anterior to the right kidney.^[1]^[2] Divided into four distinct parts—the superior (first) portion, also known as the duodenal bulb or cap; the descending (second) portion; the horizontal or inferior (third) portion; and the ascending (fourth) portion—the duodenum receives partially digested food (chyme) from the stomach and facilitates the initial stages of nutrient absorption and further chemical digestion.^[1] In the descending part, it receives bile from the gallbladder via the common bile duct at the major duodenal papilla and pancreatic enzymes through the pancreatic duct, neutralizing gastric acidity and breaking down fats, proteins, and carbohydrates.^[1]^[2] The duodenal mucosa, lined with villi and microvilli, enhances surface area for absorbing vitamins, minerals, sugars, fats, and amino acids, while specialized cells secrete hormones such as secretin (to regulate pH and stimulate pancreatic bicarbonate release) and cholecystokinin (to control gastric emptying and gallbladder contraction).^[1] Its blood supply arises from branches of the gastroduodenal and superior mesenteric arteries, ensuring robust perfusion for these metabolic activities, and it is innervated by both parasympathetic (vagal) and sympathetic nerves to coordinate motility and secretion.^[1] Embryologically derived from the foregut, the duodenum's fixed position and proximity to adjacent organs like the pancreas and liver make it clinically significant in conditions such as peptic ulcers, obstructions, and malignancies, though it plays a foundational role in overall gastrointestinal homeostasis.^[1]

Anatomy

Gross Structure and Parts

The duodenum is the initial segment of the small intestine, forming a C-shaped or horseshoe-shaped structure approximately 25 to 30 cm in length that encircles the head of the pancreas and connects the pylorus of the stomach to the jejunum.^[1]^[3] It is primarily retroperitoneal, except for the proximal 2 to 3 cm of its first part, which is intraperitoneal, and is divided into four distinct parts based on their orientation and anatomical relations: the superior (first), descending (second), inferior or horizontal (third), and ascending (fourth) parts.^[4]^[5] The superior part, also called the duodenal bulb or cap, measures about 5 cm and begins immediately distal to the pyloroduodenal junction, curving slightly to the right before turning inferiorly at the superior duodenal flexure.^[4] This segment features a dilated proximal end known as the duodenal bulb and serves as the attachment site for the hepatoduodenal ligament, which conveys the portal vein, proper hepatic artery, and common bile duct to the liver.^[1] The descending part, approximately 7 to 8 cm long, extends downward along the right lateral aspect of the first to third lumbar vertebrae, ending at the inferior duodenal flexure.^[4] It is marked by key entry points for digestive secretions, including the major duodenal papilla (ampulla of Vater) on its posteromedial wall, where the common bile duct and main pancreatic duct converge to open, and a nearby minor (accessory) duodenal papilla for the accessory pancreatic duct.^[5]^[3] The inferior (horizontal) part, about 10 cm in length, courses transversely across the abdominal cavity from right to left at the level of the third lumbar vertebra, passing anterior to the abdominal aorta and inferior vena cava.^[4] This segment lies posterior to the root of the mesentery and superior mesenteric vessels, contributing to the overall C-shaped curvature of the duodenum.^[3] The ascending part, roughly 2.5 cm long, rises cephalad on the left side of the second lumbar vertebra, terminating at the duodenojejunal flexure where it transitions into the jejunum.^[4] It is anchored to the posterior abdominal wall by the suspensory muscle of the duodenum (ligament of Treitz), which provides fixation and support at this junction.^[1] The mucosal surface throughout the duodenum exhibits longitudinal folds that give rise to plicae circulares (valvulae conniventes), permanent circular folds that commence in the second part and enhance the internal surface area.^[3]^[5]

Location and Relations

The duodenum occupies the upper posterior abdominal cavity, forming a C-shaped curve that encircles the head of the pancreas within the supramesocolic compartment. It extends from the pylorus of the stomach to the duodenojejunal flexure, measuring approximately 25–30 cm in length, and lies anterior to the lumbar vertebral column at levels L1 to L3. Primarily retroperitoneal in position—fixed to the posterior abdominal wall without a mesentery—the duodenum's second, third, and most of the fourth parts are immobile, while the initial 2–2.5 cm of the superior part remains intraperitoneally mobile. This retroperitoneal fixation stabilizes the organ but complicates surgical mobilization and increases vulnerability to extrinsic compression from adjacent structures. The superior (first) part courses horizontally to the right at the level of L1, relating anteriorly to the quadrate lobe of the liver, gallbladder, and pylorus, and posteriorly to the common bile duct, gastroduodenal artery, portal vein, and inferior vena cava. The descending (second) part extends vertically downward along the right side from L1 to L3, positioned anterior to the right kidney, its hilum, renal vessels, ureter, and psoas major muscle, while lying posterior to the transverse colon and its mesocolon; the head of the pancreas nestles within its medial concavity. The inferior (third) part traverses horizontally from right to left at L3, crossing anterior to the inferior vena cava and abdominal aorta, with the superior mesenteric artery and vein anteriorly, and relates inferiorly to the head of the pancreas. The ascending (fourth) part rises obliquely leftward from L3 to L2, anterior to the left psoas major muscle and relating posteriorly to the root of the mesentery and loops of jejunum, with the left kidney positioned laterally; it terminates at the duodenojejunal flexure, where it joins the jejunum. Peritoneally, the duodenum attaches via the hepatoduodenal ligament, which connects the superior part to the porta hepatis of the liver and encloses the portal triad (portal vein, proper hepatic artery, and common bile duct). Additionally, the paraduodenal recess—a small peritoneal fossa—lies to the left of the ascending part's termination, bounded anteriorly by the paraduodenal fold containing the inferior mesenteric vein, forming part of the superior duodenal recess near the duodenojejunal junction. These anatomical relations significantly influence surgical access and potential pathological effects. The retroperitoneal embedding and close proximity to the pancreas and major vessels necessitate maneuvers like Kocherization, which incises the lateral peritoneal reflection to mobilize the descending and horizontal parts for procedures such as pancreaticoduodenectomy or right nephrectomy, reducing risks of inadvertent injury. Conversely, the fixed position between the superior mesenteric artery anteriorly and the aorta posteriorly predisposes the horizontal part to compression in conditions like superior mesenteric artery syndrome, where reduced mesenteric fat leads to vascular impingement and obstructive symptoms.

Blood Supply and Innervation

The arterial supply to the duodenum is derived primarily from the gastroduodenal artery, a branch of the common hepatic artery from the celiac trunk, which gives rise to the anterior and posterior superior pancreaticoduodenal arteries supplying the first two parts (superior and descending).^[1] The third and fourth parts (horizontal and ascending) receive blood from the anterior and posterior inferior pancreaticoduodenal arteries, branches of the superior mesenteric artery.^[1] These superior and inferior pancreaticoduodenal arteries form anterior and posterior pancreatoduodenal arcades that anastomose, providing collateral circulation and vasa recta branches to the duodenal wall.^[6] Minor contributions arise from branches of the hepatic artery.^[1] Venous drainage parallels the arterial supply, with the superior pancreaticoduodenal veins draining into the portal vein and the inferior pancreaticoduodenal veins joining the superior mesenteric vein, which also contributes to the portal system.^[7] Innervation of the duodenum includes sympathetic fibers from the celiac and superior mesenteric plexuses, originating from preganglionic neurons in the thoracic spinal cord (T5-T9 via greater splanchnic nerves and T10-T11 via lesser splanchnic nerves), which synapse in the celiac and superior mesenteric ganglia before distributing postganglionic fibers along arterial branches.^[1] Parasympathetic innervation is provided by preganglionic fibers from the anterior and posterior vagus nerves (cranial nerve X), traveling through the celiac plexus to synapse in the enteric plexuses with short postganglionic fibers.^[1] The intrinsic enteric nervous system, consisting of the myenteric (Auerbach's) plexus between the longitudinal and circular muscle layers for motor control and the submucosal (Meissner's) plexus in the submucosa for secretory and vasomotor regulation, coordinates local reflexes independently but modulates extrinsic inputs.^[8]

Lymphatic Drainage

The lymphatic drainage of the duodenum occurs primarily through the pancreaticoduodenal lymph nodes, which are divided into anterior and posterior groups located along the superior and inferior pancreaticoduodenal arteries forming the pancreaticoduodenal arcade.^[9] The anterior group collects lymph from the anterior aspects and drains into the pancreaticoduodenal nodes, while the posterior group gathers from the posterior surfaces and connects to nodes around the pancreatic head.^[9] From these pancreaticoduodenal nodes, efferent vessels proceed to the pyloric and hepatic lymph nodes, and subsequently to the celiac and superior mesenteric nodes, ultimately converging into the cisterna chyli to enter the thoracic duct.^[9] The superior regional nodes drain toward the gastroduodenal nodes, whereas the inferior group directs flow to the nodes at the root of the mesentery.^[9] This pathway supports immune surveillance by transporting lymph and potential pathogens from the duodenal mucosa to systemic circulation. The arrangement of lymphatic vessels in the duodenum parallels the arterial supply, facilitating efficient drainage.^[10] Within the duodenal wall, lymphatics form interconnected plexuses in the mucosal, submucosal, and serosal layers, with mucosal and muscularis vessels emptying into the submucosal network before converging toward collecting trunks near the major duodenal papilla.^[11] In the context of duodenal malignancies, such as adenocarcinoma, these drainage patterns are essential for determining lymph node involvement in tumor staging. According to the American Joint Committee on Cancer (AJCC) 8th edition, regional node metastasis is classified as N1 if involving 1 to 3 nodes or N2 if 4 or more, which directly impacts prognosis, surgical extent, and adjuvant therapy decisions.^[12]

Histology

The wall of the duodenum is organized into four distinct layers, consistent with the general structure of the small intestine: the mucosa, submucosa, muscularis externa, and serosa (or adventitia in retroperitoneal portions). The innermost mucosa features finger-like projections called villi covered by simple columnar epithelium with microvilli on the apical surface of enterocytes, enhancing surface area for absorption; it includes the lamina propria (loose connective tissue with blood vessels and lymphoid elements) and a thin muscularis mucosae of smooth muscle. The submucosa consists of dense irregular connective tissue containing larger blood vessels, nerves, and the submucosal (Meissner's) plexus, which regulates glandular secretion and local blood flow. The muscularis externa comprises an inner circular layer and an outer longitudinal layer of smooth muscle, separated by the myenteric (Auerbach's) plexus that coordinates peristalsis; the retroperitoneal portions of the duodenum are covered by adventitia rather than a complete serosa, while intraperitoneal segments have a serosal layer of simple squamous epithelium supported by connective tissue.^[1]^[13]^[14] The mucosal epithelium of the duodenum is composed of several specialized cell types adapted for digestion and protection. Enterocytes (absorptive columnar cells) predominate, featuring a brush border of microvilli (approximately 1-2 μm long) that house digestive enzymes and facilitate nutrient uptake. Goblet cells are interspersed, secreting mucus to lubricate and protect the surface; Paneth cells, located at the base of crypts of Lieberkühn, produce antimicrobial peptides and enzymes stored in eosinophilic granules. Endocrine cells, such as S cells, are also present, releasing hormones like secretin in response to luminal pH changes. These cells arise from stem cells in the crypts, with the epithelium renewing every 4-6 days.^[13]^[14]^[13] Unique to the duodenum are the prominent Brunner's glands in the submucosa, which are compound tubuloacinar structures lined by mucous cells that secrete an alkaline mucus rich in bicarbonate to neutralize gastric acid entering from the pylorus; their ducts penetrate the muscularis mucosae to open at the base of villi. Additionally, the duodenum exhibits denser lymphoid tissue compared to more distal segments, with scattered lymphoid follicles (early forms of Peyer's patches) in the lamina propria providing immune surveillance against luminal pathogens. The myenteric and submucosal plexuses, part of the enteric nervous system, are briefly noted here for their structural integration but detailed innervation is covered elsewhere.^[13]^[14]^[13] In comparison to the jejunum, the duodenal villi are shorter and more variable in height (with a villus-to-crypt ratio of 3-5:1), and the submucosa contains abundant Brunner's glands absent in the jejunum; these adaptations reflect the duodenum's proximal role in acid neutralization and initial processing rather than maximal absorption.^[13]^[14]

Development and Variations

Embryological Development

The duodenum originates from the caudal portion of the foregut and the cranial portion of the midgut during weeks 4 to 8 of human embryogenesis, with its proximal half (up to the major duodenal papilla) deriving from endodermal foregut tissue and the distal half from midgut endoderm.^[15]^[16]^[17] This dual origin reflects the transitional nature of the duodenum at the foregut-midgut junction, where the epithelium arises from endoderm and the surrounding mesenchyme from splanchnic mesoderm, establishing the basic tubular structure as part of the primitive gut tube formed by lateral folding of the embryo.^[18] A critical early milestone involves temporary luminal occlusion due to rapid proliferation of endodermal cells around weeks 5 to 6, followed by recanalization through vacuole formation and apoptosis by week 8, restoring patency throughout the gastrointestinal tract including the duodenum.^[15]^[18]^[17] Failure of this recanalization process results in duodenal atresia or stenosis, a congenital obstruction often associated with Down syndrome and detectable prenatally via the "double-bubble" sign on ultrasound.^[15]^[19] The duodenum's characteristic C-shape and retroperitoneal position emerge through a series of rotational movements, beginning with a 90-degree counterclockwise rotation around the superior mesenteric artery axis during the fourth to seventh weeks, which positions it against the dorsal body wall and fuses its mesentery posteriorly.^[18]^[16] This primary rotation is coupled with the stomach's 90-degree clockwise turn, bending the duodenum rightward, while the broader midgut loop undergoes an additional 180-degree counterclockwise rotation during herniation and reduction phases to complete the 270-degree total shift.^[17]^[19] Disruptions in this process, such as incomplete rotation, can lead to intestinal malrotation, altering the duodenum's final relations.^[19] Vascular development plays a pivotal role in duodenal positioning, as the superior mesenteric artery arises from the persistence and fusion of vitelline arteries—embryonic vessels supplying the yolk sac—serving as the fixed axis for midgut rotation and defining the foregut-midgut boundary through its branches to the distal duodenum.^[20]^[19] During weeks 6 to 10, the midgut (including the distal duodenum) herniates into the umbilical cord as a U-shaped loop due to rapid growth outpacing abdominal space, then reduces back into the coelom as the liver shrinks and the cavity expands, finalizing the duodenum's C-shaped configuration encircling the pancreas head.^[19]^[18]

Anatomical Variations

The duodenum exhibits a range of anatomical variations, including congenital deviations in rotation, fixation, and associated structures, which can influence surgical approaches despite often being asymptomatic. Duodenal malrotation, a failure in the normal counterclockwise rotation of the midgut during embryogenesis, occurs in 0.2-1% of the population and frequently presents without symptoms in adults.^[21] Annular pancreas, characterized by a ring of pancreatic tissue encircling the second part of the duodenum, has a prevalence of 5-15 per 100,000 adults as reported in autopsy studies.^[22] Juxtapapillary duodenal diverticula, outpouchings near the ampulla of Vater, affect 9-27% of adults undergoing endoscopic evaluation and are usually benign.^[23] Vascular anomalies of the duodenum include a replaced right hepatic artery arising from the superior mesenteric artery, which courses anteriorly across the pancreatic head and duodenum in 11-21% of cases, increasing the risk of inadvertent injury during procedures like pancreaticoduodenectomy.^[24] The inferior pancreaticoduodenal artery, a key contributor to duodenal blood supply, is absent in 1-2.5% of individuals, often with compensatory flow from adjacent vessels such as the dorsal pancreatic artery.^[7] Positional variants involve incomplete retroperitoneal fixation, leading to a mobile duodenum that may predispose to volvulus or abnormal positioning, though specific prevalence data are limited and often overlap with malrotation cases.^[25] Duodenal duplication cysts, fluid-filled sacs sharing a muscular wall with the native duodenum, comprise 2-12% of all gastrointestinal duplications and occur in fewer than 1 per 100,000 live births.^[26] These variations are commonly identified as incidental findings on cross-sectional imaging modalities like computed tomography or magnetic resonance imaging, which provide essential details for surgical planning and risk assessment.^[27]

Gene and Protein Expression

The duodenum exhibits a distinct genetic profile characterized by the expression of genes encoding key digestive enzymes, nutrient transporters, and regulatory hormones. Genes such as SI (sucrase-isomaltase) and ALPI (intestinal alkaline phosphatase) are prominently expressed, facilitating carbohydrate hydrolysis and pH regulation at the brush border.^[28] Transporter genes from the SLC family, including SLC15A1 (PEPT1) for peptide uptake and SLC11A2 (DMT1) for iron absorption, are highly active in duodenal enterocytes to support nutrient acquisition in the proximal gut.^[29] Hormone-encoding genes like CCK (cholecystokinin) and SCT (secretin), produced by enteroendocrine I and S cells respectively, regulate pancreatic secretion and biliary function in response to luminal contents.^[30] Protein expression in the duodenal mucosa reflects its specialized roles in digestion and protection. Brush border enzymes such as sucrase-isomaltase and intestinal alkaline phosphatase are abundantly expressed on the apical membrane of enterocytes, enabling efficient breakdown of disaccharides and phosphates.^[31] In Brunner's glands, mucin MUC6 is specifically secreted, forming a protective alkaline mucus layer that shields the epithelium from acidic chyme.^[32] Spatial patterns of gene expression within the duodenum demonstrate gradients along its anatomical parts, with higher levels of antimicrobial peptides like β-defensins (DEFB1) observed in the proximal segments to counter microbial exposure from gastric contents.^[33] This proximal enrichment supports innate defense mechanisms, contrasting with more distal expression of other defensins. Recent studies post-2020 have highlighted the role of duodenal genes in metabolic signaling, such as those involved in nutrient sensing and energy homeostasis pathways, including upregulated innate immune and transporter genes that influence systemic metabolism via interactions with the microbiota.^[34] For instance, multi-omics analyses reveal duodenal expression of genes in TLR-NFκB pathways linking microbial signals to metabolic regulation.^[35]

Physiology

Role in Digestion

The duodenum serves as the initial site for the continuation of digestion, receiving partially digested food, known as chyme, from the stomach through the pyloric sphincter.^[36] This sphincter regulates the controlled release of chyme, preventing rapid influx that could overwhelm duodenal processing. Upon entry, the chyme mixes with bile secreted from the gallbladder via the cystic duct, which joins the common bile duct, and pancreatic juice delivered through the main pancreatic duct at the major papilla (also called the ampulla of Vater).^[37] Bile emulsifies fats, while pancreatic juice provides enzymes and bicarbonate, initiating further chemical breakdown in the alkaline environment of the duodenum.^[38] The highly acidic chyme (pH 2-3) from the stomach requires rapid neutralization to protect the duodenal mucosa and enable optimal enzyme function. This process occurs primarily through bicarbonate ions secreted by the pancreas, stimulated by the hormone secretin released from duodenal S cells in response to low pH.^[39] Additionally, Brunner's glands in the duodenal submucosa contribute bicarbonate-rich mucus, further buffering the chyme and raising the pH to approximately 6-7, which is essential for the activity of pancreatic enzymes.^[38] Enzymatic digestion in the duodenum focuses on the breakdown of carbohydrates, lipids, and proteins. Pancreatic amylase hydrolyzes starches into maltose and maltotriose, while pancreatic lipase, aided by bile salts, digests triglycerides into fatty acids and monoglycerides.^[37] Protein digestion advances through pancreatic proteases: trypsinogen, chymotrypsinogen, and procarboxypeptidase are secreted as inactive zymogens and activated in the duodenal lumen. Enterokinase, an enzyme on the duodenal brush border, converts trypsinogen to active trypsin, which in turn activates the other zymogens into chymotrypsin, carboxypeptidase, and elastase for peptide bond cleavage.^[37] The hormone cholecystokinin (CCK), released from duodenal I cells in response to fats and proteins, stimulates pancreatic enzyme secretion to support this process.^[38] Mechanical digestion in the duodenum involves peristaltic waves that propel chyme forward and segmentation contractions that mix it thoroughly with digestive secretions.^[36] These movements are coordinated by the enteric nervous system but modulated by duodenal hormones such as CCK and secretin, which influence overall gastrointestinal motility to ensure efficient exposure of chyme to enzymes and the mucosal surface.^[38]

Nutrient Absorption and Secretion

The duodenum plays a pivotal role in the initial stages of nutrient absorption from the intestinal lumen, primarily handling minerals and vitamins that require an acidic or proximal environment for optimal uptake. Iron absorption occurs predominantly here through the divalent metal transporter 1 (DMT1), a proton-coupled symporter that facilitates the entry of ferrous iron (Fe²⁺) across the apical membrane of enterocytes, enhanced by the low pH from gastric acid that maintains iron solubility.^[40]^[41] Calcium is absorbed via the transcellular pathway, involving the transient receptor potential vanilloid 6 (TRPV6) channel for apical entry, intracellular buffering by calbindin-D9k, and basolateral extrusion through plasma membrane Ca²⁺-ATPase (PMCA1b), with vitamin D₃ upregulating these transporters to promote uptake.^[40] Folate, in its reduced form (e.g., 5-methyltetrahydrofolate), is taken up via the proton-coupled folate transporter (PCFT/HCP1) on the brush border, concentrated in the duodenal and jejunal regions due to high expression levels.^[40] Fat-soluble vitamins (A, D, E, K) are incorporated into mixed micelles with bile salts and absorbed through passive diffusion or facilitated transport in the proximal small intestine, including the duodenum, where micelle formation begins.^[42] Initial bile acid reabsorption also commences in the duodenum via passive diffusion of unconjugated bile acids, contributing to the early phase of enterohepatic circulation before active uptake dominates in the ileum.^[43] Transport mechanisms in the duodenal epithelium rely on the microvillar brush border for enzymatic processing and carrier-mediated uptake. Brush border enzymes, such as disaccharidases (e.g., sucrase-isomaltase, lactase-phlorizin hydrolase), hydrolyze disaccharides into monosaccharides like glucose and galactose, which are then absorbed via sodium-glucose linked transporter 1 (SGLT1) or facilitative transporters like GLUT2.^[40] Specific carriers handle other nutrients: PEPT1 for di- and tripeptides, and various symporters for amino acids and ions. Water and electrolyte balance is maintained through sodium absorption via the Na⁺/H⁺ exchanger 3 (NHE3) and chloride via coupled exchangers, osmotically driving water reabsorption to handle the ~9 liters of daily fluid entering the duodenum from gastric, biliary, and pancreatic sources.^[40] The duodenum emphasizes proximal, mineral-rich uptake rather than bulk carbohydrate or protein processing.^[42] The duodenum also exhibits robust secretory functions, both exocrine and endocrine, to support digestion and protect its mucosa. Exocrine secretion arises from Brunner's glands in the submucosa, which produce an alkaline mucus rich in bicarbonate to neutralize acidic chyme and shield the epithelium from peptic damage, with daily output contributing significantly to duodenal fluid volume.^[44] Endocrine secretion involves I-cells and S-cells releasing cholecystokinin (CCK) in response to fats and proteins, stimulating gallbladder contraction for bile release and pancreatic enzyme secretion, while secretin, triggered by luminal acid, promotes pancreatic bicarbonate output to further alkalinize the environment.^[40] These secretions collectively optimize the luminal conditions for downstream absorption in the jejunum and ileum.

Clinical Significance

Peptic Ulcers and Inflammation

Duodenal ulcers, a primary form of peptic ulcer disease, most commonly develop in the superior portion of the duodenum, known as the duodenal bulb, where over 95% of cases occur within the first 3 cm distal to the pylorus.^[45] These ulcers account for the majority of peptic ulcers, with Helicobacter pylori infection implicated in 90-95% of duodenal cases, while nonsteroidal anti-inflammatory drug (NSAID) use contributes to most remaining instances, particularly in H. pylori-negative patients.^[46] The primary symptom is epigastric pain, often described as burning or gnawing, which typically improves with food intake or antacids due to neutralization of gastric acid.^[45] The pathophysiology of duodenal ulcers stems from an imbalance between aggressive factors, such as excess gastric acid and pepsin, and protective mucosal mechanisms, including bicarbonate secretion and prostaglandin-mediated mucus production.^[45] H. pylori exacerbates this by colonizing the gastric mucosa, inducing inflammation that increases acid secretion and impairs epithelial defenses, while NSAIDs inhibit cyclooxygenase enzymes, reducing prostaglandin synthesis and compromising mucosal integrity.^[46] Complications arise in 15-20% of cases and include hemorrhage from erosion into the gastroduodenal artery and posterior wall perforation into the pancreas, potentially leading to pancreatitis or peritonitis.^[45] Duodenitis, or inflammation of the duodenal mucosa, often precedes or accompanies ulceration and manifests in acute or chronic forms. Acute duodenitis typically results from infectious agents like H. pylori or chemical irritants such as NSAIDs and alcohol, causing short-term erythema and edema that may resolve spontaneously.^[47] Chronic duodenitis, in contrast, arises from persistent gastroesophageal reflux or ongoing H. pylori exposure, leading to glandular atrophy and fibrosis over time.^[47] Recent studies highlight the role of bacterial biofilms in duodenitis persistence, particularly H. pylori biofilms formed via exopolysaccharides and quorum sensing, which shield bacteria from host immunity and antibiotics, contributing to treatment-resistant inflammation in 2020-2025 research.^[48] Diagnosis of duodenal ulcers and duodenitis relies on upper gastrointestinal endoscopy, which visualizes mucosal breaks or inflammation and allows for biopsy to confirm H. pylori via histology, rapid urease testing, or culture.^[49] Treatment emphasizes acid suppression with proton pump inhibitors (PPIs), such as omeprazole, which promote healing in 80-90% of cases within 4-8 weeks by elevating intragastric pH.^[49] For H. pylori-associated disease, eradication therapy involves a 10-14 day regimen of PPIs combined with two antibiotics (e.g., clarithromycin and amoxicillin), achieving cure rates of 85-90% and preventing recurrence.^[49] NSAID-induced cases require discontinuation of the offending agent and cytoprotective alternatives like misoprostol.^[45]

Celiac Disease and Malabsorption

Celiac disease is an autoimmune disorder triggered by gluten ingestion in genetically susceptible individuals, primarily affecting the proximal duodenum through a T-cell mediated immune response that leads to mucosal damage. This results in characteristic histological changes, including villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes, which impair the absorptive surface area of the duodenal mucosa.^[50]^[51] The global prevalence of celiac disease is approximately 1%, with nearly all patients carrying HLA-DQ2 or HLA-DQ8 haplotypes, which facilitate gluten peptide presentation to T cells.^[52]^[53] In the pathophysiology of celiac disease, gluten-derived gliadin peptides are deamidated by tissue transglutaminase, enhancing their binding to HLA-DQ2 or DQ8 molecules on antigen-presenting cells in the duodenal lamina propria, thereby activating CD4+ T cells that release pro-inflammatory cytokines such as interferon-gamma. This adaptive immune response, combined with innate immunity activation, damages enterocytes and disrupts the epithelial barrier, exacerbating nutrient malabsorption. Recent studies from 2020 to 2025 have highlighted the role of gut microbiome dysbiosis in celiac disease pathogenesis, with reduced beneficial taxa like Bifidobacterium and Lactobacillus preceding disease onset and potentially modulating immune tolerance to gluten.^[54]^[55]^[56] Beyond celiac disease, other malabsorption syndromes specifically involving the duodenum include tropical sprue and Whipple's disease, which reduce the effective absorptive area and lead to deficiencies in nutrients such as iron and vitamin B12. Tropical sprue, prevalent in tropical regions, causes chronic inflammation and partial villous blunting in the duodenum and jejunum, resulting from environmental factors like bacterial overgrowth or toxins that impair folate and B12 uptake. Whipple's disease, caused by Tropheryma whipplei infection, leads to foamy macrophage infiltration in the duodenal lamina propria, obstructing nutrient absorption and causing steatorrhea along with iron and B12 deficiencies. These conditions mimic celiac histology but differ in etiology and distribution.^[57]^[58] Diagnosis of celiac disease and related duodenal malabsorption typically begins with serologic testing for anti-tissue transglutaminase (anti-tTG) IgA antibodies, which have high sensitivity and specificity exceeding 95% in symptomatic patients. Confirmation requires duodenal biopsy, graded using the Marsh classification: Marsh 1 shows increased intraepithelial lymphocytes; Marsh 2 adds crypt hyperplasia; and Marsh 3 indicates villous atrophy of varying severity. For tropical sprue and Whipple's disease, biopsies reveal distinct features like subtotal villous atrophy without lymphocytosis in sprue or PAS-positive macrophages in Whipple's, guiding targeted therapy.^[59]^[60] The primary treatment for celiac disease is a strict, lifelong gluten-free diet, which promotes mucosal healing, resolves malabsorption, and prevents complications in over 90% of adherent patients. Supplementation addresses deficiencies like iron and B12 during recovery, while tropical sprue responds to antibiotics and folate/B12 replacement, and Whipple's requires prolonged antibiotic therapy such as ceftriaxone followed by trimethoprim-sulfamethoxazole. Ongoing research into microbiome-targeted interventions, such as probiotics, aims to enhance treatment efficacy in refractory cases.^[61]^[62]

Duodenal Cancer

Duodenal cancer encompasses malignant tumors originating in the duodenal mucosa or submucosa, representing a rare subset of gastrointestinal malignancies that account for approximately 25-50% of all small bowel cancers.^[63] Adenocarcinoma is the predominant histological type, comprising 50-70% of cases and often arising in the periampullary or ampullary regions, while neuroendocrine tumors (such as somatostatinomas) and lymphomas constitute less common subtypes, with neuroendocrine tumors representing about 2.7% of all gastrointestinal neuroendocrine neoplasms and an incidence of 0.17 per 100,000 individuals.^[64]^[65] These tumors are far less frequent than colorectal adenocarcinomas, with small bowel adenocarcinomas occurring at a rate of roughly 3.7 per million population annually.^[66] Key risk factors include chronic inflammatory conditions such as celiac disease and Crohn's disease, which elevate the risk through prolonged mucosal irritation, as well as genetic syndromes like familial adenomatous polyposis (FAP).^[67]^[68] In celiac disease, diagnostic delays and poor adherence to a gluten-free diet can significantly increase the risk of small bowel adenocarcinoma (up to 80-fold).^[69] Recent studies from 2020-2025 have highlighted the significance of microsatellite instability-high (MSI-H) subtypes in duodenal adenocarcinomas, which occur in about 10-15% of cases and show promising responses to immunotherapy due to their high mutational burden.^[70] Staging follows the American Joint Committee on Cancer (AJCC) TNM system, assessing tumor depth (T), regional lymph node involvement (N), and distant metastasis (M), with lymphatic spread commonly occurring via the pancreaticoduodenal, pyloric, hepatic, and superior mesenteric nodes.^[71]^[72] Clinical presentation often includes symptoms of obstruction, such as abdominal pain and vomiting, or jaundice in ampullary tumors due to biliary obstruction.^[64] For resectable tumors, the standard treatment is surgical resection, typically via the Whipple procedure (pancreaticoduodenectomy), which removes the duodenum, pancreatic head, gallbladder, and regional nodes, achieving 5-year overall survival rates of around 46% in curative cases.^[73]^[74] Adjuvant chemotherapy regimens like FOLFOX (folinic acid, fluorouracil, and oxaliplatin) are employed for advanced or node-positive disease to improve outcomes.^[75] In MSI-H cases, neoadjuvant immunotherapy with checkpoint inhibitors has demonstrated pathological complete responses, paving the way for organ-sparing approaches in select patients.^[70] Overall prognosis remains guarded, with 5-year survival rates approximating 85% for localized disease but dropping to around 45% for metastatic cases.^[76]

Metabolic Disorders

The duodenum functions as a central metabolic hub by sensing ingested nutrients through specialized enteroendocrine cells, which trigger the release of hormones such as glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) to suppress appetite, slow gastric emptying, and enhance insulin secretion for glycemic control.^[77] These cells detect carbohydrates, fats, and proteins via G-protein-coupled receptors, initiating neural and hormonal signaling that communicates with the brain and pancreas to regulate energy balance.^[78] Additionally, the duodenum responds to bile acids recirculating from the liver, activating farnesoid X receptor (FXR) pathways that promote GLP-1 secretion and inhibit hepatic glucose production, thereby integrating bile acid homeostasis with systemic metabolism.^[79] In metabolic disorders like obesity and type 2 diabetes, dysfunction of the "duodenal brake"—the nutrient-sensing mechanism that normally induces satiety signals—leads to diminished GLP-1 and PYY release, resulting in accelerated gastric emptying, overeating, and impaired glucose regulation.^[80] This dysregulation contributes to insulin resistance and hyperglycemia, as evidenced by studies showing reduced postprandial hormone responses in obese individuals with type 2 diabetes compared to lean controls.^[81] In metabolic syndrome, altered enteroendocrine signaling in the duodenum exacerbates these issues, with decreased L-cell activity leading to blunted incretin effects and heightened inflammation that disrupts nutrient absorption and energy homeostasis.^[82] The duodenum also plays a role in non-alcoholic fatty liver disease (NAFLD) through impaired fibroblast growth factor 19 (FGF19) signaling, an ileal hormone influenced by duodenal bile acid flux; in NAFLD patients, hepatic insensitivity to FGF19 promotes steatosis by failing to suppress lipogenesis and bile acid synthesis.^[83] This connection highlights how duodenal-mediated bile acid dysregulation can propagate liver fat accumulation in metabolic syndrome.^[84] Recent advances from 2020 to 2025 have focused on endoscopic duodenal mucosal resurfacing (DMR), a minimally invasive ablation of the duodenal mucosa that regenerates enteroendocrine cells, improving glycemic control in type 2 diabetes patients with suboptimal medical therapy by enhancing GLP-1 secretion and insulin sensitivity.^[85] Clinical trials demonstrate sustained HbA1c reductions of 0.7-1.0% at 12-24 months post-DMR, with low complication rates, positioning it as a targeted intervention for duodenal dysfunction in metabolic disorders; as of 2025, studies confirm durable improvements when combined with GLP-1 receptor agonists.^[86]^[87] Bariatric procedures like the biliopancreatic diversion with duodenal switch (BPD/DS) address these issues by bypassing the duodenum, altering nutrient exposure to distal gut regions and restoring satiety hormone profiles, achieving up to 40% excess weight loss and diabetes remission in 80-90% of cases through enhanced GLP-1 and PYY signaling.^[88]

Surgical and Diagnostic Approaches

Diagnostic approaches to duodenal conditions primarily involve endoscopic and imaging modalities to visualize and sample abnormalities. Upper gastrointestinal endoscopy (EGD) is the cornerstone for direct inspection, biopsy, and detection of ulcers or mucosal lesions in the duodenum, allowing for histopathological confirmation of pathologies such as inflammation or early neoplasms.^[89]^[90] Computed tomography (CT) and magnetic resonance imaging (MRI) are essential for evaluating masses, assessing extraluminal involvement, and planning interventions by delineating duodenal wall thickening or adjacent structure invasion.^[91] Endoscopic retrograde cholangiopancreatography (ERCP) facilitates detailed evaluation of the major duodenal papilla, enabling cannulation for therapeutic drainage or biopsy in cases of biliary or pancreatic duct obstruction related to duodenal pathology.^[92]^[93] Recent advancements in endoscopic ultrasound (EUS) from 2020 to 2025 have enhanced the assessment of submucosal duodenal lesions, providing superior characterization of lesion depth, vascularity, and lymph node involvement through high-resolution imaging and fine-needle aspiration.^[94]^[95] EUS-guided techniques, including saline-assisted submucosal injection, have improved diagnostic accuracy for distinguishing superficial from invasive lesions, reducing unnecessary surgeries and aiding in staging with reported sensitivities exceeding 85% in specialized centers.^[96] Surgical interventions for duodenal disorders range from localized repairs to extensive resections, tailored to the underlying condition. Duodenotomy, often performed laparoscopically, is indicated for perforated ulcers or accessible bleeding sites, involving direct suture closure to restore integrity while minimizing morbidity.^[97] For malignancies involving the periampullary region, the Whipple procedure (pancreaticoduodenectomy) remains the standard curative approach, resecting the duodenum, pancreatic head, and associated structures with 5-year survival rates of approximately 46% in early-stage duodenal adenocarcinoma.^[73]^[74] In cases of obstruction, such as from tumors or extrinsic compression, duodenal bypass procedures like duodenojejunostomy provide palliation, with laparoscopic variants offering reduced recovery time and complication rates below 10% in experienced hands.^[98]^[99] Endoscopic options, including self-expanding metal duodenal stenting, serve as minimally invasive alternatives for malignant obstructions, achieving clinical success in over 80% of patients with rapid symptom relief.^[100] Therapeutic endoscopy has expanded treatment options for early duodenal neoplasms, emphasizing organ preservation. Endoscopic mucosal resection (EMR) or submucosal dissection techniques enable en bloc removal of superficial non-ampullary adenomas or carcinomas, with R0 resection rates of 70-90% and low recurrence when combined with defect closure.^[101]^[102] For residual or Barrett's-like metaplastic changes post-resection, thermal ablation using argon plasma coagulation or radiofrequency effectively eradicates abnormal mucosa, reducing metachronous lesion risk by up to 50% in follow-up studies.^[103] Common complications of these approaches require vigilant management to optimize outcomes. Post-ERCP pancreatitis occurs in 3-10% of cases, often mild but potentially severe, necessitating prophylactic measures like rectal indomethacin in high-risk patients.^[104]^[105] Surgical procedures carry risks of anastomotic leaks (2-5% incidence) and infections, exacerbated by duodenal contamination.^[97] Preoperative imaging to identify vascular anomalies, such as aberrant hepatic arteries, is crucial during planning to avoid inadvertent injury and intraoperative hemorrhage.^[106]^[107]

Etymology and History

Origin of the Term

The term "duodenum" derives from the Medieval Latin phrase intestinum duodenum digitorum, meaning "intestine of twelve fingers' breadth," referring to the approximate length of this segment of the small intestine as measured by ancient anatomists.^[108] This nomenclature originated from observations of the organ's size, estimated at around 25 cm, which roughly corresponded to twelve ancient finger widths, or digiti.^[1] The earliest recorded use of a similar term traces back to the Greek anatomist Herophilus in the 3rd century BCE, who described the structure as dodekadaktylon, literally "twelve fingers long," based on dissections conducted in Alexandria.^[109] This Greek term was later Latinized in Medieval Latin as duodenum digitorum, which was adopted and propagated in anatomical writings.^[108] The ancient Roman digitus, equivalent to about 1.85 cm, provided the measurement standard, making the total length align closely with the duodenum's observed dimensions in cadavers.^[110] During the Renaissance, the term "duodenum" became standardized in anatomical literature, notably in Andreas Vesalius's seminal 1543 work De humani corporis fabrica, where it was employed consistently alongside detailed illustrations to denote the first part of the small intestine.^[109] This adoption helped solidify the nomenclature in Western medical tradition, transitioning it from classical descriptions to modern usage.^[108]

Historical Milestones in Understanding

In the 3rd century BCE, the Greek anatomists Herophilus and Erasistratus conducted the first known systematic human dissections in Alexandria, enabling early descriptions of the duodenum as the initial segment of the small intestine. Herophilus specifically described it as dodekadaktylon, deriving the term from its approximate length of twelve finger breadths, marking a foundational step in identifying its distinct anatomical identity separate from the rest of the intestines.^[111]^[112] During the 2nd century CE, the physician Galen advanced understanding of the duodenum's positional relationships within the abdomen. Through animal dissections, as human dissection was restricted, he described the pancreas as a spongy, cushion-like structure positioned adjacent to the duodenum and major vessels, emphasizing its supportive role in protecting nearby organs and vessels while noting the duodenum's curved enclosure around the pancreatic head. The Renaissance brought renewed focus on direct observation, with Andreas Vesalius in 1543 providing one of the earliest precise illustrations of the duodenum's C-shaped (or horseshoe) form in his groundbreaking text De Humani Corporis Fabrica. This work corrected prior misconceptions from Galenic traditions and depicted the duodenum's retroperitoneal fixation and relations to adjacent viscera, establishing a visual standard for anatomical study that influenced subsequent generations. In the 1570s, Gabriele Falloppio further refined knowledge of duodenal structures and pancreatic anatomy, enhancing comprehension of their positional relationships.^[113]^[114] The 19th and early 20th centuries shifted emphasis toward physiological functions, culminating in the 1902 discovery by William Bayliss and Ernest Henry Starling of secretin, the first recognized hormone. By extracting acid from duodenal mucosal scrapings and observing its stimulatory effect on pancreatic bicarbonate secretion, they demonstrated how the duodenum regulates digestion through chemical signaling, independent of neural control, thereby founding endocrinology and illuminating the organ's role in neutralizing gastric acidity.^[115] In 1935, Allen Oldfather Whipple developed the pancreaticoduodenectomy (Whipple procedure), a radical surgical resection for periampullary tumors encroaching on the duodenum, which involved removing the duodenal head along with portions of the pancreas and bile duct; this innovation, initially performed in stages, proved the feasibility of such operations and improved survival for duodenal-adjacent malignancies.^[116] From 2020 to 2025, endoscopic and genetic research has increasingly positioned the duodenum as a central metabolic regulator, influencing glucose homeostasis and nutrient sensing via interactions with the gut microbiome and enteroendocrine cells. Proteogenomic analyses of duodenal tissues have revealed molecular signatures underlying metabolic disorders, while endoscopic interventions like duodenal mucosal resurfacing (DMR)—which ablates the mucosal lining to reset metabolic signaling—have shown promise in glycemic control for type 2 diabetes, with clinical trials demonstrating sustained HbA1c reductions without major adverse events.^[117]^[118]

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Biliopancreatic Diversion with Duodenal Switch - ASMBS
The Biliopancreatic Diversion with Duodenal Switch, abbreviated BPD-DS, begins with creation of a tube-shaped stomach pouch similar to the sleeve gastrectomy.Missing: disorders | Show results with:disorders
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Duodenal Biopsy - StatPearls - NCBI Bookshelf
Jul 24, 2023 · A duodenal biopsy is performed during endoscopy in either a directed or random manner. The biopsy results further characterize visualized areas on endoscopy.
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Diagnosis of Peptic Ulcers (Stomach or Duodenal Ulcers) - NIDDK
What tests do doctors use to diagnose peptic ulcers? · Blood test · Urea breath test · Stool test · Upper gastrointestinal (GI) endoscopy and biopsy · Upper GI ...Missing: approaches | Show results with:approaches
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Imaging of non-neoplastic duodenal diseases. A pictorial review ...
Both MDCT and MRI have proven very useful in evaluating the intraluminal content, duodenal wall, and extraduodenal space [2]. MDCT has become the modality of ...
[91]
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Mar 6, 2023 · With the scope in this position, the major duodenal papilla is identified and inspected for abnormalities. This structure is a protrusion of ...
[92]
Anatomy of Major Duodenal Papilla Influences ERCP Outcomes and ...
May 28, 2020 · The aim of our study is to evaluate whether the morphology of the major duodenal papilla influences the ERCP outcomes and complication rates.
[93]
Endoscopic Ultrasound Assessment of the Duodenal Wall Lesions
Mar 24, 2021 · EUS is able to accurately diagnose duodenal lesions, perform a biopsy if considered useful, guide the approach for resection and provide appropriate follow-up.
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Endoscopic Ultrasound and Gastric Sub-Epithelial Lesions - MDPI
Oct 15, 2024 · In case of lesions originating from the submucosal layer, EUS is required to evaluate the depth of invasion and the presence of lymph nodes [13] ...
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Endoscopic ultrasound with submucosal saline injection improves ...
Apr 29, 2025 · Conclusion: EUS-SSI differentiates between T1a and T1b stages of superficial SESCC with better diagnostic accuracy than EUS-C, thereby reducing ...Missing: duodenal | Show results with:duodenal
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Duodenal Perforation - StatPearls - NCBI Bookshelf - NIH
Mar 13, 2023 · Early diagnosis, quick resuscitation, and urgent surgical intervention are crucial to improving outcomes. Experienced teams should direct ...
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Pancreaticoduodenectomy (Whipple Procedure) - StatPearls - NCBI
The procedure involves the resection of the pancreatic head and uncinate process, duodenum, proximal jejunum, distal bile duct, gallbladder, and usually part of ...Figure · Figure, Pancreas and... · Figure, Lymphatics and...
[98]
Laparoscopic Management of Duodenal Obstruction Resulting From ...
This retrospective review provides evidence that laparoscopic duodenojejunostomy is safe and effective for duodenal obstruction from superior mesenteric.
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Laparoscopic gastroenterostomy for duodenal obstruction
Laparoscopic gastroenterostomy is a safe procedure for treatment of duodenal obstruction. Good palliation can be expected in patients with obstruction of the ...
[100]
Practical guide to duodenal stenting for gastric outlet obstruction
Jun 16, 2025 · However, long-term outcomes are impacted by stent occlusion, migration, and other complications. This review comprehensively compares duodenal ...Missing: laparoscopic | Show results with:laparoscopic
[101]
Endoscopic Resection for Superficial Non-Ampullary Duodenal ...
Sep 4, 2024 · Endoscopic resection is the first-line treatment for SNADETs, with methods including cold snare polypectomy (CSP), conventional endoscopic mucosal resection ( ...
[102]
Current Management of Duodenal Neoplasia: Endoscopic ...
Jul 21, 2025 · U-EMR submucosal injection and marking has demonstrated a higher en bloc resection rate compared to C-EMR, and a higher R0 resection rate ...
[103]
Outcomes of thermal ablation of the defect margin after duodenal ...
Dec 4, 2020 · Methods: We sought to evaluate the effectiveness of thermal ablation of the defect margin after EMR (EMR-T) in reducing recurrence at first ...
[104]
Complications of Endoscopic Retrograde Cholangiopancreatography
ERCP is most often complicated by acute pancreatitis, bleeding, infection, or perforation, although myriad other adverse events may occur.
[105]
Complications of Endoscopic Retrograde Cholangiopancreatography
Complications including infection, pancreatitis, hemorrhage, and perforation can occur even in expert hands.
[106]
Impact of Vascular Anomalies on Pancreatoduodenectomy Procedure
The most common vascular anomaly was replaced right hepatic artery, noticed in 34 patients (83%). The most common indication for PD for both groups (anatomical ...
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Hepatic Artery Anomalies in Pancreaticoduodenectomy: Outcomes ...
Sep 12, 2023 · They had either an accessory (n = 28, 40.8%) or replaced (n = 26, 36.6%) right hepatic artery. ... Incidence and management of arterial anomalies ...
[108]
Duodenum - Etymology, Origin & Meaning
Coined by Gerard of Cremona (d. 1187) in "Canon Avicennae," a loan-translation of Greek dodekadaktylon, literally "twelve fingers long." The intestine part was ...
[109]
[PDF] Human Anatomy, from the Origin to the Renaissance
The name “duodenum” is attributed to him. He knew that damage of the motor nerves led to paralysis. Herophilus is also given the credit for stating that ...
[110]
Digitus (finger). Conversion Chart - Ancient Roman - Convert-me.Com
... the main length conversion page. digitus (finger) to kilometer (km). 0.0000185. digitus (finger) to meter (m). 0.0185. digitus (finger) to centimeter (cm). 1.85.
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Greek anatomist herophilus: the father of anatomy - PMC - NIH
Herophilus is recognized as the first person to perform systematic dissection of the human body predating even Andreas Vesalius, (often regarded as the founder ...
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Duodenum - an overview | ScienceDirect Topics
Duodenum is a Latin corruption of the Greek dodekadaktulus meaning 12 finger breadths, and was first coined by Herophilus in 300BC to describe the length of the ...
[113]
Physiology of the small bowel - Oxford Academic
An accurate description of the anatomy of the GI system was laid out by Andreas Vesalius (1514–1564) in the De humani corporis fabrica, and further work ...Missing: milestones | Show results with:milestones
[114]
Historical considerations regarding the first descriptions of pancreas ...
Jun 7, 2019 · ... Gabriel Fallopius, Johann Georg Wirsung, Francis Glisson, Giovanni Domenico Santorini. ... The accessory pancreatic duct with its minor papilla, ...
[115]
Secretin and the exposition of hormonal control - PMC - NIH
Bayliss and Starling first communicated their discovery to the Royal Society only one week after the experiment (Bayliss & Starling, 1902a) and published the ...
[116]
History of pancreaticoduodenectomy: early misconceptions, initial ...
Whipple performed a total of 37 pancreaticoduodenectomies in his career of which 30 were for periampullary carcinoma and 7 for chronic pancreatitis. His ...Missing: tumors | Show results with:tumors
[117]
Comprehensive proteogenomic characterization of early duodenal ...
Mar 29, 2023 · We present comprehensive characterization of 438 samples from 156 DC patients, covering 2 major and 5 rare subtypes.
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A Thorough Assessment of the Duodenal Mucosa After Resurfacing ...
Jan 8, 2025 · The PDZK1 gene is known to play a role in intestinal epithelial function, particularly in transporters that are involved in glucose uptake, like ...