An unusual duodenal cloverleaf

A 69-year-old female underwent an esophagog-astroduodenoscopy (EGD) due to a 6-month history of recurrent episode of vomiting. She had been suffering from rheumatoid arthritis for 20 years, and was under intermittent treatment with non-steroid anti-inflammatory drugs (NSAIDs).

On endoscopic examination, esophagus was normal, and stomach showed mild antral hyperemia. On the anterior wall of the duodenal bulb, four pseudo-diverticula were found designing a kind of cloverleaf, with long white scars on the stalk of this pattern (Fig. 1). Rapid urease test was positive a diagnosis of complicated scars of healed Helicobacter pylori (H. pylori)-positive duodenal ulcer was posed, and the patient was successfully treated with H. pylori eradication regimen.

Figure 1

Four pseudo-diverticula located on the duodenal anterior wall and designing a kind of cloverleaf with long white scars on the stalk of this pattern

H. pylori infection is the most important cause of duodenal ulcer. Although its prevalence and incidence is currently decreasing in the western world, it is still able to cause complications.

Both H. pylori infection and NSAID use are currently identified as independent risk factors for the development of peptic ulcer disease and associated bleeding. Current guidelines advise H. pylori eradication before starting long-term NSAID treatment, whilst H. pylori eradication in those who are already long-term users is of no clear benefit. Treatment with maintenance proton pump inhibitors (PPIs) for preventing NSAID-associated ulcers is advised too [1].

It is therefore hypothesized that the “duodenal cloverleaf” discovered in our patient may be the outcome of a complicated duodenal ulcer, associated with chronic H. pylori infection and worsened by long-term NSAID use without concurrent PPI gastroprotection.