Endoscopic management of a bleeding duodenal diverticulum

Two Cases of Bleeding Angiodysplasias Within Duodenal Diverticulum

Although duodenal diverticula are relatively common, the bleeding complications from duodenal diverticula are exceedingly rare. We report 2 cases of obscure upper gastrointestinal bleeding secondary to angiodysplasias within a duodenal diverticula. These cases highlight the importance of considering duodenal diverticular angiodysplasias as a clinically significant etiology for upper gastrointestinal bleeding.

[Successful Management of Periampullary Diverticular Bleeding with Hemoclipping Using Side-viewing Endoscope during Endoscopic Retrograde Cholangiopancreatography]

Periampullary diverticulum is commonly found during endoscopy and can occur at any age although its prevalence increases with age. Periampullary diverticular bleeding is a rare and difficult to diagnose during clinical practice because of its unique appearance and location. This often can lead to massive bleeding and interfere with adequate bleeding control. Endoscopic management on duodenal diverticular bleeding is limited compared to colonic diverticular bleeding due to lack of experience. Herein, we report a case of active bleeding from a periampullary diverticulum during bile duct stone extraction diagnosed by side-viewing endoscope and successfully controlled using hemoclips without any complications.

Active bleeding from a periampullary duodenal diverticulum that was difficult to diagnose but successfully treated using hemostatic forceps: a case report

Introduction

Although duodenal diverticula are common, periampullary duodenal diverticula are rare. Periampullary duodenal diverticula are usually asymptomatic and may be difficult to diagnose and treat. However, they may present with massive bleeding, requiring prompt diagnosis.

Case presentation

We report the case of a 71-year-old Asian woman with bleeding from a periampullary duodenal diverticulum. She presented with severe anemia and tarry stools. Two examinations using a forward-viewing endoscope did not identify the source of the bleeding. However, examination using a side-viewing endoscope found an exposed bleeding vessel overlying the bile duct within a periampullary diverticulum of the descending part of the duodenum. The bleeding was successfully controlled by using hemostatic forceps.

Conclusions

Bleeding periampullary duodenal diverticula are rare, and a bleeding point in the mucosa overlying the bile duct within a large periampullary duodenal diverticulum is very rare. Identification of a bleeding point within a duodenal diverticulum often requires repeated examination and may require the use of a side-viewing endoscope. Use of hemostatic forceps to control bleeding from a periampullary duodenal diverticulum is very rare but, for bleeding lesions overlying the bile duct within a periampullary duodenal diverticulum, is the best way to prevent obstructive jaundice.

[The effect of periampullary diverticulum on the outcome of bile duct stone treatment with endoscopic papillary large balloon dilation]

BACKGROUND/AIMS

Periampullary diverticulum (PAD) causes difficulty in the extraction of common bile duct (CBD) stones with conventional endoscopic therapy. Our study was designed to evaluate the effect of PAD on endoscopic large balloon dilation (EPLBD) with/without limited endoscopic sphincterotomy (EST) for CBD stone treatment.

METHODS

We retrospectively reviewed cases of 141 patients treated CBD stones by EPLBD with/without limited EST at Gachon Gil Medical Center from September 2008 to February 2010. PAD were classified into three groups according to the location of the papilla and diverticulum. Clinical parameters, endoscopic parameters, and procedure outcomes were analyzed.

RESULTS

PAD were identified in 46.1% (65/141), with 23 male (35.4%) and 42 female (64.6%) and a mean age of 72.9±11.1 years. Mean diameter of the stones was 14.8±6.0 mm and mean diameter of CBD was 21.6±7.7 mm. PAD group was significantly older than control group (72.9 vs. 68.6, p=0.043) and the incidence of large stone (≥15 mm) was higher in PAD group (60.0% vs. 42.1%, p=0.034). Success rate of complete removal of stones in the first session was 32/65 patients (49.2%) and overall successful complete stone removal rates was 63/65 (96.9%). There was no significant difference between the PAD and control groups in success rate. Major complications were similar between two groups.

CONCLUSIONS

PAD is associated with an increased incidence of large bile duct stones and older age. PAD seems to not increase technical failure rate or complication risk on EPLBD with/without limited EST.

Laparoscopic diverticulectomy for massive hemorrhage in a duodenal diverticulum

Hemorrhagic duodenal diverticula are rare and are treated by endoscopy or open diverticulectomy, especially when there is a massive hemorrhage. We report what we believe to be the first instance of urgent laparoscopic diverticulectomy of a large, inflamed duodenal diverticulum with massive hemorrhage. An elderly patient had a screening colonoscopy and additional upper gastrointestinal endoscopy because of vague upper gastrointestinal symptoms; however, both were reported to be normal. She subsequently developed massive hematemesis. Clinical examination revealed a tender right upper quadrant mass and imaging confirmed a large duodenal diverticulum with surrounding inflammatory changes. Urgent laparoscopic diverticulectomy was performed with an uneventful recovery and follow-up. Laparoscopic diverticulectomy should be considered in managing hemorrhagic duodenal diverticula.

Pneumoretroperitoneum and pneumoperitoneum following argon plasma coagulation for a bleeding duodenal diverticulum: a case report

Duodenal diverticula are usually asymptomatic, with an incidence of 0.16% to 22%. Symptomatic bleeding from a duodenal diverticulum is an even rarer event. The management of such a hemorrhage is almost entirely surgically based. Since the first reported case of endoscopic therapy for duodenal diverticular bleeding (DDB) by Sim et al, only two case series have been reported in the literature regarding endoscopic therapy for DDB. Hence, the optimal therapy modality for DDB remains unclear. A rare case involving massive pneumoretroperitoneum and pneumoperitoneum following argon plasma coagulation treatment for DDB is presented. A short discussion of the optimal endoscopic therapy for this rare disease is provided.

Endoscopic management of duodenal diverticular bleeding

BACKGROUND

Although the presence of a duodenal diverticulum is usually asymptomatic, bleeding in this tissue is sometimes difficult to diagnose and treat.

OBJECTIVE

To investigate the strategy for treatment, we reviewed the clinical data of patients diagnosed and treated for duodenal diverticular bleeding.

DESIGN

Retrospective case series.

SETTING

Single tertiary-referral center.

PATIENTS

Seven consecutive patients with bleeding from a duodenal diverticulum (mean age, 73.7 +/- 3.4 years old).

INTERVENTIONS

The clinical characteristics, endoscopic findings, and treatment strategy for duodenal diverticular bleeding.

MAIN OUTCOME MEASUREMENTS

All 7 patients achieved hemostasis. Six of 7 patients were treated endoscopically. There were no complications with endoscopic treatment.

RESULTS

Three patients bled from diverticula located at the second portion of the duodenum, and 4 patients bled from that located at the third portion. In 6 of 7 patients, lesions were identified and treated endoscopically with hemoclips, hypertonic saline solution and epinephrine (HSE), and/or 1% polidocanol injection. In 1 case, the lesion could not be detected during the first endoscopic examination, and the patient, therefore, was treated with transarterial embolization followed by surgical resection.

LIMITATIONS

This preliminary case series described the feasibility of the endoscopic treatment. However, optimal management, including angiography and/or surgery, should be individualized to the patients, location, and type of hemorrhage.

CONCLUSIONS

Bleeding from a duodenal diverticulum should be considered in the case of upper-GI bleeding of unknown origin. An endoscopy may be an effective alternative to surgery in the management of a bleeding duodenal diverticulum.

Impact of endoscopy in the management of duodenal diverticular bleeding: experience of a single medical center and a review of recent literature

BACKGROUND

Duodenal diverticulum (DD) is a rare cause of upper-GI bleeding. The diagnosis and treatment of DD bleeding (DDB) is challenging. Surgical management was the mainstay of therapy before the 1990s.

OBJECTIVE

To evaluate the clinical feature, diagnosis, and management of cases of DDB at our institution and the literature after the first description of endoscopic therapy of this disease.

DESIGN

Retrospective single-center clinical review.

SETTING

Primary- and tertiary-care centers.

PATIENTS

A retrospective study of patients with DDB from January 2000 to January 2005 at Changhua Christian Medical Center.

MAIN OUTCOME MEASUREMENTS

Diagnostic yield and therapy results of endoscopy on DDB.

RESULTS

At our institution, from January 2000 to January 2005, a total of 11 patients (4 men and 7 women, mean age 75 years) were found to have DDB. The diverticulum was located in the second portion (n = 10) and the third portion (n = 1). Endoscopy was used as the diagnostic method in all of these cases and as the therapeutic method in 72.73% of these cases. None of our patients experienced recurrent bleeding.

LIMITATIONS

The study is limited to the small case number and was retrospective.

CONCLUSIONS

To our knowledge, this is the first report and the largest series that studied endoscopic management of DDB in the literature. We concluded that endoscopy is useful to diagnose and treat patients with DDB.

Clinical analysis and literature review of massive duodenal diverticular bleeding

A duodenal diverticulum (DD) appears in 2.5% of upper gastrointestinal (UGI) examinations and up to 22% of endoscopic retrograde cholangiopancreaticographies (ERCP) and autopsies. Most of these patients are asymptomatic, but the lesion is occasionally associated with bleeding, inflammation, perforation, obstruction of the duodenum or biliary-pancreatic duct (or both), fistula formation in the bile duct, and bezoar formation inside the diverticulum. A total of 816 patients have undergone ERCP examination at our institution since January 1987, and 100 (12.25%) of them have DD. Seven (7%) patients presented with bloody or tarry stools from massive UGI bleeding followed by shock. Only two could be diagnosed by UGI endoscopy preoperatively. The lesions were demonstrated in angiographic studies in another four cases. However, only one was correctly interpreted and one required reoperation after a correct repeat endoscopic finding. The lesions in the other two patients were identified by thorough exploration during laparotomy. The remaining case was diagnosed by intraoperative endoscopy via pyloroduodenotomy. Six underwent surgical intervention, and one was successfully treated by expectant treatment. Three (50%) had leakage from the duodenotomy but recovered uneventfully with conservative treatment. In conclusion, we believe that DD bleeding is more frequent than usually thought. A high index of suspicion should be raised in cases of UGI bleeding when more obvious and common causes have been excluded by routine endoscopy. Aggressive but careful endoscopic examination combined with accurate angiography can help us diagnose most of the cases preoperatively. Diverticulectomy is an effective surgical procedure, though it is associated with a considerable leakage rate. The morbidity is minimal if we can identify the lesion earlier and evacuate the lesion without delay.