No abstract

Duodenal diverticulum (DD) is a common incidental finding, which rarely causes complications. Perforation is one of the most feared and the least common complications. Surgery is the mainstay for complicated duodenal diverticulum, but with the advancement of medical treatment and intensive care, nonoperative management has been reported. We present a rare case of perforated DD that failed medical management and subsequently underwent surgical intervention.A 77-year-old, healthy female presented with right-sided abdominal pain with low-grade fever and leukocytosis. Computed tomography (CT) of the abdomen showed retroperitoneal fluid collection around the second part of the duodenum, which was not amenable to percutaneous drainage. Contrast studies showed no evidence of perforation or leak of the stomach or duodenum. The diagnosis was made via an upper endoscopy that showed a large periampullary duodenal diverticulum with purulent drainage and normal-looking ampulla. After failed conservative management with broad-spectrum antibiotics and worsening symptoms, she underwent excision and primary repair of the diverticulum with a jejunal serosal patch and exploration of the common bile duct (CBD). She had an uncomplicated postoperative course and was discharged home on postoperative day four.Although rare, the duodenal diverticular perforation can be a life-threatening complication. Combined subjective, clinical, and radiological assessment of the patient is crucial in deciding whether to operate or not.

Introduction: Mesodiverticular band (MDB) is a rare congenital intestinal malformation. It originates from the embryonic remnant of the vitelline artery and is usually associated with Meckel’s diverticulum (MD). Persistent MDB may cause small bowel obstruction by trapping a loop of bowel, hemoperitoneum due to aneurysmal or traumatic rupture of MDB. The purpose of this article is to review the literature of MDB and identify the patterns of presentation, complications, and management options. Methods: We searched PubMed for articles containing terms: “Mesodiverticular band,” “Vitelline band,” and “Vitelline artery remnant.” Abstracts were reviewed in detail and we included all the case reports available in full-text and in English language. We excluded all case reports of patients younger than 18 years of age. Results: Only 20 case reports were included. Only adult patients were included. The male to female ratio was 3:1. The most common presentation was small bowel obstruction followed by hemoperitoneum. The majority required exploratory laparotomy with more than half requiring small bowel resection. One death report secondary to undiagnosed internal hernia. Conclusion: MDB with MD is a rare cause of intestinal obstruction or hemoperitoneum in adults. It remains a diagnostic dilemma as it is usually diagnosed intraoperatively.

Highlights Colonic perforation after colonoscopy could be intraperitoneal, extraperitoneal or a combination of both. Majority of the perforations are intraperitoneal. Risk factors include advance age, female sex, diverticulosis, previous abdominal surgery and colonic strictures. Extraperitoneal perforations can manifest as pneumoretroperitoneum, pneumomediastinum, pneumothorax and/or subcutaneous emphysema. Non operative management in isolated retroperitoneum while surgery required in majority of peritoneal perforation.