Pseudotumors in a Periampullary Duodenal Diverticulum

Abstract

Duodenal diverticula are common findings during barium meal studies, and are usually asymptomatic. 1 Symptoms and complications are rare and usually due to biliary and pancreatic abnormalities, perforation, hemorrhage, inflammation, bezoar formation and neoplasia. [2][3][4][5] We report on two patients in whom a filling defect was noted within a periampullary duodenal diverticulum on barium meal studies, confirmed by endoscopy to be due to a pseudotumor caused by a bezoar and redundant prominent mucosal folds. Review of the literature for the significance and implications of this finding was carried out. Case Reports Case 1A 60-year-old woman suffered from recurrent attacks of right upper quadrant pain related to fatty meals of several years' duration. She gave no history of jaundice, but her biochemical profile revealed slight elevation of the alkaline phosphatase. Ultrasound examination of the biliary tract and gallbladder was negative on two previous occasions. Recently, she was admitted with severe acute right upper quadrant pain associated with vomiting and low grade fever. Murphy's sign was negative. Her liver enzymes and serum bilirubin level were elevated. Ultrasound showed gallbladder calculi with no bile duct dilatation. A provisional diagnosis of acute cholangitis was made. ERCP showed multiple gallbladder stones and a large periampullary duodenal diverticulum with the ampulla of Vater opening at its neck. A barium meal and follow-through examination showed a 1.5 cm lobulated constant filling defect at the base of the periampullary duodenal diverticulum (Figure 1). There was another diverticulum in the third part of the duodenum. A second look by duodenoscopy was felt necessary to assess the nature of the filling defect and to exclude tumor. It revealed no evidence of a neoplasm, but prominent normal mucosa at the neck of the diverticulum, which was the cause of the filling defect seen on the barium examination. A few days later, the patient's general condition improved. She underwent cholecystectomy with uneventful recovery. Case 2A 74-year-old woman was admitted because of longstanding recurrent epigastric pain, sometimes colicky in nature, associated with nausea but no vomiting. The pain had no relation to food intake. There was no history of jaundice. All the laboratory tests, including the liver enzymes, were normal on several occasions. Ultrasound examination of the gallbladder was normal. Barium meal showed a periampullary duodenal diverticulum with a fixed smooth lobulated filling defect within it (Figure 2). The stomach and duodenal bulb were unremarkable. ERCP showed a rounded, greenish-yellow, sprout-like bezoar (Figure 3) that was easy to disintegrate and to clear off the diverticulum. The ampulla opened at the rim of the diverticular orifice, it was cannulated and the common bile duct together with pancreatic duct were normally outlined. It was felt that the bezoar was probably an incidental finding causing no complications. The patient's symptoms resolved spontaneously. She was discharge...