Clinical analysis and literature review of massive Duodenal diverticular bleeding

Abstract

A duodenal diverticulum (DD) appears in 2.5% of upper gastrointestinal (UGI) examinations and up to 22% of endoscopic retrograde cholangiopancreaticographies (ERCP) and autopsies. Most of these patients are asymptomatic, but the lesion is occasionally associated with bleeding, inflammation, perforation, obstruction of the duodenum or biliary-pancreatic duct (or both), fistula formation in the bile duct, and bezoar formation inside the diverticulum. A total of 816 patients have undergone ERCP examination at our institution since January 1987, and 100 (12.25%) of them have DD. Seven (7%) patients presented with bloody or tarry stools from massive UGI bleeding followed by shock. Only two could be diagnosed by UGI endoscopy preoperatively. The lesions were demonstrated in angiographic studies in another four cases. However, only one was correctly interpreted and one required reoperation after a correct repeat endoscopic finding. The lesions in the other two patients were identified by thorough exploration during laparotomy. The remaining case was diagnosed by intraoperative endoscopy via pyloroduodenotomy. Six underwent surgical intervention, and one was successfully treated by expectant treatment. Three (50%) had leakage from the duodenotomy but recovered uneventfully with conservative treatment. In conclusion, we believe that DD bleeding is more frequent than usually thought. A high index of suspicion should be raised in cases of UGI bleeding when more obvious and common causes have been excluded by routine endoscopy. Aggressive but careful endoscopic examination combined with accurate angiography can help us diagnose most of the cases preoperatively. Diverticulectomy is an effective surgical procedure, though it is associated with a considerable leakage rate. The morbidity is minimal if we can identify the lesion earlier and evacuate the lesion without delay.

Duodenal obstruction after successful embolization for duodenal diverticular hemorrhage: A case report

“…Since then, angiography and endoscopy have become the most useful modalities for diagnosing and managing gastrointestinal bleeding, suggesting TAE as the treatment of choice of duodenal diverticular hemorrhage [6,7] . However, due to the complex vascular anatomy of duodenum, TAE must be done with extreme caution.…”

Duodenal Diverticulitis Due to Impacted Foreign Body: Enteroscopic Diagnosis and Treatment

“…1 A duodenal diverticulum is classified as congenital or acquired, and the latter is more common. 2 Congenital diverticula contain all layers of the duodenal wall and are called true diverticula. 7 The acquired or false type is formed by a protrusion of the mucosa, muscularis mucosa, or submucosa through a focal weakness in the duodenal wall.…”

“…2 Although the majority of duodenal diverticula are asymptomatic and clinically insignificant, approximately 10% of patients develop clinical symptoms. 3 Duodenal diverticulitis is rare.…”

Duodenal Diverticular Bleeding Stopped Spontaneously: Case Report and a Brief Review of Literature

“…Fibrotic contraction of a healing ulcer, motor dysfunction due to myenteric plexus anomalies are other factors in etiopathogenesis. 5,6 They occur in second, third and fourth portions of duodenum and may be multiple. Their distributions are 62% in the second part, 30% in the third part and 8% in the fourth part of the duodenum.…”

“…5 DD can be classified into congenital and acquired diverticula. Acquired diverticula are most common.…”