Duodenal White Spot Syndrome (DWSS) is a new syndrome concept proposed by Japanese scholars in recent years based on endoscopic findings, referring to scattered white spots or patches resembling foxtail millet grains on the duodenal mucosa, distinct from duodenal ulcers. Since duodenal inflammation is consistently found in biopsy pathological examinations, most domestic scholars believe it should not be classified as an independent syndrome. In essence, it is a special manifestation of duodenitis, more appropriately termed "white spot duodenitis." This term has recently begun to appear in domestic literature.

bubble_chart Etiology

Some believe that upper consumptive thirst is caused by digestive tract inflammation, particularly atrophic gastritis, which reduces gastric acid secretion and pancreatic juice output. The deficiency of pancreatic lipase in the pancreatic juice exacerbates the dysfunction of fat digestion, absorption, and transport, leading to lipid retention in the absorptive epithelial cells or the mucous membrane's lamina propria, resulting in white lesions. Clinically, this manifests as symptoms like steatorrhea. However, in Chinese patients, atrophic gastritis lesions are mostly located in the antrum, an area devoid of acid-secreting cells, so many cases of atrophic gastritis show normal gastric acid secretion. Additionally, pathological biopsies of duodenal white spots consistently reveal inflammation, leading some to conclude that this condition is a specific form of duodenitis.

bubble_chart Pathological Changes

Light microscopy revealed chronic inflammatory changes in the duodenal mucosa at the white spots, primarily manifested as infiltration of lymphocytes, plasma cells, monocytes, and eosinophils, dilation of lymphatic and blood vessels in the villous stroma, enlargement of duodenal gland lumens, and focal translucent vacuoles at the tips of the villi. Under electron microscopy, normal duodenal villi appeared finger-like or lobulated, with crypt enlargement. The characteristic change was the presence of abundant lipid accumulation in the absorptive epithelial cells of the intestinal mucosa. As the condition worsened, compression of the nuclei and organelles could be observed. The submicroscopic structure of the organelles showed degenerative changes, with reduced electron density. Mitochondria became degenerated and increased in number, densely distributed around the nuclei. The rough endoplasmic reticulum expanded into sac-like or spherical forms, while the smooth endoplasmic reticulum increased compensatorily. Some chromatin exhibited condensation.

The disease is more common in men than in women, particularly among young and middle-aged adults. Clinically, it often presents with irregular upper abdominal pain or discomfort, nausea, poor appetite, belching, and other dyspeptic symptoms. Some cases exhibit typical steatorrhea: large, loose, brownish-yellow or slightly grayish stools with a foul odor and a greasy sheen on the surface, containing numerous fat globules upon microscopic examination. Others may be accompanied by chronic superficial gastritis, atrophic gastritis, peptic ulcers, chronic cholecystitis, pancreatitis, or cholelithiasis, further complicating the clinical presentation and making it difficult to estimate the presence of DWSS in most cases prior to endoscopic examination.

bubble_chart Auxiliary Examination

1. In laboratory tests, except for elderly patients who may have elevated blood lipids, there are usually no significant abnormalities.

2. Endoscopic examination: Under endoscopy, white spots on the duodenal mucosa are mostly located in the bulb, particularly on the anterior wall and greater curvature. They are less common on the posterior wall, which may be related to the course of blood vessels and lymphatic vessels. Some are also found in the superior angle and descending part. The white spots appear as sparse scattered distributions or densely clustered, round or oval, with a diameter of about 1–3 mm. Most are flat, while some grade I depressions appear umbilicated or slightly elevated like patches, with a milky white or grayish-white surface due to localized fat retention and lymphatic dilation. Sometimes, they are stained yellow by bile. Usually, there is no secretion covering them, and the borders are clear, transitioning gradually from light yellow to normal duodenal mucosa. The white spots or patches have a smooth surface, slightly firm texture, and enhanced reflectivity. Upon closer observation, they appear as white villous structures and remain unchanged after rinsing with water. The surrounding duodenal mucosa may show patchy or congested changes, appearing rough and uneven, losing the normal villous appearance.

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Therefore, during endoscopy, one should not be satisfied with the discovery of a single lesion. A thorough examination should be conducted to identify any accompanying fistula diseases and make a complete diagnosis.

bubble_chart Treatment Measures

For patients with high gastric acid and {|###|}abdominal pain{|###|}, H₂^- receptor blockers (such as cimetidine, ranitidine, famotidine, etc.) or even proton pump inhibitors (omeprazole or lansoprazole) can be administered; alkaline medications like Gaviscon or aluminum hydroxide gel also show good efficacy in relieving symptoms. Since the role of Helicobacter pylori in the pathogenesis of this disease remains unclear, the use of antibiotics and bismuth preparations lacks definitive indications. However, it has been observed that among 16 cases of DWSS treated with cimetidine and anti-Helicobacter pylori therapy, white spots disappeared in 13 cases and decreased in 2 within three months. Further research is needed.

bubble_chart Complications

Accompanied by duodenal ulcer, gastric ulcer, superficial or atrophic gastritis, etc.

bubble_chart Differentiation

The diseases that need to be differentiated under endoscopy mainly include duodenal inflammatory polyps, Brunner's gland hyperplasia of the duodenum, duodenal frost-like ulcers, etc. Duodenal inflammatory polyps are mostly flat, broad-based elevations with surface congestion, and the surrounding duodenal mucosa shows varying degrees of inflammation. Brunner's gland hyperplasia of the duodenum presents as nodular multiple micro-elevations with a normal surface complexion. Duodenal frost-like ulcers appear as multiple patchy erosions, often scattered with incomplete white membranes, accompanied by mucosal congestion and edema, resembling a frost-like appearance, and generally without depression. Differential diagnosis is usually not difficult.