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      Perforated Duodenal Diverticulum Treated Conservatively: Another Two Successful Cases

      case-report

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          Abstract

          Diverticula of the duodenum proceed those of the colon in respect to frequency of location. Incidence at times of autopsy ranges from 15 to 23%. Despite the fact that more than 90% of duodenal diverticulum cases are asymptomatic, complications if they do occur can be calamitous. Perforation is one of these rare complications. Surgical intervention has always been the mainstay for symptomatic/complicated duodenal diverticula, but with the advancement of imaging, medical treatment, and proper intensive observation, conservative treatment came forth. We hereby present two cases of duodenal diverticula, complicated by perforation and fistulization into the retroperitoneal cavity, both treated conservatively by Taylor's approach of upper gastrointestinal tract perforation. Review of other cases of duodenal diverticulum perforation has also been presented.

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          Most cited references23

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          The perforated duodenal diverticulum.

          Chad M. Thorson (2012)
          To perform a literature review of perforated duodenal diverticulum with attention to changes in management. We searched PubMed for relevant studies published from January 1, 1989, through August 1, 2011. In addition, we identified and reviewed 4 cases at our institution. Search phrases were perforated duodenal diverticulum and duodenal diverticulitis. Patient demographics, clinical characteristics, radiologic findings, treatment, and outcomes were obtained. We reviewed 39 studies producing 57 cases, which were combined with the 4 at our institution for a total of 61 patients. The addition of 2 previous series revealed a total of 162 patients in the world literature. Perforations were most commonly located in the second or third portion of the duodenum (60 of 61 cases [98%]), and the most frequent cause was diverticulitis (42 of 61 [69%]). There has been a dramatic improvement in the preoperative diagnosis of perforated diverticula. Only 13 of 101 reported cases (13%) were correctly diagnosed before 1989, and 29 of 61 (48%) in the present series were identified with radiologic examinations. Most patients in the current series (47 of 61) underwent operative treatment for their perforation, although 14 underwent successful nonoperative management. Complications were reported in 17 of 47 patients in the surgical group (36%), whereas only 1 complication was seen in patients undergoing nonoperative management. Mortality in the surgical group was 6% (3 of 47), and no deaths were reported in the nonoperative group. Perforation of a duodenal diverticulum is rare, with only 162 cases reported in the world literature. Nonoperative management has emerged as a safe, practical alternative to surgery in selected patents.
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            Management of complicated duodenal diverticula.

            N Oukachbi, S Brouzes (2013)
            The duodenum is the second most common location of intestinal diverticula after the colon. Duodenal diverticulum (DD) is usually located in the second portion of the duodenum (D2), close to the papilla. Most duodenal diverticula are extraluminal and acquired rather than congenital; more rare is the congenital, intraluminal diverticulum. DD is usually asymptomatic and discovered incidentally, but can become symptomatic in 1% to 5% of cases when complicated by gastroduodenal, biliary and/or pancreatic obstruction, by perforation or by hemorrhage. Endoscopic treatment is the most common first-line treatment for biliopancreatic complications caused by juxtapapillary diverticula and also for bleeding. Conservative treatment of perforated DD based on fasting and broad-spectrum antibiotics may be offered in some selected cases when diagnosis is made early in stable patients, or in elderly patients with comorbidities who are poor operative candidates. Surgical treatment is currently reserved for failure of endoscopic or conservative treatment. The main postoperative complication of diverticulectomy is duodenal leak or fistula, which carries up to a 30% mortality rate.
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              Diverticulitis of the small bowel: CT diagnosis.

              Bruno Coulier, Philippe Maldague, Albert Bourgeois … (2006)
              In contrast with their colonic equivalents, noncolonic diverticula of the gastro-intestinal tract are much rarer and an uncommon site of inflammation. Symptoms and signs are generally nonspecific and before the advent and development of CT, clinical and radiological diagnosis was very difficult. As a result laparotomy was carried out in most cases without correct preoperative diagnosis. We report three rare cases of noncolonic diverticulitis, respectively, affecting the duodenum, the jejunum, and the distal ileum. MDCT with multiplanar reconstructions revealed unambiguously diagnostic features in the three cases and allowed minimally invasive endoscopic drainage in the duodenal case and successful conservative medical treatment in the jejunal and ileal cases. We discuss and review the prevalence, physiopathology, symptoms, and complications of diverticula of the duodenum and jejuno-ileum and emphasis on the high performance of MDCT for the diagnosis of acute diverticular complications.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Case Rep Surg
                Journal ID (iso-abbrev): Case Rep Surg
                Journal ID (publisher-id): CRIS
                Title: Case Reports in Surgery
                Publisher: Hindawi
                ISSN (Print): 2090-6900
                ISSN (Electronic): 2090-6919
                Publication date (Print): 2017
                Publication date (Electronic): 7 May 2017
                Volume: 2017
                Electronic Location Identifier: 4045970
                Affiliations
                1Division of General Surgery, Department of Surgery, American University of Beirut Medical Center, Riad El-Solh, Beirut 1107 2020, Lebanon
                2Division of Interventional Radiology, Department of Diagnostic Radiology, American University of Beirut Medical Center, Riad El-Solh, Beirut 1107 2020, Lebanon
                Author notes
                *Ali H. Hallal: ah05@ 123456aub.edu.lb

                Academic Editor: Dimitrios Mantas

                Author information
                http://orcid.org/0000-0002-1624-1189
                http://orcid.org/0000-0001-7567-4454
                http://orcid.org/0000-0002-3182-8797
                Article
                DOI: 10.1155/2017/4045970
                PMC ID: 5438833
                SO-VID: e894bede-bc2c-468f-8a15-51058c468093
                Copyright © Copyright © 2017 Jad A. Degheili et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 26 March 2017
                Date accepted : 18 April 2017
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Surgery
                Data availability:
                ScienceOpen disciplines: Surgery

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