Laparoscopic resection of duodenal diverticulum. A case report

We report the case of a laparoscopic resection of a symptomatic duodenal diverticulum. A 35 year old female with history of pain in the upper abdomen, nausea and regurgitation was diagnosed with a diverticulum of the second portion of the duodenum on the external border at upper gastrointestinal radiography. The diverticulum size was medium (2 cm in diameter). Under general anesthesia, a pneumoperitoneum was created. Four trocars were inserted into the peritoneal cavity for this intervention. After the sectioning of posterior parietal peritoneum on the external border of the second portion of duodenum, the diverticulum was dissected. The resection was performed with an endo-GIA linear stapler at the base of the diverticulum. One subhepatic drain was inserted. The operative time was 30 min. There were no intra- or postoperative complications. Postoperative gastrointestinal series revealed no signs of diverticulum or stenosis on the second portion of the duodenum. The patient was discharged in the fifth postoperative day after a normal course. The follow-up evaluation was normal.     

Perforated duodenal diverticulum successfully diagnosed preoperatively with abdominal CT scan associated with upper gastrointestinal series

Although duodenal diverticulum is not uncommon, precise preoperative diagnosis is occasionally difficult. We report a patient with perforated duodenal diverticulum successfully diagnosed preoperatively by an upper gastrointestinal series followed by abdominal computed tomography (CT) scanning. An 81-year-old Japanese woman visited a local hospital because of right-sided abdominal pain. Physical examination revealed diffuse muscle guarding localized in the entire right-side of the abdomen indicative of peritonitis. While plain abdominal X-ray film revealed no free air, abdominal ultrasound and abdominal CT scanning revealed fluid collection and gas in the anterior perirenal space. An emergency upper gastrointestinal series, using water-soluble contrast media, demonstrated multiple diverticula in the descending portion and the horizontal portion of the duodenum. Leakage of the contrast material was found by the upper gastrointestinal series followed by the abdominal CT scanning, suggesting that the peritonitis was caused by the perforated duodenal diverticulum, and an emergency laparotomy was performed. The diverticulum in the descending portion of the duodenum was mobilized from the retroperitoneum and complete resection and peritoneal drainage were performed. The resected specimen showed that the diverticulum was 42 × 23mm in size, and two separate sites of perforation were identified. The present case suggests that upper gastrointestinal series followed by CT scan is useful for the preoperative diagnosis of perforated duodenal diverticulum.     

Endoscopic removal of an intraluminal duodenal diverticulum in an adult with upper abdominal pain

We report here on a 44-year-old previously healthy patient with a two-year history of intermittent upper abdominal pain. In the outpatient gastroduodenoscopy and X- ray examinations of the small intestine an intraluminal duodenal diverticulum was suspected. Clinical examination and laboratory tests did not show any abnormal findings. In order to exclude other causes for the patient's complaints coloscopy, ERP and MRCP were performed. The latter was done because the bile duct could not be intubated in the ERCP due to the altered anatomy. By use of endoscopic ultrasound a mucosal duplication was demonstrated and thus the diagnosis confirmed. Subsequently, the diverticulum sac was sliced by argon plasma coagulation. The postinterventional course was without complications and the patient was without symptoms afterwards. The intraluminal duodenal diverticulum is a rare differential diagnosis of pain in the upper abdomen. The diverticulum should be endoscopically removed if other causes for abdominal pain have been ruled out and possibly associated malformations have been excluded.     

CASE OF HEMORRHAGE FROM A DUODENAL DIVERTICULUM TREATED SUCCESSFULLY BY ENDOSCOPIC INJECTIONS OF EPINEPHRINE

Although duodenal diverticula are found relatively frequently in adult gastrointestinal tracts, the majority are asymptomatic. We report a case of duodenal diverticulum complicated with hemorrhage. A 74‐year‐old woman developed hematemesis and tarry stools. An emergent upper gastrointestinal endoscopy revealed a diverticulum, about 3 cm in diameter, in the posteromedial aspect of the second duodenal segment, right oral to the papilla. The diverticulum was filled with blood clots. After removing them by gentle suction, a linear ulcer became visible and an actively oozing site was seen at one edge of the ulcer. Three injections of epinephrine in a 2.5% sodium chloride solution (epinephrine concentration 0.05 mg/mL), each 1.0 mL for a total volume of 3.0 mL, were made at the oozing site. The exuding ceased immediately after the third injection and bleeding did not reappear. In our patient, successful and complete hemostasis was obtained by this endoscopic injection of epinephrine, although most cases of duodenal diverticulum complicated with hemorrhage had been treated surgically. We think that endoscopic, instead of surgical treatment is considerably becoming another choice for treating patients with a bleeding duodenal diverticulum.     

症状性十二指肠憩室的临床特点分析

目的探讨症状性十二指肠憩室病例的临床、内镜及影像学表现、治疗方法,并分析其临床意义。方法回顾性分析武汉大学人民医院2008年1月-2011年1月症状性十二指肠憩室病例,分析其临床表现、内镜及影像学表现、治疗方法等临床资料。结果共35例患者诊断为症状性十二指肠憩室,其中腹痛者15例、呕吐者2例、呕血或黑便者12例、黄疸患者6例,腹痛患者4例有反复发作史、黑便患者2例。所有病例中并发十二指肠憩室炎5例、急性胰腺炎1例、胆总管结石6例、肠梗阻1例、上消化道出血12例。35例症状性十二指肠憩室分别位于十二指肠球部9例、降部22例、水平部4例,其中单发25例、多发10例。经由消化道钡餐检查发现十二指肠憩室13例、胃镜9例、经内镜逆行胰胆管造影(endoscopic retrograde cholangio-pancreatography,ERCP)7例,双气囊小肠镜2例、腹部CT检查4例。结论十二指肠憩室症状不典型,对于不明原因上腹痛、消化道出血及胰腺炎患者,需考虑此病因,可行相关检查明确,治疗上除内科保守外还可以进行内镜下或者手术治疗。     

Unique intestinal CT imaging with bleeding from a duodenal diverticulum following myelodysplastic syndrome

Duodenal diverticula generally occur in 2.5% of upper gastrointestinal examinations and are usually asymptomatic, but can cause hemorrhage on rare occasions. The frequency of gastrointestinal hemorrhage in patients with MDS or hematologic neoplasm caused by duodenal diverticulum is not known. Therefore, the correct diagnosis of intestinal hemorrhage is important, as severe enterocolitis may cause a patient with MDS to bleed from the diverticulum.     

Endoscopic management of upper gastrointestinal bleeding from a duodenal diverticulum

Hemorrhage from duodenal diverticulum is a rare cause of upper gastrointestinal hemorrhage. The side-viewing endoscope was used for almost all cases of diagnosis and endoscopic hemostasis. However, a forward-viewing endoscope is used in emergent endoscopic study for upper gastrointestinal hemorrhage. We report a case in which the endoscopic hemostasis of bleeding duodenal diverticulum was performed during emergent forward-viewing endoscopic study.     

Intraluminal Duodenal Diverticulum

A 46-year-old woman was seen for evaluation of dyspepsia of 8-wk duration. X-rays of the upper gastrointestinal tract revealed an intraluminally projecting diverticulum of the duodenal bulb. Diagnostic features and management of intraluminal duodenal diverticulum are reviewed.     

Pankreatitis und zystische Raumforderung des Pankreaskopfes

The intraluminal duodenal diverticulum is among the rarest congenital duodenal malformations. These sack-like structures in the middle section of the duodenum can cause symptoms ranging from upper abdominal pain to hemorrhaging. We report on the case of a 33-year-old male patient who presented in our clinic with symptoms of acute pancreatitis. The diagnosis is based on ERCP and endosonography. Important differential diagnoses are the choledochocele and duodenal duplications. Interventional endoscopy is now an established therapy option with few serious courses.     

Intraluminal duodenal diverticulum

Summary A case of intraluminal duodenal diverticulum, detected by upper gastrointestinal roentgenogram is reported in a 54-year-old woman. The diagnosis was confirmed by gastroduodenal endoscopy. The typical diverticulum was attached to the posterior and internal wall of the descending duodenum, arose 1.0 cm below the papilla of Vater, and extended distally. The proximal extremity of the diverticulum presented a large aperture, and the pouch showed no distal orifice communicating with the duodenum. The internal and external surfaces of the diverticulum were both covered with normal duodenal mucosa. When surgical intervention, as in this case, is not required, gastroduodenal endoscopy alone permits an accurate differentiation of intraluminal diverticulum from incomplete mucous diaphragm prolapsed into the duodenum which strikingly resembles the diverticulum on x-ray films.     

Angiodysplasia in a duodenal diverticulum as an unusual cause of upper gastrointestinal bleeding.

The majority of duodenal diverticula are asymptomatic but may also induce major haemorrhage on rare occasions. Gastrointestinal bleeding due to angiodysplasia in a duodenal diverticulum is very rare. We present a 70-year-old woman with repeated melaena in whom the diagnosis of angiodysplasia in a diverticulum of the fourth part of the duodenum could be made by standard upper endoscopy.     

Perforated duodenal diverticulum: report of two cases.

Duodenal diverticula may be complicated by diverticulitis, perforation, hemorrhage, pancreatitis, or biliary obstruction. Two cases of perforated duodenal diverticulum are reported. Both patients were elderly females. Computed tomography of the abdomen showed retroperitoneal air around the duodenum in the first case, and an enterolith in a duodenal diverticulum and a retroperitoneal abscess in the second case. Laparotomy and diverticulectomy with two-layer closure of the duodenum was performed in the first case. The second patient was treated conservatively with antibiotics, percutaneous abscess drainage, and endoscopic lithotomy. Both recovered well. Computed tomography is useful in the diagnosis of a perforated duodenal diverticulum. Although surgical intervention is the standard treatment, conservative therapy is also an option. Duodenal enteroliths are rare but may cause perforation of a diverticulum or biliary obstruction. The duodenal blind loop created by a Billroth II gastrectomy provides a static environment for the formation of enteroliths in duodenal diverticula.     

A Case of Postbulbar Duodenal Ulcer with Jaundice

Abstract: A 63-year-old man was hospitalized because of jaundice and anorexia. An upper gastrointestinal series and hypotonic duodenography revealed circumferential sclerosis and stenosis of the duodenal wall. Endoscopic examination disclosed an ulcer, the upper margin of which was located at the papilla of Vater. The papilla was situated in the base of the ulcer. Endoscopic retrograde cholangiopancreatography disclosed mild dilatation of the common bile, intrahepatic bile and pancreatic ducts, but with neither severe stenosis nor occlusion. Nevertheless, there was some degree of circumferential compression and mild stenosis of the terminal portions of the bile and pancreatic ducts, as potential causes of obstructive jaundice in this patient. Computed tomographic examination of the abdomen revealed a tumorous lesion at the duodenal bulb. Because malignancy in the duodenum could not be ruled out, a pancreatoduodenectomy was performed. Histopathological examination showed a postbulbar duodenal ulcer, associated with inflammation of the papillary orifice and fibrosis of the region near the papilla. There was no evidence of a tumorous lesion. In this case, a postbulbar duodenal ulcer may have caused obstructive jaundice.     

Excision of a juxtapapillary duodenal diverticulum causing biliary obstruction: report of three cases

We report three cases of biliary obstruction caused by a juxtapapillary duodenal diverticulum that were treated by excision of the diverticulum. A 72-year-old man, a 77-year-old woman, and an 81-year-old woman each presented with recurrent obstructive jaundice. Diagnostic imaging revealed a juxtapapillary duodenal diverticulum compressing the common bile duct (CBD). Following cholecystectomy, the diverticulum between the intrapancreatic CBD and pancreatic parenchyma was isolated and excised successfully in each case. The patients have been followed up for 34, 31, and 22 months, respectively. In one patient, choledocholithiasis developed 33 months after the surgery, necessitating endoscopic sphincterotomy. Duodenal diverticulectomy is a useful procedure to relieve biliary obstruction caused by a juxtapapillary duodenal diverticulum. However, it remains unclear whether excision of the diverticulum is preferred to biliodigestive anastomosis from the point of view of long-term prognosis. Subsequent surveillance is necessary.     

Duodenal stenosis, a new finding on congenital rubella syndrome: case description and literature review

Congenital rubella syndrome (CRS) continues to represent a public healthcare problem although an effective vaccination program. Gastrointestinal involvement is rather infrequent and the association of CRS with duodenal stenosis has been never reported. In this study a case of CRS with duodenal diaphragm is reported and the gastrointestinal diseases described in association with CRS are reviewed. A 10-month-old child affected by CRS with congenital hearth disease, perceptive deafness and microcephaly, was admitted because of vomiting and failure to thrive. An upper endoscopy demonstrated dilated proximal duodenum and a perforated diaphragm in the second segment of the duodenum. Endoscopic membranectomy was therefore performed. Two months later the patient was submitted to a further endoscopic evaluation that showed a partial diaphragm persistence and a second excision was performed. Follow-up one year after the first treatment showed good clinical conditions, reasonable physical growth and disappearance of vomiting. In conclusion we report the first case of CRS in association with duodenal stenosis. Duodenal stenosis in the absence of other intestinal localizations may be due to rubella capacity of infecting only small numbers of fetal cells but we cannot exclude that the duodenal stenosis in our patient be only a casual association.     

Resection for Intraluminal Duodenal Diverticulum

We report a patient with intraluminal duodenal diverticulum in whom symptoms recurred after gastrojejunostomy. Resection of the diverticulum resulted in the disappearance of symptoms.     

Double sténose gastrique et duodénale révélant une maladie de Crohn (à propos d’un cas)

Abstract

Gastric and duodenal in Crohn’s disease is rare. We report an exceptional case of double gastric and duodenal stenosis revealing a Crohn’s disease, we define its epidemiological, clinical, therapeutic and evolutive caracteristics.

Case report

patient, 25 years old, followed since 2004 for chronic diarrhea, was wrongly treated for intestinal tuberculosis without clinical improvement, Crohn’s disease was diagnosed on the following arguments.

Clinical

presence of postprandial food vomiting, a feeling of fullness, two episodes of of low abundance hematemesis and epigastric pain.

Endoscopic and histological

an oesogastroduodénale endoscopy showed erythematous gastritis, gastric stenosis, micronodular duodenal mucosa. Gastric biopsy revealed noncaseating granulomas. Colonoscopy was normal. Colonic biopsy found a noncaseating granulomas. Radiology: The upper gastrointestinal transit found a gastric and duodenal stasis and short, regular antral stenosis. The SBFT showed a duodenal stenosis. The patient was treated with corticosteroids, immunosuppressive drugs and proton pump inhibitor with a good clinical and biological evolution.     

Recurrent bleeding from a duodenal diverticulum 8 years after endoscopic treatment: case report and review of the literature

A 70-year-old woman presented with a 2-day history of tarry stool. She had a history of hemorrhage from a duodenal diverticulum of the 2nd portion 8 years previously that had been managed successfully by endoscopic hemostasis. Initial gastrointestinal endoscopy revealed ulceration of the diverticulum with no active bleeding; nevertheless the ulceration was presumed to be the source of the tarry stool. Despite medical treatment, bleeding started again, but endoscopic ethanol injection achieved hemostasis. When bleeding started yet again 8 days after the endoscopic therapy, the patient underwent diverticulectomy. Although duodenal diverticula are frequently found in the adult gastrointestinal tract, they rarely show hemorrhage. Recently, there has been controversy about whether bleeding diverticula should be managed surgically or endoscopically. We describe for the first time a rare case of recurrent hemorrhage of a duodenal diverticulum after an 8-year interval; the case was treated by surgical diverticulectomy as a definitive therapy for the recurrent bleeding ulcer. We also present a review of the literature.     

Heterotopic pancreas in the stomach which caused obstructive stenosis in the duodenum

The patient, a 43-year-old Japanese man suffering from duodenal ulcer and reflux esophagitis, was admitted to our hospital because of submucosal tumor in the antrum and obstructive stenosis of duodenum. Several imaging tests could not rule out the possibility of malignant disease. Therefore, the patient was surgically treated. Pathohistological examination of resected tissue demonstrated Heinrich type I heterotopic pancreas in the gastric lesion and submucosal abscess in the duodenal lesion with stenosis. In this case, it was considered that the heterotopic pancreas caused chronic inflammation to form the gastric tumor, and submucosal abscess leading to the severe duodenal stenosis.     

Difficulty for cannulation of Vater´s ampulla in the presence of duodenal diverticulum

"Background: There are conflicting results in the literature regarding the impact of duodenal diverticula on the technical success and complications of endoscopic retrograde cholangiopancreatography (ERCP). Aim: To evaluate if the presence of periampullary duodenal diverticulum increases the risk of failure of ampulla cannulation. Methods: Patients who underwent ERCP between January 2008 and December 2009 were evaluated. They were divided in group A (without duodenal diverticulum) or group B (with duodenal diverticulum). Gender, age, endoscopic and radiological diagnosis, difficulty to cannulate, endoscopic sphincterotomy, precut technique, therapeutic procedure and complications were documented. Results: 1159 patients were included: 1100 in group A and 59 in group B. A successful cannulation was obtained in 1061 patients of group A and 53 of group B (96.46 vs. 89.83%, p < 0.0001, OR 0.03). The failure of cannulation was observed in 39 patients of group A and 6 of group B (3.54 vs. 10.17%, p= 0.021, OR 2.94). The presence of intradiverticular papilla was the cause of failure in all cases. The therapeutic procedures showed statistical differences in choledocholithiasis clearance as well as endoscopic sphincterotomy and biliary stents insertion, but there was no significant difference in complications. We found statistical significant differences in biliary lithiasis, malignant stenosis, mechanical lithotripsy and insertion of biliary stents. Conclusions: Periampullary duodenal diverticula increase the risk of failure for cannulation of ampulla. However, it should not be considered as contraindication for ERCP."