1Department of Surgery, Harlem Hospital Center, Columbia University, New York, NY, USA2Department of Medicine, Richmond University Medical Center, Staten Island, New York, NY, USA
Correspondence should be addressed to Khuram Khan; [email protected]
Received 22 April 2018; Accepted 13 June 2018; Published 7 August 2018
Introduction. Duodenal diverticulum is a rare disease that can be easily missed. The incidence of duodenal diverticulum diagnosedby upper GI study is approximately 5%. Autopsy results show that 22% of the population have duodenum diverticulum. Mostpatients with duodenal diverticulum are asymptomatic. However, complications like inflammation, perforation withretroperitoneal abscess, sepsis, pancreatitis, bile duct obstruction, and bleeding can occur. Approximately 162 cases of perforatedduodenal diverticulum have been reported in the literature. Case Presentation. We present a rare case of an 82-year-old femalewith perforation of a duodenal diverticulum caused by small bowel obstruction; in addition to this, there was a synchronouscolonic tumor. Conclusion. Diagnosis and management of this rare disorder are controversial. Nonoperative management isadvocated in some cases. Some of the cases require early aggressive surgical intervention. The mortality rate remainsapproximately 45% in all these patients.
1. Introduction
Perforation of the duodenum diverticulum (DD) is a rare dis-ease that can be easily missed as it can be a clinical diagnosis.Management of the perforation requires urgent surgicalintervention for favorable outcomes. Perforation can becaused by infections such as diverticulitis, ulceration, foreignbody, trauma, and iatrogenic perforation after ERCP andwould require CT scan of the abdomen for diagnosis andtreatment in some cases, while diagnosis of duodenal diver-ticulum can be made with upper gastrointestinal series.
2. Case Presentation
An 82-year-old African American female with history ofhypertension, chronic active smoker for 60 years along withprior surgical history significant for a laparotomy more than20 years previously for unknown reason who was initiallyadmitted to the medical service after a fall. She had a long his-tory of nonspecific lower abdominal pain. As per her family,
she had not seen a doctor for 10 years and never had a colo-noscopy. She reported unintentional weight loss. Vital signsat the time of presentation were stable. On physical examina-tion, she appeared cachectic and dehydrated. Her abdomenwas soft, non-tender with audible bowel sounds. Mild rightlower quadrant tenderness was noted. Labs were significantfor microcytic hypochromic anemia and urine analysis posi-tive for leukocyte esterase. Liver function test was normal.Chest X-ray showed cardiomegaly. Abdominal US revealedmild ascites and dilated common bile duct to 1 cm. Thepatient was admitted to medical service with a diagnosis ofdehydration, failure to thrive, and for work-up of an occultgastrointestinal malignancy. She was scheduled for EGDand colonoscopy by gastroenterology team. In addition toall of this, her CEA was 12.2 ng/ml (normal less than 3ng/ml). While the patient was on the medical service, her hemo-globin dropped to 6.2 gm/dL requiring blood transfusions.During the second unit of blood transfusion, the patientbecame hypoxemic and tachypneic. She was transferred toMedical Intensive Care Unit (MICU) and subsequently
HindawiCase Reports in SurgeryVolume 2018, Article ID 6197828, 4 pageshttps://doi.org/10.1155/2018/6197828
intubated for acute respiratory failure. Chest X-ray at thispoint showed bilateral infiltrates, and the patient was startedon IV antibiotics for possible pneumonia. The scheduled GIprocedures were cancelled due to critical health status. Shehad echocardiography in MICU which revealed mitral steno-sis and severe pulmonary hypertension, with normal ejectionfraction. Her respiratory status improved, and she was trans-ferred back to medical floor after staying four days in MICU.She also had urine culture which grew klebsiella. Three dayslater after being transferred from MICU, she developedabdominal distension. A CT scan of the abdomen withoutcontrast was obtained which revealed gastric, small bowel,and colonic distension. There was copious amount of stoolin the colon. She was transferred to the surgical service formanagement of possible ileus/stool impaction pending colo-noscopy to rule out colonic lesion. She was managed with nilper os, nasogastric tube suction, intravenous fluid hydration,and enemas. Nasogastric tube output was minimal but thepatient’s abdomen remained distended while on surgicalservice. The patient became hypotensive and tachycardicand less responsive. After fluid resuscitation, another CTof the chest and abdomen with oral and intravenous con-trast was performed one week from prior CT, whichrevealed persistent dilation of the stomach, small bowel,and large bowel, a left colonic mass, and large amount ofretroperitoneal free fluid in the region of the duodenumand pancreas (Figures 1 and 2). She was taken to the oper-ating room for exploratory laparotomy. A midline laparot-omy was performed, and numerous adhesions from theprevious laparotomy were seen. The patient had a high-grade small bowel obstruction with a transition point inthe mid ileum caused by adhesions. Lysis of adhesionswas performed. There was a large left descending colonicmass invading the lateral abdominal wall causing partiallarge bowel obstruction. The transverse colon was attachedto the left colon mass with adhesions, creating a spacethrough which there was herniation of dilated small bowel.However, this did not cause an obstruction. These dilatedbowel loops were reduced. Because of the finding of freeair in the retroperitoneum of the upper abdomen, wedecided to explore that area. Generous kocherization ofthe duodenum was performed. The head of the pancreasand hepatic flexure were mobilized and found to be nor-mal. With further mobilization of the duodenum, a perfo-rated duodenal diverticulum was noticed in the third partof the duodenum. There was a leak of bile in the area.There was extensive retroperitoneal necrosis extendingacross the upper abdomen to the tail of the pancreas. Theduodenal diverticulum was broad based, inflamed, andclosely attached to the superior mesenteric artery. Thediverticulum was dissected off, stapled, and sent for pathol-ogy (Figure 3). The third part of the duodenum becamedusky, and we decided to resect it with a GIA. At this point,the patient was hypotensive and acidotic. A decision wasmade to perform damage control and a temporary abdomi-nal closure and to transfer the patient to ICU for resuscita-tion. In the ICU, she was aggressively resuscitated withcorrection of her acidosis, coagulopathy, and hypothermia.She was brought back to the OR the following day. There
were no signs of bowel ischemia, and the small bowelobstruction had resolved. An end to side duodenojejunost-omy was performed using an EEA. The anastomosis was pro-tected with a Stamm’s gastrostomy through which a feedingjejunostomy was passed distal to the anastomosis. A drainwas left in the right upper quadrant. We then performed atransverse colon loop colostomy to divert the colonic tumor.Blood cultures later grew pseudomonas and yeast. Thepatient subsequently developed multiorgan failure, and the
Figure 1: CT scan of the abdomen. Retroperitoneal free air.
Figure 2: CT scan of the abdomen. Image shows dilated small bowelloops with air fluid level and small bowel obstruction.
Figure 3: Histology slide. Small intestinal tissue with acute serositis(red arrow) consistent with perforated viscus.
2 Case Reports in Surgery
family requested DNI/DNR. Their after family requestedterminal extubation 12 days after the last operation.
3. Discussion
Duodenal diverticulum complications are rarely seen, and itis the second most common site of diverticula of the gastro-intestinal tract after the colon [1]. DD can be congenital oracquired [2]. The acquired type is usually a pseudodiverticu-lum where there is herniation of the mucosa through the wallof the duodenum. Most of these occur along the mesentericborder of the duodenum [3]. Duodenal diverticulum is notrare, but complications like perforation, bleeding, pancreati-tis, and bile duct obstruction are very rare. Less than 200cases of perforated duodenal diverticulitis have been reportedin the literature [2]. Causes of perforation include diverticu-litis, ulceration, foreign body, trauma, and iatrogenic perfora-tion after ERCP. In our case, we believe that the perforationoccurred secondary to duodenal distension as a result ofback pressure from associated bowel obstruction. The diag-nosis is difficult as patients present with nonspecific signsand symptoms. Usually, there is no tenderness on abdomi-nal exam because of retroperitoneal perforation. Computer-ized tomography plays an important role in diagnosis byshowing free retroperitoneal air and phlegmon. Upper GIstudies and endoscopy can be used in stable patients. Thediagnosis is usually made with intraoperative exploration,as in our case. Because of rarity of the disease, there are noclear guidelines regarding conservative versus surgical man-agement. Some cases of known perforated duodenal diver-ticulum in stable patients were managed conservatively bynil per os, intravenous fluid hydration, intravenous antibi-otics, parenteral nutrition, and percutaneous drains for thelocalized collections.
Many operative techniques have been described. Afteradequate mobilization of the duodenum, the diverticulumshould be dissected completely down to the base and eitherhandsewn or stapled diverticulectomy can be performed.The defect can be closed in layers [3]. The relation of theneck of the diverticulum to the common bile duct mustbe ascertained to avoid bile duct injury. The bile ductshould be cannulated from either the ampulla of Vater, bymaking a choledochotomy, or through the cystic duct [4].Simple closure of the perforation with drainage, withoutdiverticulum resection, because of close proximity of thebile duct to the diverticulum, was described in one casereport [5].
If the perforated duodenal diverticulum is in the fourthportion of the duodenum, partial duodenectomy can be per-formed and reconstruction with end-to-side doudenojeju-nostomy [2].
In the presence of significant inflammation, more com-plex procedures have been described. A Roux-en-Y loop ofthe jejunum is brought through a rent in the transversemesocolon, the duodenum is transected, and the duodenalstump is oversewn. The Roux limb of the jejunum was anas-tomosed end to end to the duodenum. A jejunojejunostomyis created 40 cm distal to the duodenojejunostomy. A drainshould be placed. As an alternative, vagotomy, antrectomy
closure of duodenal stump, and Billroth 2 reconstructioncan be performed. This decreases the risk of duodenal fis-tula [3]. For large duodenal diverticulum causing dilationand obstruction of the bile duct, choledochoduodenostomyis the best approach and avoids the complications associ-ated with attempts to resect the diverticulum. Sphinctero-plasty has been described as well [4]. For duodenaldiverticulum causing bleeding, preoperative localizationwith endoscopy or angiography should be done. Excisionof the diverticulum with suture ligation of the bleedingpoint is essential [6].
4. Conclusion
Duodenal diverticular perforation can be challenging as itis a rare disease and difficult to diagnose. Nonoperativemanagement is only in selected patient’s population. CTscan can help diagnose the perforation and require urgentsurgical intervention.
Ethical Approval
Ethical approval is not required by our institution. This was acase report, and permission and consent have been takenfrom the patient.
Consent
The authors have obtained a written informed consent fromthe patient for publication of this case report and alsoaccompanying images. A copy of the written consent isavailable on request.
Conflicts of Interest
The authors declare that they have no competing interests.
Authors’ Contributions
Khuram Khan, MD, and Saqib Saeed, MD, helped in writingthe abstract, figure collections, writing, and format. HaythamMaria helped in writing and format. Mohammed Sbeihhelped in writing and editing. Farhana Iqbal helped inwriting, format, and others. Brian Donaldson and AlexiusRamcharan helped in review and final editing.
References
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[2] M. Wilson and A. Bradley, “Management of perforated duode-nal diverticula,” Canadian Journal of surgery, vol. 48, no. 1,pp. 79-80, 2005.
[3] V. C. Simões, B. Santos, S. Magalhães, G. Faria, D. S. Silva, andJ. Davide, “Perforated duodenal diverticulum: surgical treat-ment and literature review,” International Journal of SurgeryCase Reports, vol. 5, no. 8, pp. 547–550, 2014.
[4] J. W. Donald, “Major complications of small bowel diverticula,”Annals of Surgery, vol. 190, no. 2, pp. 183–188, 1979.
3Case Reports in Surgery
[5] T. De Perrot, P. A. Poletti, C. D. Becker, and A. Platon, “Thecomplicated duodenal diverticulum: retrospective analysis of11 cases,” Clinical Imaging, vol. 36, no. 4, pp. 287–294, 2012.
[6] S. Yokomuro, E. Uchida, Y. Arima et al., “Simple closure of aperforated duodenal diverticulum: “a case report”,” Journal ofNippon Medical School, vol. 71, no. 5, pp. 337–339, 2004.
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