JSUR Journal

Keywords: Abdominal pain; Conservative management; Duodenal diverticulitis; Duodenal diverticulum

Introduction

The Duodenal Diverticulum (DD) was first described by Chommal in 1710. In 1951 Patterson and Bromberg first described a case of DD bleeding. Only a few cases have been reported in the literature, so the experience and knowledge of the surgeon in terms of diagnosis and treatment in this area is still somewhat limited. [1-3] DD corresponds to small sacculations into the wall of the gastrointestinal tract as a result of increased intraluminal pressure and weakness in the muscle wall, which could involve the mucosa and submucosa in case of an acquired lesion, what is known as a false diverticula, or also involving the muscular layer, known as a true diverticula. The duodenum is the second most common site in the intestine, involved in the formation of diverticula after the colon. [4]. The incidence of DD has been 1-5% in radiological series and 11-22% in autopsy series. [1,2,5,6] Its prevalence varies according to the portion of the duodenum, 62% of cases are found in the second portion of the duodenum within a radius of 2 cm, usually contiguous to the duodenal papilla, also called juxta-ampullary duodenal diverticulum. Another 30% of cases are located in the third portion of the duodenum and only 8% of cases in the fourth portion of the duodenum. [1,2,5,6] Generally, this pathology occurs after the age of 40, with more than 60% of the cases reported in patients older than 70 years, with no predominance of sex [3].

Regarding its clinical presentation, extraluminal or false DD tends to be asymptomatic in 95% of cases, being discovered incidentally during the diagnostic investigation of other pathologies. [7,8] In the 5% of DDs that become symptomatic, the most typical symptoms come from biliopancreatic complications (acute cholangitis, jaundice, or acute pancreatitis), diverticulitis, perforation (more common in D2), and hemorrhage (usually in D3 or D4). [2,8] Diverticulitis is the most common among these, presenting as a colicky abdominal pain of moderate-intensity, located in the epigastrium, without radiation, accompanied by nausea and vomit. Currently, it is more commonly diagnosed incidentally by an abdominal and oral IV contrast CT scan as a rounded image, with well-defined edges that protrude from the duodenal lumen, with air or fluid-filled. [3,4,7]Unlike extraluminal DD, intraluminal or true DD is more frequently symptomatic. Typical symptoms occur in adults between the ages of 30-50 and rarely in childhood. It usually presents as an intermittent duodenal obstruction in 40% of cases, acute pancreatitis in 20% of cases, gastrointestinal bleeding in 25% of cases. Biliary symptoms occur in the context of a complication, so we can find nausea, vomiting, recurrent episodes of cholangitis, or acute pancreatitis. The diagnosis can be made through an upper endoscopy by demonstrating a protrusion of the duodenal mucosa in the form of a “glove finger”; or by an upper gastrointestinal series with the pathognomonic image of a non-opaque sac surrounded by intraluminal barium; or by ERCP which allows us to observe the relationship of the DD with the duodenal ampulla. [3]Regarding the management of DD, we can divide it into conservative or surgical. In asymptomatic extraluminal DD, intervention is not indicated, since the risk of developing symptoms or complications is relatively low (1-5%) [2,5,9].

Case Presentation

Case 1

97-year-old female patient with long-standing systemic arterial hypertension under medical treatment. Her current condition began 5 days before her admission to the emergency service when she presented insidiously colicky abdominal pain of moderateintensity, located in the epigastrium with radiation to both flanks, without aggravating, mitigating, or accompanying symptoms. She progressed 12 hours before admission with said symptoms, adding fever of up to 39 ^°C and increased pain. Upon admission, she was afebrile with vital signs within normal parameters, and laboratory studies reported normochromic normocytic anemia with leukocytosis at the expense of associated neutrophilia. At physical examination on general abdominal inspection it was observed general abdominal distension with no visible masses or scars; disminished bowel sounds on auscultation; her abdomen was painful in epigastrium and both flanks on palpation with no evidence of peritoneal irritation, masses or organomegaly; resonant sounds on percussion in epigastrium. It was decided to take an Abdomen CT with IV and oral contrast, which showed an image compatible with a diverticulum in the second portion of the duodenum measuring 5.5 X 5.2 X 3.8 cm, with food retained inside and micro-perforation data, with changes in the paraduodenal fatty planes, with extrinsic compression effect on the distal portion of the common bile duct and pancreatic duct, which were dilated. (Figure 1) It was decided to proceed with a conservative approach, which consisted of an intravenous fluid plan, carbapenem-based antibiotic therapy, non-steroidal anti-inflammatory drugs, a proton pump inhibitor, and a liquid diet. A soft diet was introduced on the 2nd day of Hospital Stay (HS), showing a decrease in pain and symptomatic improvement. On her 4^th day of HS, an improvement was also shown in the laboratory results, showing the leukocyte count within normal parameters, which is why he proceeded to progress to a low-fat diet. A control abdominal CT scan was requested, which showed no clinical signs of acute inflammation or micro-perforation of the DD. On the 5th day of HS, the patient continued with conservative treatment with no signs of recurrence, which is why her discharge was decided.

Figure 1: Computerized Axial Tomography of the abdomen that identified an image compatible with a diverticulum in the second portion of the duodenum measuring 5.5 X 5.2 X 3.8 cm, with food retained inside, perforation data with changes in the paraduodenal fatty planes, with extrinsic compression effect on the distal portion of the common bile duct and pancreatic duct. (A) cross-section, (B) coronal section.

Case 2

42-year-old female, with a history of long-standing multiple sclerosis under medical treatment, started 3 days previously with stabbing pain, of moderate intensity, located in the epigastrium with radiation to the right iliac fossa, aggravated by movement and food intake, attenuated at rest, accompanied by nausea without reaching vomiting. She persisted with this symptomatology, which is why she was admitted for evaluation and management. Upon admission, she was afebrile with vital signs within normal parameters, finding leukocytosis at the expense of neutrophilia in laboratory studies. At physical examination on general abdominal inspection it was observed general abdominal distension with no visible masses or scars; disminished bowel sounds on auscultation; her abdomen was painful in epigastrium and right iliac fossa on palpation with no evidence of peritoneal irritation, masses or organomegaly; resonant sounds on percussion in epigastrium. Computed tomography imaging of the abdomen/pelvis with IV and oral contrast demonstrated a saccular image was visualized in the third portion of the duodenum, with changes in the surrounding fat, showing data suggestive of acute inflammation. (Figure 2) Due to her comorbidities and when finding the patient stable, it was decided to start conservative management with analgesics and a double antibiotic scheme. On his 2nd day of HS, he presented clinical improvement with a significant decrease in pain, for which conservative treatment was maintained, and later he progressed to a soft diet. On the fourth day, a normal diet was started and on the fifth day of hospitalization, the discharge was decided due to clinical improvement, to be followed up by outpatient consultation.

Figure 2: Computerized Axial Tomography of the abdomen that identified a saccular image in the third portion of the duodenum, with changes in the surrounding fat, showing data suggestive of acute inflammation with perforation towards the posterior aspect of the duodenum. (A) cross-section, (B) coronal section.