JDDH Journal

Introduction

Small bowel diverticula are uncommon occurring in 0.3-1.3% of post-mortem cases with the duodenum being the most likely site, and are usually asymptomatic [1,2]. However, although rare, complications include abdominal pain, small bowel diverticulitis, small bowel perforation, pancreaticobiliary obstruction, and related sequela (i.e. ascending cholangitis, pancreatitis) [2].  When complications arise, clinical suspicion and early diagnosis are crucial as these patients can often suffer from a delay in diagnosis and treatment. Here, we present a case of a 42-year-old female with peri-ampullary duodenal diverticulitis complicated by pancreaticobiliary obstruction successfully managed conservatively.

Case Presentation

A 42-year-old female with a past medical history of hypertension, hyperlipidemia, migraines, pleomorphic adenoma of the right salivary gland, herpes labialis, and prior laparoscopic cholecystectomy presented with acute onset of nausea and bilious vomiting ongoing for 4 days accompanied by severe epigastric abdominal pain. She complained of associated poor oral intake, loose stools, fevers, and chills. On initial presentation, she was noted to be tachycardic but vital signs were otherwise unremarkable. The patient had no prior history of heavy alcohol, tobacco, or illicit drug use. On physical examination, the patient had diffuse tenderness to abdominal palpation with normal active bowel sounds. Labs were significant for leukocytosis, hypokalemia, and elevations to serum liver chemistries: alkaline phosphatase 159, ALT 318, AST 347. Hepatitis panel was negative and lipase was within normal limits. Computerized tomography (CT) abdomen/pelvis (AP) showed a prominent duodenal diverticulum in the second portion of the duodenum, measuring 3.8 x 2.3 x 2.5 cm, and containing particulate material. The extrahepatic common bile duct was mildly prominent at 8 mm, and the diverticulum was noted to exert some mass effect on the adjacent ampulla of Vater, although the degree of dilatation was also within normal limits given prior cholecystectomy. Given these findings, gastroenterology was consulted. Magnetic resonance cholangiopancreatography (MRCP) showed redemonstration of a relatively large duodenal diverticulum emanating from the second portion of the duodenum along with generalized body wall edema and small bilateral pleural effusions. Endoscopy with ultrasound excluded pancreatic pathology and bile duct stones and confirmed a duodenal diverticulum impacted with solid debris. Endoscopic ultrasound (EUS) revealed edematous bulging of the medial duodenal wall suspicious for diverticulum with impacted solid debris.

Partial disimpaction with the tip of a sphincterotome revealed purulent drainage which was aggressively lavaged with sterile saline (Figures 1 and 2). Common bile and cystic ducts were dilated to 9mm and 6mm, respectively as seen on EUS. Multiple biopsies were taken from the margins to differentiate duodenal diverticulitis from a cavitary mass lesion. Endoscopic retrograde cholangiopancreatography (ERCP) was initially planned but was deferred due to features of duodenal diverticulitis. Post-procedure, the patient was treated with intravenous (IV) Levofloxacin and Metronidazole for one week. Day one post-procedure, the patient developed sharp epigastric pain radiating to the back. Vital signs remained stable; however, lipase was elevated to 1689, with elevated serum liver chemistries: alkaline phosphatase 313, ALT 212, AST 225. The patient was treated symptomatically for acute pancreatitis with IV fluids, pain control, and diet restriction. A repeat CT-AP was obtained showing new thickening of the wall of the diverticulum, with mild mucosal enhancement and adjacent inflammatory change, suggestive of mild inflammation/ diverticulitis. Given these findings, endoscopy with lavage was repeated after 3 days showing significant improvement (Figure 3 and 4). A repeat CT scan at one week showed collapse of the diverticulum and improvement in inflammatory changes (Figure 5). The patient was discharged with oral antibiotics. At 6 month follow-up, she was asymptomatic with normal liver enzymes.

 Figures 1 and 2: EUS.

Figures 3 and 4: EGD with lavage.

Figure 5: CT-abdomen/pelvis with contrast.