Images for surgeons
516
Perforated duodenal diverticulum as an unusual sequelae of intestinal obstruction An 81‐year‐old woman was admitted for symptoms of constipation, abdominal distension and vomiting for 1 week. On admission, although she was haemodynamically stable, her abdomen was distended and she had tenderness in the periumbilical region. Her initial white blood cell count was 25 × 103 U/L, procalcitonin 3.04 μg/L and Hb 15.6 g/dL, lipase 35 U/L, bilirubin 10.9 μmol/L. There was no free air under the right hemidiaphragm seen on the chest X‐ray. Computed tomography (CT) scan done showed dilated small bowel with an intraluminal mass at the transition point likely due to a bezoar. A pocket of free air was seen adjacent to the second part of the duodenum (Fig. 1). A retroperitoneal pocket of free air was seen posterior to the pancreatic head and the intraluminal duodenal contents were contiguous with a retroperitoneal collection (Figs 2, 3). Intraoperatively, a lateral perforation of the second part of the duodenum was noted, direct communication was seen between the duodenal diverticulum to the retropancreatic abscess. The bezoar was located 60 cm from the ileocecal valve; it was broken and milked into the caecum. There was no stricture in the terminal ileum. Surgical mobilization of the retropancreatic abscess was abandoned due to dense inflammatory adhesions that bled easily. Omental patch of the perforations was performed and drains were placed to drain the abscess. As the patient was haemodynamically unstable intraoperatively, pyloric exclusion and gastrojejunostomy was not performed due to the risk of an anastomotic leak. Instead, a decompressive gastrostomy and T tube choledochostomy were performed to divert the gastric and bilious content. At the same time, a distal feeding jejunostomy was performed to establish enteral feeding. Intraoperative pus cultures grew Escherichia coli and Klebsiella, which were treated with appropriate antibiotics. The T tube was
removed 20 days after the initial operation as the output from the gastrostomy and T tube decreased gradually. Repeat CT scan done showed resolution of the retroperitoneal collection and no extraluminal air pockets (Fig. 3). The gastrostomy closed spontaneously without the need for further surgery. Perforated duodenal diverticulum is a rare condition and is distinguished by its location in the more distal duodenum. The frequent causes are diverticulitis (62%), enterolithiasis (10%), iatrogenic (5%) and trauma (4%).1,2 Perforation of duodenal diverticulum due to intestinal obstruction has never been described in the literature. This case demonstrates an unusual association of perforated duodenal diverticulum due to back pressure from an obstructing bezoar in the distal small bowel. As this patient does not have the typical risk factors of development of a bezoar, another possibility is the development of the bezoar within the duodenal diverticulum, which later migrated into the terminal ileum and caused obstruction distally.3 Historically, accurate pre‐operative diagnosis was made in only 13% of the cases. Recent series however showed an improved detection rate of 42.8–50%.1,4 The florid findings of a large diverticulum and retroperitoneal abscesses on the CT scan resulted in the accurate preoperative diagnosis. Upper gastrointestinal tract contrast examinations are able to aid in identification of the diverticulum in up to 80% of the patients but are unable to demonstrate the contrast extravasation in the cases where perforations have occurred.5 Conservative treatment of perforated duodenal diverticulum has been well described and was successful in selected cases (23%; 14 of 61 cases described).1 There are also a variety of surgical options ranging from simple diverticulectomy, isolated
Fig. 1. Computed tomography scan showing the free air adjacent to the second part of the duodenum (1), retroperitoneal air from the perforated duodenal diverticulum (2), dilated distal small bowel secondary to the obstructing bezoar (3).
Fig. 2. Computed tomography scan showing the retroperitoneal air at the perforated duodenal diverticulum (4), posterior to the head of pancreas (5). © 2014 Royal Australasian College of Surgeons
Images for surgeons
517
References
Fig. 3. Computed tomography scan showing the retroperitoneal air contiguous with the perforated duodenal diverticulum with surrounding inflammatory changes (6), free air adjacent to the second part of the duodenum (7), dilated distal small bowel (8).
retroperitoneal drainage, roux loop duodenojejunostomy and even a Whipple's procedure.6,7 However, the selection of these procedures are dependent upon the extent of inflammation, tissue friability in the area and the time interval from perforation to accurate diagnosis. In this case, the presence of a precipitating cause of intestinal obstruction and the underlying sepsis with signs of haemodynamic instability required prompt surgical decompression and drainage.
1. Thorson CM, Paz Ruiz PS, Roeder RA, Sleeman D, Casillas VJ. The perforated duodenal diverticulum. Arch. Surg. 2012; 147: 81–8. 2. Duarte B, Nagy KK, Cintron J. Perforated duodenal diverticulum. Br. J. Surg. 1992; 79: 877–81. 3. Nijhof HW, Bisselink J, Rijbroek A. Small bowel obstruction due to enterolith expelled from duodenal diverticulum. ANZ J. Surg. 2009; 79: 77–8. 4. Andrea R, Christian BN, Pascal B, Stephane D, Philippe M. Perforated duodenal diverticulum, a rare complication of a common pathology: a seven‐patient case series. World J. Gastrointest. Surg. 2013; 5: 47–50. 5. Miller G, Mueller C, Yim D et al. Perforated duodenal diverticulitis: a report of three cases. Dig. Surg. 2005; 22: 198–202. 6. Lee VT, Chung AY, Soo KC. Mucosal repair of posterior perforation of duodenal diverticulitis using roux loop duodenojejunostomy. Asian J. Surg. 2005; 28: 139–41. 7. Schnueriger B, Vorburger SA, Banz VM, Schoepfer AM, Candinas D. Diagnosis and management of the symptomatic duodenal diverticulum: a case series and a short review of the literature. J. Gastrointest. Surg. 2008; 12: 1571–6.
Ye Xin Koh, MBBS, MRCS Aik Yong Chok, MRCS Andrew Siang Yih Wong, FRCS Upper Gastrointestinal Surgery Service, Department of General Surgery, Changi General Hospital, Singapore doi: 10.1111/ans.12705
Retroperitoneal lymphangiectasia A 50‐year‐old lady presented with complaints of recurrent vomiting for 4 months. Besides significant weight loss, she did not complain of haematemesis, melaena, jaundice or fever. She denied prior history of dyspepsia. Physical examination was unremarkable. On laboratory analysis, liver and renal function tests were normal. Urine examination (routine and microscopic) was also normal. She underwent gastroduodenoscopy, which revealed a dilated stomach and an ulcero‐proliferative growth in the second part of duodenum. Histopathological examination of punch biopsy specimen confirmed duodenal adenocarcinoma. Contrast‐enhanced computed tomography (CECT) of the abdomen revealed an intraluminal mass in the second part of the duodenum. There was no ascites or focal liver lesion. There was a sheet‐like hypodense soft tissue mass (arrows) in the retroperitoneum encircling the aorta and inferior vena cava. The lesion was very low in attenuation, and no separate lymph nodes were visualized in the retroperitoneum (Fig. 1). Coronal reformatted CECT image displayed the distribution of the retroperitoneal lesion in the aorto‐caval and para‐aortic locations, which extends into the right renal hilum (arrows) (Fig. 2a). The very low density of the lesion pointed towards the diagnosis of dilated lymphatics rather than lymphadenopathy. Coronal HASTE magnetic resonance (MR) image of © 2014 Royal Australasian College of Surgeons
abdomen further confirmed the distribution of the dilated retroperitoneal lymphatics (arrows) (Fig. 2b). Laparotomy revealed a 5 × 4 cm mass palpable in the second part of the duodenum. There
Fig. 1. Axial contrast‐enhanced computed tomography (CECT) image of the abdomen reveals a sheet‐like hypodense soft tissue lesion (arrow) in the retroperitoneum encircling the aorta and inferior vena cava.
516
Perforated duodenal diverticulum as an unusual sequelae of intestinal obstruction An 81‐year‐old woman was admitted for symptoms of constipation, abdominal distension and vomiting for 1 week. On admission, although she was haemodynamically stable, her abdomen was distended and she had tenderness in the periumbilical region. Her initial white blood cell count was 25 × 103 U/L, procalcitonin 3.04 μg/L and Hb 15.6 g/dL, lipase 35 U/L, bilirubin 10.9 μmol/L. There was no free air under the right hemidiaphragm seen on the chest X‐ray. Computed tomography (CT) scan done showed dilated small bowel with an intraluminal mass at the transition point likely due to a bezoar. A pocket of free air was seen adjacent to the second part of the duodenum (Fig. 1). A retroperitoneal pocket of free air was seen posterior to the pancreatic head and the intraluminal duodenal contents were contiguous with a retroperitoneal collection (Figs 2, 3). Intraoperatively, a lateral perforation of the second part of the duodenum was noted, direct communication was seen between the duodenal diverticulum to the retropancreatic abscess. The bezoar was located 60 cm from the ileocecal valve; it was broken and milked into the caecum. There was no stricture in the terminal ileum. Surgical mobilization of the retropancreatic abscess was abandoned due to dense inflammatory adhesions that bled easily. Omental patch of the perforations was performed and drains were placed to drain the abscess. As the patient was haemodynamically unstable intraoperatively, pyloric exclusion and gastrojejunostomy was not performed due to the risk of an anastomotic leak. Instead, a decompressive gastrostomy and T tube choledochostomy were performed to divert the gastric and bilious content. At the same time, a distal feeding jejunostomy was performed to establish enteral feeding. Intraoperative pus cultures grew Escherichia coli and Klebsiella, which were treated with appropriate antibiotics. The T tube was
removed 20 days after the initial operation as the output from the gastrostomy and T tube decreased gradually. Repeat CT scan done showed resolution of the retroperitoneal collection and no extraluminal air pockets (Fig. 3). The gastrostomy closed spontaneously without the need for further surgery. Perforated duodenal diverticulum is a rare condition and is distinguished by its location in the more distal duodenum. The frequent causes are diverticulitis (62%), enterolithiasis (10%), iatrogenic (5%) and trauma (4%).1,2 Perforation of duodenal diverticulum due to intestinal obstruction has never been described in the literature. This case demonstrates an unusual association of perforated duodenal diverticulum due to back pressure from an obstructing bezoar in the distal small bowel. As this patient does not have the typical risk factors of development of a bezoar, another possibility is the development of the bezoar within the duodenal diverticulum, which later migrated into the terminal ileum and caused obstruction distally.3 Historically, accurate pre‐operative diagnosis was made in only 13% of the cases. Recent series however showed an improved detection rate of 42.8–50%.1,4 The florid findings of a large diverticulum and retroperitoneal abscesses on the CT scan resulted in the accurate preoperative diagnosis. Upper gastrointestinal tract contrast examinations are able to aid in identification of the diverticulum in up to 80% of the patients but are unable to demonstrate the contrast extravasation in the cases where perforations have occurred.5 Conservative treatment of perforated duodenal diverticulum has been well described and was successful in selected cases (23%; 14 of 61 cases described).1 There are also a variety of surgical options ranging from simple diverticulectomy, isolated
Fig. 1. Computed tomography scan showing the free air adjacent to the second part of the duodenum (1), retroperitoneal air from the perforated duodenal diverticulum (2), dilated distal small bowel secondary to the obstructing bezoar (3).
Fig. 2. Computed tomography scan showing the retroperitoneal air at the perforated duodenal diverticulum (4), posterior to the head of pancreas (5). © 2014 Royal Australasian College of Surgeons
Images for surgeons
517
References
Fig. 3. Computed tomography scan showing the retroperitoneal air contiguous with the perforated duodenal diverticulum with surrounding inflammatory changes (6), free air adjacent to the second part of the duodenum (7), dilated distal small bowel (8).
retroperitoneal drainage, roux loop duodenojejunostomy and even a Whipple's procedure.6,7 However, the selection of these procedures are dependent upon the extent of inflammation, tissue friability in the area and the time interval from perforation to accurate diagnosis. In this case, the presence of a precipitating cause of intestinal obstruction and the underlying sepsis with signs of haemodynamic instability required prompt surgical decompression and drainage.
1. Thorson CM, Paz Ruiz PS, Roeder RA, Sleeman D, Casillas VJ. The perforated duodenal diverticulum. Arch. Surg. 2012; 147: 81–8. 2. Duarte B, Nagy KK, Cintron J. Perforated duodenal diverticulum. Br. J. Surg. 1992; 79: 877–81. 3. Nijhof HW, Bisselink J, Rijbroek A. Small bowel obstruction due to enterolith expelled from duodenal diverticulum. ANZ J. Surg. 2009; 79: 77–8. 4. Andrea R, Christian BN, Pascal B, Stephane D, Philippe M. Perforated duodenal diverticulum, a rare complication of a common pathology: a seven‐patient case series. World J. Gastrointest. Surg. 2013; 5: 47–50. 5. Miller G, Mueller C, Yim D et al. Perforated duodenal diverticulitis: a report of three cases. Dig. Surg. 2005; 22: 198–202. 6. Lee VT, Chung AY, Soo KC. Mucosal repair of posterior perforation of duodenal diverticulitis using roux loop duodenojejunostomy. Asian J. Surg. 2005; 28: 139–41. 7. Schnueriger B, Vorburger SA, Banz VM, Schoepfer AM, Candinas D. Diagnosis and management of the symptomatic duodenal diverticulum: a case series and a short review of the literature. J. Gastrointest. Surg. 2008; 12: 1571–6.
Ye Xin Koh, MBBS, MRCS Aik Yong Chok, MRCS Andrew Siang Yih Wong, FRCS Upper Gastrointestinal Surgery Service, Department of General Surgery, Changi General Hospital, Singapore doi: 10.1111/ans.12705
Retroperitoneal lymphangiectasia A 50‐year‐old lady presented with complaints of recurrent vomiting for 4 months. Besides significant weight loss, she did not complain of haematemesis, melaena, jaundice or fever. She denied prior history of dyspepsia. Physical examination was unremarkable. On laboratory analysis, liver and renal function tests were normal. Urine examination (routine and microscopic) was also normal. She underwent gastroduodenoscopy, which revealed a dilated stomach and an ulcero‐proliferative growth in the second part of duodenum. Histopathological examination of punch biopsy specimen confirmed duodenal adenocarcinoma. Contrast‐enhanced computed tomography (CECT) of the abdomen revealed an intraluminal mass in the second part of the duodenum. There was no ascites or focal liver lesion. There was a sheet‐like hypodense soft tissue mass (arrows) in the retroperitoneum encircling the aorta and inferior vena cava. The lesion was very low in attenuation, and no separate lymph nodes were visualized in the retroperitoneum (Fig. 1). Coronal reformatted CECT image displayed the distribution of the retroperitoneal lesion in the aorto‐caval and para‐aortic locations, which extends into the right renal hilum (arrows) (Fig. 2a). The very low density of the lesion pointed towards the diagnosis of dilated lymphatics rather than lymphadenopathy. Coronal HASTE magnetic resonance (MR) image of © 2014 Royal Australasian College of Surgeons
abdomen further confirmed the distribution of the dilated retroperitoneal lymphatics (arrows) (Fig. 2b). Laparotomy revealed a 5 × 4 cm mass palpable in the second part of the duodenum. There
Fig. 1. Axial contrast‐enhanced computed tomography (CECT) image of the abdomen reveals a sheet‐like hypodense soft tissue lesion (arrow) in the retroperitoneum encircling the aorta and inferior vena cava.
