Preoperative diagnosis of perforated duodenal diverticulum with ultrasonography

Sonographic features of Lemmel's syndrome: Differential diagnosis from stones in the lower portion of the common bile duct

BACKGROUND AND STUDY AIMS

Periampullary diverticula (PAD), a location-specific type of duodenal diverticula, can cause serious complications. PAD is difficult to differentially diagnose, mainly due to its nonspecific symptoms. This study aimed to identify sonographic features of PAD and to evaluate their value in the differential diagnosis of PAD from stones in the lower common bile duct (CBD).

PATIENTS AND METHODS

A total of 30 patients with PAD and 60 patients with lower CBD stones were retrospectively enrolled, and sonographic features were analyzed. Measurements of sonographic features included echo shaped, posterior echo changes, location and relation to surrounding organs, and status of intrahepatic and extrahepatic bile duct dilation, and their diagnostic performance was assessed.

RESULTS

Characteristic sonographic features of PAD were identified, including strong echoes (28/30, 93.3 %), strip shape (28/30, 93.3 %), multiple reflections in the posterior echo (27/30, 90.0 %), and location outside the CBD or near the biliary wall in connection with the duodenum (27/30, 90.0 %). Inter-observer agreement was good (Kappa values = 0.69-0.82). Comparative analysis of sonographic features revealed significant differences in echo shape, posterior echo changes (multiple reflections and acoustic shadowing), location and relation to surrounding organs, and intrahepatic and extrahepatic bile duct dilatation status between the dilatation status of the two groups. In particular, these characteristics achieved a sensitivity of 100 % and a specificity of 98 % for the differential diagnosis of PAD and lower CBD stones.

CONCLUSIONS

This study identified characteristic sonographic features of PAD, which could be used as potential diagnostic indicators to distinguish PAD from lower CBD stones.

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.

Ultrasonographic findings in dogs and cats with gastrointestinal perforation

A retrospective study was performed to evaluate the sonographic features of gastrointestinal (GI) perforation in dogs and cats. Sonographic findings in 19 animals (14 dogs and 5 cats) included regional bright mesenteric fat (19), peritoneal effusion (16), fluid-filled stomach or intestines (12), GI wall thickening (11), presence of free air (9), loss of GI wall layering (9), regional lymphadenopathy (8), reduced GI motility (7), pancreatic changes (4), corrugated intestines (4), presence of a mass (3), presence of a foreign body (3), and mineralization of the gastric wall (1). In 14 patients, "perforation" was listed as a differential diagnosis by the sonographer. Abdominal radiographs and radiographic reports were available for 14 patients. Radiographic findings were decreased serosal detail (12), free air (8), peritoneal contrast medium (1), and suspected foreign body (1). GI perforation was listed as radiographic diagnosis in eight patients, seven of which had evidence of pneumoperitoneum, and one had leakage of contrast material on an upper GI study. In 9/14 patients with radiography, "GI perforation" was listed as a sonographic diagnosis. In three patients in which free air was diagnosed sonographically, radiographs were either not available (2) or the presence of free air was not detected at presentation (1). Peritoneal fluid analysis was performed in nine patients, five of which were identified as septic inflammation, and the remaining four were classified as neutrophilic inflammation with no etiologic agent identified. The histologic or surgical diagnoses were as follows: three intestinal surgical dehiscence; one percutaneous endoscopic gastrostomy tube site leakage; one duodenal adenocarcinoma; one ileocolic lymphoma; one trichobezoar; one ascarid impaction; and one bobby pin foreign body. In the remaining 10 patients, a focal area of gastric/intestinal ulceration or transmural necrosis with perforation was identified without evidence of an underlying cause.