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Sasaki Y, Nakahodo J, Onishi T, Tachibana A, Minami R, Noma E, Moriguchi Y, Tabata H, Shimizuguchi R, Takao A, Shibata S, Chiba K, Arakawa T, Iizuka T, Kamisawa T. Duodenal Diverticular Perforation Treated Conservatively: Reassessing Indications for Treatment. Intern Med 2023; 62:3327-3331. [PMID: 36948615 DOI: 10.2169/internalmedicine.1211-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Abstract
A 59-year-old woman presented with a chief complaint of melena. She had no abdominal findings, such as tenderness or tapping pain. Laboratory tests revealed a white blood cell count of 5,300 cells/μL and C-reactive protein level of 0.07 mg/dL. Inflammation and anemia (hemoglobin 12.4 g/dL) were denied. Contrast-enhanced computed tomography (CT) revealed multiple duodenal diverticula and air surrounding a descending duodenal diverticulum. Based on these findings, duodenal diverticular perforation (DDP) was suspected. Oral food intake was stopped, and nasogastric tube feeding and conservative treatment with cefmetazole, lansoprazole, and ulinastatin were begun. On day 8 of hospitalization, follow-up CT revealed the disappearance of the air surrounding the duodenum, and the patient was discharged on day 19 after the resumption of oral feeding.
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Affiliation(s)
- Yuri Sasaki
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Jun Nakahodo
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Tomoko Onishi
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Ayu Tachibana
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Ryogo Minami
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Eriko Noma
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Yoshiaki Moriguchi
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Hiroki Tabata
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Ryoko Shimizuguchi
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Satomi Shibata
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Kazuro Chiba
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Takeo Arakawa
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Toshiro Iizuka
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
| | - Terumi Kamisawa
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan
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Mansour M, Abboud Y, Bilal R, Seilin N, Alsuliman T, Mohamed FK. Small bowel diverticula in elderly patients: a case report and review article. BMC Surg 2022; 22:101. [PMID: 35303837 PMCID: PMC8932322 DOI: 10.1186/s12893-022-01541-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background Small intestine diverticula are rare findings that were mostly reported in the elderly population as asymptomatic findings. However, they can also present with a wide range of symptoms (bloating, early satiety, chronic abdominal discomfort, and diarrhea/steatorrhea) or complications (gastrointestinal bleeding, small bowel obstruction, acute diverticulitis, or perforation) which in turn warrant medical treatment or urgent surgical intervention.
Case presentation This is a case report of an 84-year-old female who presented with an acute surgical abdomen. An exploratory laparotomy revealed complicated small bowel diverticula with a jejunal diverticulum perforation, for which a diverticulectomy was performed. Conclusions Throughout this paper, we are aiming to outweigh the consideration of the possibility of complicated small bowel diverticula as a differential in the evaluation of any acute abdomen, especially in the elderly, which warrants emergency surgical management.
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Affiliation(s)
- Marah Mansour
- Faculty of Medicine, Tartous University, Tartous, Syrian Arab Republic.
| | - Yazan Abboud
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Racha Bilal
- Faculty of Medicine, Damascus University, Damascus, Syrian Arab Republic
| | - Nour Seilin
- Department of Internal Medicine, Damascus Hospital, Damascus, Syrian Arab Republic
| | - Tamim Alsuliman
- Hematology and Cell Therapy Department, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France
| | - Fawaz K Mohamed
- Department of General Surgery, Al-Basel Hospital, Tartous, Syrian Arab Republic
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CUMBO P, CAVALOT G, ROCCA R, FONIO P, ROTONDELLA C, BREATTA DORIGUZZI A, AZZELLINO M, LO PICCOLO LB. Multidisciplinary treatment of perforated duodenal diverticulum and postoperative stenosis of the papilla of Vater. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.21.05260-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tomida H, Nakagawa K, Matsumura H, Shinichiro I, Matsushita A, Koike S. Perforated Duodenal Diverticulum With Postoperative Diverticulum Bleeding Successfully Treated Using Transcatheter Arterial Embolization. Cureus 2021; 13:e18219. [PMID: 34722030 PMCID: PMC8544636 DOI: 10.7759/cureus.18219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 11/16/2022] Open
Abstract
A diverticulum is a relatively common finding that is generally discovered incidentally; it is most commonly observed in the colon, followed by the duodenum. However, duodenal diverticulum perforation (DDP) is a rare complication. Due to its rarity, its diagnosis is often challenging and the appropriate treatment remains unclear, possibly contributing to its high mortality rate. Traditionally, surgical repair is the primary mode of treatment. However, with the recent advancements in medical technology, conservative management such as bowel rest and endoscopic drainage help successfully manage DDP. Duodenal diverticulum bleeding (DDB) is a rare cause of upper gastrointestinal bleeding. While endoscopic, angiographical, and surgical treatments have been performed to achieve hemostasis, there is no consensus regarding the optimal treatment for DDB. We describe a case of a perforated duodenal diverticulum (DD) with postoperative diverticulum bleeding. Our patient, an elderly female, complained of abdominal pain. Computed tomography images revealed free air in the retroperitoneum, and gastrointestinal perforation was suspected. During the emergency surgery, a perforated DD was detected in the third portion of the duodenum. Due to severe inflammation, diverticulectomy was not performed as it was deemed risky. Instead, we directly sutured the orifice using an omental patch. Duodenal leakage was observed from postoperative day (POD) 3 with bleeding from the remnant DD occurred on PODs 6 and 13. An attempt at endoscopic hemostasis failed, but transcatheter arterial embolization (TAE) was successfully performed. The postoperative course was complicated, and the patient died on POD 54. To the best of our knowledge, this is the first report on DD perforation with postoperative DDB. The remnant DD may be damaged by the digestive juices and result in bleeding. Precautionary measures for duodenal leakage should be undertaken when the DD is unresectable. Additionally, TAE is effective for postoperative DDB.
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Affiliation(s)
- Hidenori Tomida
- Surgery, Shinshu University School of Medicine, Matsumoto, JPN
| | - Kan Nakagawa
- Surgery, National Hospital Organization Matsumoto Medical Center, Matsumoto, JPN
| | - Hideyasu Matsumura
- Surgery, National Hospital Organization Matsumoto Medical Center, Matsumoto, JPN
| | - Imai Shinichiro
- Surgery, National Hospital Organization Matsumoto Medical Center, Matsumoto, JPN
| | - Akimasa Matsushita
- Surgery, National Hospital Organization Matsumoto Medical Center, Matsumoto, JPN
| | - Shoichiro Koike
- Surgery, National Hospital Organization Matsumoto Medical Center, Matsumoto, JPN
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A systematic review of the perforated duodenal diverticula: lessons learned from the last decade. Langenbecks Arch Surg 2021; 407:25-35. [PMID: 34164722 PMCID: PMC8847262 DOI: 10.1007/s00423-021-02238-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/09/2021] [Indexed: 11/23/2022]
Abstract
Background The perforated duodenal diverticulum remains a rare clinical entity, the optimal management of which has not been well established. Historically, primary surgery has been the preferred treatment modality. This was called into question during the last decade, with the successful application of non-operative therapy in selected patients. The aim of this systematic review is to identify cases of perforated duodenal diverticula published over the past decade and to assess any subsequent evolution in treatment. Methods A systematic review of English and non-English articles reporting on perforated duodenal diverticula using MEDLINE (2008–2020) was performed. Only cases of perforated duodenal diverticula in adults (> 18 years) that reported on diagnosis and treatment were included. Results Some 328 studies were identified, of which 31 articles met the inclusion criteria. These studies included a total of 47 patients with perforated duodenal diverticula. This series suggests a trend towards conservative management with 34% (16/47) of patients managed non-operatively. In 31% (5/16) patients initially managed conservatively, a step-up approach to surgical intervention was required. Conclusion Conservative treatment of perforated duodenal diverticula appears to be an acceptable and safe treatment strategy in stable patients without signs of peritonitis under careful observation. For patients who fail to respond to conservative treatment, a step-up approach to percutaneous drainage or surgery can be applied. If surgery is required, competence in techniques ranging from simple diverticulectomy to Roux-en-Y gastric diversion or even Whipple’s procedure may be required depending on tissue friability and diverticular collar size.
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Shimada A, Fujita K, Kitago M, Ichisaka S, Ishikawa K, Kikunaga H, Kumai K, Miura H. Perforated duodenal diverticulum successfully treated with a combination of surgical drainage and endoscopic nasobiliary and nasopancreatic drainage: a case report. Surg Case Rep 2020; 6:129. [PMID: 32514821 PMCID: PMC7280391 DOI: 10.1186/s40792-020-00891-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/29/2020] [Indexed: 12/03/2022] Open
Abstract
Background Perforation of a duodenal diverticulum is a rare complication that may become fatal with a delay in appropriate treatment. However, the optimal treatment for perforated duodenal diverticulum remains controversial, ranging from conservative therapy to surgery including pancreatoduodenectomy. Case presentation The patient was a 60-year-old woman with no particular medical history who visited our hospital with chief complaints of continuous fever and right dorsal pain. Upon arrival, she had tenderness in the right upper quadrant of the abdomen. Laboratory data showed the elevation of inflammatory markers. Computed tomography revealed free air with abscess formation around the duodenum, which was diagnosed as duodenal perforation with abdominal abscess. We decided on emergent surgery, and we identified the perforation site on the dorsal side of the second portion of the duodenum intraoperatively. However, the inflammation around the perforation site was severe, and it was difficult to perform primary closure or dissection of the perforated diverticulum. Therefore, we finished surgery by placing four indwelling intra-abdominal tubes. Since postoperative day (POD) 1, the elevation of inflammation markers appeared to be uncontrollable, owing to the leakage of bile and pancreatic juice. We decided to perform endoscopic retrograde cholangiopancreatography on POD 2, and inserted endoscopic nasobiliary drainage and nasopancreatic drainage tubes. The patient showed a good postoperative course and was discharged on POD 57. Conclusions Endoscopic nasobiliary and nasopancreatic drainage in combination with surgical drainage may be an effective treatment for perforated duodenal diverticulum.
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Affiliation(s)
- Ayako Shimada
- Department of Surgery, Hino Municipal Hospital, 4-3-1 Tamadaira, Hino, Tokyo, 191-0062, Japan. .,Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare Narita Hospital, Narita, Japan.
| | - Koji Fujita
- Department of Surgery, Hino Municipal Hospital, 4-3-1 Tamadaira, Hino, Tokyo, 191-0062, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Shinjuku, Japan
| | - Shunsuke Ichisaka
- Department of Surgery, Hino Municipal Hospital, 4-3-1 Tamadaira, Hino, Tokyo, 191-0062, Japan
| | - Keiichi Ishikawa
- Department of Surgery, Hino Municipal Hospital, 4-3-1 Tamadaira, Hino, Tokyo, 191-0062, Japan
| | - Hiroyuki Kikunaga
- Department of Surgery, Hino Municipal Hospital, 4-3-1 Tamadaira, Hino, Tokyo, 191-0062, Japan
| | - Koichiro Kumai
- Department of Surgery, Hino Municipal Hospital, 4-3-1 Tamadaira, Hino, Tokyo, 191-0062, Japan
| | - Hiroshi Miura
- Department of Radiology, Hino Municipal Hospital, Hino, Japan
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