[Solitary duodenal diverticulum with enterolith as a rare cause of acute abdomen]

Bezoar in a periampullary duodenal diverticulum causing pancreaticobiliary obstruction and ascending cholangitis

Ascending cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain. It is caused by stasis and infection in the biliary tract with severity ranging from mild to life threatening. The most frequent causes of biliary obstruction and ascending cholangitis are choledocholithiasis, benign biliary stricture, and obstructing malignancy. In this report, we describe a rare case of a large periampullary duodenal diverticulum impacted with a food bezoar, causing pancreaticobiliary obstruction and ascending cholangitis.

Clinical Impacts of Juxtapapillary Duodenal Diverticulum Detected on Computed Tomography

BACKGROUND

Diverticula are commonly observed in the duodenum. Duodenal diverticulum (DD) usually does not give symptoms throughout life and is diagnosed by coincidence. However, it may present with different symptoms in patients.

OBJECTIVE

This study aims to evaluate the prevalence of DD and juxtapapillary duodenal diverticulum (JDD) and its association with other possible pathologies and to determine its clinical impact by using Computed Tomography (CT).

METHODS

This retrospective observational study, which was taken consecutively between the years of 2013-2020, was evaluated in the Radiology Department. The total number of cases was 4850 (male-2440; female-2410). CT images were evaluated by two experienced radiologists at the workstation. DD and JDD prevalence and clinical findings in the hospital registry system were examined.

RESULTS

The age of the patients included in the study ranged from 17 to 92 years (mean age 46.94±16.42). In patients with DD (female-130; male-101), mean age was 62.24 ± 12.69 (21-92). The prevalence of DD was 4.76% (n=231). The prevalence of JDD was 4.02% (n=195) and increased with age (p<0.01). The average diameter of the JDD was measured as 23.29±8.22(9.5-55.3) mm. A significant positive correlation was found between age and DD diameter (p=0.039). DDs were found most commonly 84.42% (n=195) in the second segment of the duodenum as JDD. In patients with JDD, the mean diameter of choledochus and wirsung canal were 6.7 ± 2.4 (3-15.3) mm and 0.31 ± 0.1 (0.1-6.5) mm respectively. The choledochal diameter was correlated with the JDD size (p = 0.004). Cholelithiasis (n=56), choledocholithiasis (n=20), cholecystitis (n=52), diverticulitis (n=15), duodenitis (n=37), pancreatitis (n=5) and hiatal hernia (n=60) with JDD were observed. Periampullary carcinoma was detected in one patient.

CONCLUSION

Our study shows that cholelithiasis, choledocholithiasis, cholecystitis, diverticulitis, duodenitis, pancreatitis may be associated with JDD. Therefore, in contrast-enhanced abdominal CT scans taken for various reasons, investigation of the presence and characteristics of JDD and detection of pathologies that may be associated with JDD are important for patients to benefit from early diagnosis and treatment opportunities and to take precautions against possible complications.

Contrast Enhanced Computed Tomographic Study on the Prevalence of Duodenal Diverticulum in Indian Population

INTRODUCTION

Duodenal diverticulum (DD) is the second most common diverticulum, yet its incidence varies widely from 1-22% based on the mode of investigation. Computed Tomography (CT) of abdomen is the preferred modality to diagnose acute abdomen including those of complications of DD. Moreover, the prevalence of DD in Indian population is not yet been studied using CT.

AIM

The current study aim to look for the prevalence of DD in Indian population using Contrast Enhanced Computed Tomography (CECT) abdomen.

MATERIALS AND METHODS

A retrospective study was done to assess the presence of DD using the CECT abdomen of 565 patients. The number, size, location, wall thickness and the contents of the diverticulum were noted. The data obtained was analysed using SPSS version 17.0. The mean, percentage of frequency of each variable and the association of DD with pancreatitis, cholelithiasis and colonic diverticulum were also looked for. Frequencies and percentages were calculated for all categorical variables. Spearman's rho correlation was done for age, diameter and content of DD.

RESULTS

The prevalence of DD in Indian population was 8.3% with the mean diameter of 17.13mm+7.26. The prevalence increased with age with no sex predilection. 89.3% were solitary and 10.64% were multiple. It was predominantly seen in the second part of duodenum (90.38%) and juxtapapillary type was the commonest. As the diameter of DD increased, fluid became its content. No significant association was observed between the presence of DD with pancreatitis, cholelithiasis or colonic diverticulum. A case of periampullary carcinoma arising from DD, a rare entity is being reported in this study.

CONCLUSION

The prevalence of DD in Indian population is high compared to western population. DD has been attributed to the cases of acute abdomen and fluid alone as a content of DD with an incidence of 1.92% can be mistaken for a cystic neoplasm of pancreas. Rarely, a periampullary carcinoma can also arise from the wall of the pre-existing DD. This knowledge should be emphasised upon by the radiologist, surgeons and gastroenterologist who will be dealing with cases of acute abdomen and periampullary carcinoma.

Perforated duodenal diverticulum: A case report

Duodenum is the second most frequent location for diverticulum in the digestive tract, surpassed only by the colon. Perforation is rare, but it is the most serious complication of duodenum diverticula. Presently described is case of 22-year-old male patient who presented at emergency department with abdominal pain and vomiting. Surgery was performed with prediagnosis of perforated duodenum diverticula based on results of computed tomography.

Endoscopic rendez-vous after damage control surgery in treatment of retroperitoneal abscess from perforated duodenal diverticulum: a techinal note and literature review

Introduction

The duodenum is the second seat of onset of diverticula after the colon. Duodenal diverticulosis is usually asymptomatic, but duodenal perforation with abscess may occur.

Case presentation

Woman, 83 years old, emergency hospitalised for generalized abdominal pain. On the abdominal tomography in the third portion of the duodenum a herniation and a concomitant full-thickness breach of the visceral wall was detected. The patient underwent emergency surgery. A surgical toilette of abscess was performed passing through the perforated diverticula and the Petzer’s tube drainage was placed in the duodenal lumen; the duodenostomic Petzer was endoscopically removed 4 months after the surgery.

Discussion

A review of medical literature was performed and our treatment has never been described.

Conclusion

For the treatment of perforated duodenal diverticula a sequential two-stage non resective approach is safe and feasible in selected cases.

Perforated duodenal diverticulum, a rare complication of a common pathology: A seven-patient case series

Duodenal diverticula (DD) are frequently encountered and are usually asymptomatic, with an incidence at autopsy of 22%. Perforation of DD is a rare complication (around 160 cases reported) with potentially dramatic consequences. However, little evidence regarding its treatment is available in the literature. The aim of this study was to review our experience of perforated DD, with a focus on surgical management. Between January 2001 and June 2011, all perforated DD were retrospectively reviewed at a single centre. Seven cases (5 women and 2 men; median age: 72.4 years old, rang: 48-91 years) were found. The median American Society of Anesthesiologists’ score in this population was 3 (range: 3-4). The perforation was located in the second portion of duodenum (D2) in six patients and in the third portion (D3) in one patient. Six of these patients were treated surgically: five patients underwent DD resection with direct closure and one was treated by surgical drainage and laparostomy. One patient was treated conservatively. One patient died and one patient presented a leak that was successfully treated conservatively. The median hospital stay was 21.1 d (range: 15-30 d). Perforated DD is an uncommon presentation of a common pathology. Diverticular excision with direct closure seems to offer the best chance of survival and was associated with a low morbidity, even in fragile patients.

[Meckel's diverticulum and enteroliths complicating Crohn's disease]

We describe the case of a 43-year-old man recently diagnosed with ileal Crohn's disease complicated by a free peritoneal perforation of a Meckel's diverticulum and the presence of enteroliths in the intestinal lumen. The coexistence of Crohńs disease, Meckel's diverticulum and enteroliths has rarely been reported. Meckel's diverticulum can hamper the management of Crohn's disease.

Duodenal obstruction following acute pancreatitis caused by a large duodenal diverticular bezoar

Bezoars are concretions of indigestible materials in the gastrointestinal tract. It generally develops in patients with previous gastric surgery or patients with delayed gastric emptying. Cases of periampullary duodenal divericular bezoar are rare. Clinical manifestations by a bezoar vary from no symptom to acute abdominal syndrome depending on the location of the bezoar. Biliary obstruction or acute pancreatitis caused by a bezoar has been rarely reported. Small bowel obstruction by a bezoar is also rare, but it is a complication that requires surgery. This is a case of acute pancreatitis and subsequent duodenal obstruction caused by a large duodenal bezoar migrating from a periampullary diverticulum to the duodenal lumen, which mimicked pancreatic abscess or microperforation on abdominal computerized tomography. The patient underwent surgical removal of the bezoar and recovered completely.

Complicated jejunal diverticulitis: a challenging diagnosis and difficult therapy

BACKGROUND/AIM

In contrast to diverticulosis of the colon, jejunal diverticulosis is a rare entity that often becomes clinically relevant only after exacerbations occur. The variety of symptoms and low incidence make this disease a difficult differential diagnosis.

PATIENTS AND METHODS

Data from all patients who were treated in our surgical department for complicated jejunal diverticulitis, that is, gastrointestinal hemorrhage or a diverticula perforation were collected prospectively over a 6-year period (January 2004 to January 2010) and analyzed retrospectively.

RESULTS

The median age among the 9 patients was 82 years (range: 54-87). Except for 2 cases (elective operation for a status postjejunal peridiverticulitis and a re-perforation of a diverticula in a patient s/p segment resection with free perforation), the diagnosis could only be confirmed with an exploratory laparotomy. Perforation was observed in 5 patients, one of which was a retroperitoneal perforation. The retroperitoneal perforation was associated with transanal hemorrhage. Hemodynamically relevant transanal hemorrhage requiring transfusion were the reason for an exploratory laparotomy in 2 further cases. In one patient, the hemorrhage was the result of a systemic vasculitis with resultant gastrointestinal involvement. A singular jejunal diverticulum caused an adhesive ileus in one patient. The extent of jejunal diverticulosis varied between a singular diverticulum to complete jejunal involvement. A tangential, transverse excision of the diverticulum was carried out in 3 patients. The indication for segment resection was made in the case of a perforation with associated peritonitis (n=4) as well as the presence of 5 or more diverticula (n=2). Histological analysis revealed chronic pandiverticulitis in all patients. Median operating time amounted to 142 minutes (range: 65-210) and the median in-hospital stay was 12 days (range: 5-45). Lethality was 0%. Major complications included secondary wound closure after s/p repeated lavage and bilateral pleural effusions in one case. Signs of malabsorption as the result of a short bowel syndrome were not observed. Minor complications included protracted intestinal atony in 2 cases and pneumonia in one case. Median follow-up was 6 months (range: 1-18).

CONCLUSION

Complicated jejunal diverticulitis often remains elusive preoperatively due to its unspecific clinical presentation. A definitive diagnosis can often only be made intraoperatively. The resection of all diverticula and/or the complete diverticula-laden segment is the goal in chronic cases. The operative approach chosen (tangential, transverse excision vs segment resection) should be based on the extent of the jejunal diverticulosis as well as the intraoperative findings.

Diagnosis and management of the symptomatic duodenal diverticulum: a case series and a short review of the literature

INTRODUCTION

The incidence of duodenal diverticula (DD) found at autopsy may be as high as 22%. Perforation is the least frequent but also the most serious complication. This case series gives an overview of the management of this rare entity.

METHODS

This study is a case series of eight patients treated for symptomatic DD.

RESULTS

Two patients had a perforated DD. One perforation was in segments III-IV, which to our knowledge is the first published case; the other perforation was in segment II. A segmental duodenectomy was performed in the first patient and a pylorus-preserving duodeno-pancreatectomy (pp-Whipple) in the second. A third patient with chronic complaints and recurring episodes of fever required an excision of the DD. In a fourth patient with biliary and pancreatic obstruction, a pp-Whipple was carried out, and a DD was discovered as the underlying cause. Four patients (one small perforation, one hemorrhage, and two recurrent cholangitis/pancreatitis caused by a DD) were treated conservatively.

CONCLUSIONS

Symptomatic DD and, in particular, perforations are rare, encompass diagnostic challenges, and may require technically demanding surgical or endoscopic interventions. The diagnostic value of forward-looking gastroduodenoscopy in this setting seems limited. If duodenoscopy is performed at all, the use of a side-viewing endoscope is mandatory.