Perforated duodenal diverticulum case report

Highlights

• •

  1–5% of patients with duodenal diverticula become symptomatic (Oukachbi, 2013) [2].

• •

  The least common but most serious complication is perforation.

• •

  Duodenal diverticula perforation can be the result of the peptic digestion, ulceration, enterocoliths, blunt abdominal trauma, or iatrogenic perforation during an ERCP (Schnueriger et al., 2008; Duarte and Cintron, 1992) [5,6].

• •

  The most sensitive exam to detect a duodenal diverticulum perforation is an abdominal CT scan (Song, 2015) [4].

• •

  A duodenal diverticulum perforation usually necessitates operative treatment with a diverticulectomy and two-layer closer of the duodenum, Kocher maneuver, and drainage of the retroperitoneum.

Abstract

Introduction

The duodenum is the second most common location of intestinal diverticula following the colon (Juler et al., 1969) [1]. Only 1–5% of patients with duodenal diverticula become symptomatic (Oukachbi, 2013) [2]. The least common but most serious complication of duodenal diverticula is perforation, which has a mortality rate of 20% (Oukachbi, 2013; Yin et al., 2001; Song, 2015; Schnueriger et al., 2008) [2–5].

Presentation of case

A 65 year old female presented with sudden onset periumbilical and epigastric pain. Her abdomino-pelvic CT without contrast revealed a duodenal perforation of the anterior wall of the duodenum. After attempting a laparoscopic approach, the operation was converted to an open procedure to enhance visualization. A wide Cattell-Braasch maneuver was performed, mobilizing the duodenum, which revealed an inflamed diverticulum. Following a pyloric exclusion, a gastrojejunostomy and a Braun enteroenterostomy were completed in addition to a jejunostomy tube on the efferent limb.

Discussion

Clinical presentation of duodenal diverticula is vague and often varies. Although difficult to elucidate on imaging, the most sensitive exam to detect a duodenal diverticulum perforation is an abdominal CT scan, which can reveal thickened bowel wall, mesenteric fat stranding, and an extraluminal, retroperitoneal collection of air or fluid (Song, 2015) [4]. Due to the rareness of perforated duodenal diverticulum, surgical treatment guidelines are lacking.

Conclusion

Ultimately, it is necessary to have a high index of suspicion to detect a duodenal diverticulum perforation. The perforation usually necessitates operative treatment that consists of a diverticulectomy and two-layer closer of the duodenum, Kocher maneuver, and drainage of the retroperitoneum.