Acute bleeding and anemia associated with intraluminal duodenal diverticulum: case report and review

Imaging Findings of an Intraluminal Duodenal Diverticulum Associated with Adult Duodeno-Duodenal Intussusception and Recurrent Pancreatitis: A Case Report

Intraluminal duodenal diverticulum (IDD) is a rare congenital abnormality, consisting of a sac-like mucosal lesion in the duodenum. Cases of IDD can present with gastrointestinal bleeding, duodenal obstruction, or pancreatitis. Here, we report a rare case of a 25-year-old female presenting with IDD complicated by duodeno-duodenal intussusception and recurrent pancreatitis. The diagnosis was based on findings from radiologic examinations (CT and MRI), upper gastrointestinal series (barium swallow), and gastroduodenofiberscopy. Laparoscopic excision of the presumed duodenal duplication was performed. The subsequent histopathologic evaluation of the excised sac revealed normal mucosa on both sides, but the absence of a proper muscle layer confirmed the diagnosis of IDD. Radiologic detection of a saccular structure in the second portion of the duodenum can indicate IDD with duodeno-duodenal intussusception as the lead point.

Duodenal diverticulum mimicking duodenal stromal tumor

A patient with duodenal diverticulitis who was initially misdiagnosed with stromal tumor of the duodenum is presented. This case is of interest because it illustrates difficulties in the interpretation of auxiliary investigations and the choice of the best treatment option. US and CT images revealed two large ovoid masses of fluid density in the duodenal wall which may have suggested stromal tumor of the duodenum as well as periampullary cystic neoplasm, the more so because intramural tumor of the duodenum was seen in duodenoscopy. A similar picture may also be seen in duodenal diverticula, especially in diverticula which are not filled with gas or a combination of fluid and gas. This case demonstrates one such entity.

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.