1986 An Unusual Case of Massive Duodenal Diverticulum Bleeding: A Challenging Treatment Approach

Abstract

INTRODUCTION: Duodenal diverticula are relatively common findings in the small bowel with reported prevalence ranging between 0.6–22%. The vast majority of them are asymptomatic and found incidentally. We present an unusual case of hemorrhagic shock resulting from bleeding duodenal diverticula. CASE DESCRIPTION/METHODS: A 46-year-old male with history of alcohol abuse presented with 1-day history of multiple episodes of hematochezia and dark tarry emesis. He had associated lightheadedness, dyspnea, diaphoresis along with 1 episode of syncope. He did not use any medications on regular basis. His heart rate was 125 beats/minute and blood pressure 99/53 mmHg. Labs included hemoglobin (Hgb) of 4.5 gm/dL, platelets 75000/mcL, creatinine 1.81 mg/dL and lactic acid 4.4 mmol/L. Patient was subsequently intubated for airway protection due to recurrent episodes of hematemesis. An esophagogastroduodenoscopy (EGD) showed 3 large diverticula in the second portion of duodenum with active bleeding noted from a non-periampullary proximal diverticulum (Figure 1). Hemostasis was achieved with epinephrine injection followed by Hemospray. A follow up arterial angiogram was unremarkable. Patient experienced recurrent bleeding within 48 hours requiring 2 additional EGDs with therapeutic interventions (epinephrine, ablation and endoclips). Repeat angiography was done due to persistent drop in Hgb. This time, an area of irregularity in one of the gastroduodenal artery branches was identified adjacent to the previously placed endoclips. Coil embolization was performed successfully with excellent results. Patient’s condition eventually stabilized without any recurrent bleed. Upon follow up, his Hgb was 10.7 gm/dL 3 weeks after discharge. DISCUSSION: The majority of duodenal diverticula are asymptomatic. About 1% result in complications requiring definite endoscopic or surgical intervention. Potentially fatal bleeding represents minimal proportion of these complications and its management can be challenging. Our case demonstrates an extreme example of massive gastrointestinal bleeding that was difficult to control despite multiple endoscopic interventions. Initial angiography was not successful to identify the bleeding. Applying endoclips helped to subsequently localize and control the source of bleeding in the second angiogram. Using this approach can be an invaluable asset in such conditions.