2. Duodenal diverticula can be
extraluminal or intraluminal.
EXTRALUMINAL DIVERTICULA
Cause and Pathogenesis
Extraluminal duodenal diverticula are noted in about 5% of
upper gastrointestinal x-rays, and in about 25% of endoscopic
retrograde cholangiopancreatography (ERCP) studies
or autopsies. They are thought to be acquired. They arise
in an area of the duodenal wall where a vessel penetrates
the muscularis or where the dorsal and ventral pancreas
fuse in embryologic development. Approximately 75% are
located within 2 cm of the ampulla and are termed juxtapapillary
diverticula (JPD).
(sleisenger)
GI & hepatology hosp.-baghdad
3. Clinical Features and Diagnosis
Duodenal diverticula are typically diagnosed on upper
gastrointestinal x-rays . They are easily missed on
endoscopy unless a side-viewing endoscope is used. The
sensitivity of computed tomography (CT) and magnetic
resonance imaging (MRI) for duodenal diverticula is
low. If a diverticulum is suspected on CT or MRI, the
diagnosis can be clarified by having the patient drink
water and repeating the scan. The presence of an air-
fluid level in
4. the structure will clarify the diagnosis. A
duodenal diverticulum may be mistaken for a
pancreatic pseudocyst, peripancreatic fluid
collection, cystic pancreatic tumor,
hypermetabolic mass, or distal common bile
duct stone on ultrasound, CT, MRI, or positron
emission tomography
(PET)-Ct
5. Problems associated with extraluminal duodenal
diverticula include perforation or diverticulitis,
bleeding, acute pancreatitis, and common bile
duct stones.
6. Bleeding has been reported from Dieulafoy like
lesions or ulcers within diverticula
Patients with multiple duodenal diverticula may develop
bacterial overgrowth and malabsorption
Juxtapapillary diverticula have been associated with
common bile duct stones, cholangitis, and recurrent pancreatitis.
The presence of a juxtapapillary diverticulum has
been shown to lead to sphincter of Oddi dysfunction.
Delayed emptying of the common bile duct may occur, even
after sphincterotomy.
Stasis within diverticula can result in
local bacterial overgrowth, favoring deconjugation of bilirubin
and thus increasing the risk of primary common bile
duct stones.
7.
8. Treatment and Prognosis
Extraluminal duodenal diverticula rarely require
therapeutic intervention. Resection of duodenal
diverticula should never be done for vague
abdominal complaints.
Bleeding, diverticulitis, and perforation are the
most common problems associated with
duodenal diverticula. Endoscopic control of
bleeding from diverticula has been accomplished
using various techniques, including bipolar cautery,
epinephrine injection, and hemoclips
9. INTRALUMINAL DIVERTICULA
Intraluminal duodenal diverticula (windsock diverticula)
are single saccular structures that originate in the
second portion of the duodenum. They are connected
to the entire circumference or only to part of the wall
of the duodenum and may project as far distally as the
fourth part of theduodenum.
There is often a second opening located eccentrically
in the sac (Fig. 23-9). Both sides of the diverticulum
are lined by duodenal mucosa. Fewer than 100 cases
have been reported.
10. Intramural duodenal
diverticulum (windsock diverticulum).
A, The diverticulum is attached to the
entire duodenal circumference. B, The
diverticulum is attached to only part
of the duodenal circumference
11. Intraluminal diverticula may become
symptomatic at any age. The most common
symptoms are those of incomplete duodenal
obstruction.
12. If the diagnosis is not made preoperatively, surgical control of
bleeding can be accomplished through a duodenotomy.
Damage to the pancreatic and biliary ducts may occur during
surgery in patients with periampullary diverticula. Most
patients with perforation or diverticulitis undergo
laparotomy for diagnosis.
The usual surgical treatment is drainage and resection of the
involved diverticulum, if feasible.
If the diagnosis is made preoperatively, successful
conservative therapy by percutaneous drainage and
antibiotics is possible
13. At endoscopy, an intraluminal diverticulum is a sac-
like
structure with an eccentric aperture or a large, soft,
polypoid mass if the diverticulum is inverted
orad. Endoscopic diagnosis may be difficult.
A long sac may be mistaken for the duodenal
lumen, whereas an inverted diverticulum may be
mistaken for a large polyp. Gastric retention or
dilation of the duodenal bulb may result from
chronic partial obstruction caused by the
diverticulum.
