An adult case of congenital duodenal diaphragm that was successfully treated by endoscopic resection using a grasping‐type scissor forceps

Abstract

Congenital duodenal diaphragm (CDD) is a rare disease that is usually diagnosed in the neonatal period; however, it is sometimes diagnosed later in the adult period. A 39‐year‐old woman was referred to our hospital due to tarry stool and anemia. Emergent esophagogastroduodenoscopy (EGD) revealed an obstructing membranous structure with a small orifice in the second portion of the duodenum, together with dilatation of the bulbar part. The membranous structure was accompanied by a Dieulafoy‐like vessel on the backside, which was considered to have caused tarry stool and anemia. The Dieulafoy‐like vessel was successfully treated by endoscopic hemostasis. Based on the computed tomographic gastrography and barium duodenography findings, it was diagnosed as CDD. Later, endoscopic resection of the diaphragm was conducted by an endoscopic submucosal dissection (ESD)‐based procedure, with the use of an electrosurgical grasping‐type scissor forceps (ClutchCutter [CC]). There were no procedure‐related complications. The definite diagnosis of CDD was made based on the observation of typical structures in a pathological examination. This is the first case report of adult CDD that was successfully treated by endoscopic resection using ESD‐based techniques with a CC.

Clinical application of endoscopic diaphragmotomy and dilation in a congenital duodenal diaphragm

“…The appearance of a duodenal diaphragm on preoperative UGI is similar to that of an annular pancreas, making it difficult to distinguish between the two. The following features should be noted for identifying a diaphragm ( Figure 1 ): The proximal end of the obstruction may present as a blind end with or without depression or fissure in the mucosa ( 10 , 19 , 23 ), or as a stenosis with a well-defined opening under gastroscopy ( 19 , 20 , 24 – 26 ). During inspiration with the gastroscope, the diaphragm forms a dome-shaped structure ( 19 , 20 ), and its boundary with the bowel wall can be recognized.…”

“…The following features should be noted for identifying a diaphragm ( Figure 1 ): The proximal end of the obstruction may present as a blind end with or without depression or fissure in the mucosa ( 10 , 19 , 23 ), or as a stenosis with a well-defined opening under gastroscopy ( 19 , 20 , 24 – 26 ). During inspiration with the gastroscope, the diaphragm forms a dome-shaped structure ( 19 , 20 ), and its boundary with the bowel wall can be recognized. In older children, due to long-term proximal pressure, the diaphragm becomes elongated and hypertrophic, presenting as a sleeve-like structure prolapse proximally during inspiration.…”

“…The left side of the duodenum is constrained by structures such as the mesentery and pancreaticobiliary duct, making it less flexible than the right side, which can be easily expanded and extended. Consequently, diaphragmatic openings are predominantly eccentrically distributed close to the papilla's side (left side) ( 17 , 19 ). If the duodenal papilla is visible in gastroscopy, the duodenal papilla can be avoided by incising the diaphragm from the opening to the opposite side of the papilla ( 10 , 11 , 17 , 20 ) ( Figure 2 ).…”

“…In the last two decades, there has been a gradual increase in reports of endoscopic treatment (10)(11)(12). Some of the reported methods are laser ablation (6,8), balloon dilation (12, 14-16), diaphragmotomy (15,17), and diaphragmectomy (18)(19)(20). Although most reports have shown positive outcomes, except for a few cases of perforation and restenosis (13, 15,21,22), because of their type, that is, being case reports rather than systematic studies, it is still premature to draw definitive conclusions regarding the safety and efficacy of the aforementioned methods.…”

Celiac Disease Is a Rare Cause of Benign Duodenal Stricture: A Case Report

“…Peptic ulcer disease (PUD) is a significant cause of benign duodenal stricture, which is often caused by Helicobacter pylori (H. pylori) and the use of non-steroidal anti-inflammatory drugs (NSAIDs) [1][2][3][4]. Duodenal strictures have also been reported in other benign conditions such as inflammatory bowel disease (IBD), pancreatitis, and congenital malformation [5][6][7]. Precise estimates on the incidence of benign duodenal strictures are lacking.…”