Duodenal Diverticulitis: To Operate or Not To Operate?

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.

Perforated duodenal diverticulum successfully treated with a combination of surgical drainage and endoscopic nasobiliary and nasopancreatic drainage: a case report

“…Applicable surgical procedures should be determined based on the severity of inflammation surrounding the perforation site. If the inflammation is too severe and the risk of anastomosis leakage may be unavoidable, we may be forced to dissect the intestine, leading to pancreatoduodenectomy [3][4][5][6]. However, the surgical procedure may be highly invasive for the patients.…”

“…Duodenal diverticulum is a relatively common disease and usually asymptomatic unless complications occur [1]. Perforation of a duodenal diverticulum is a rare complication that may become fatal with a delay in diagnosis owing to bile and pancreatic juice leakage [2][3][4][5][6][7]. However, the most appropriate treatment for perforated duodenal diverticulum remains disputable, which ranges from conservative therapy to surgery, including pancreatoduodenectomy.…”

Duodenal Diverticulosis as an Unusual Cause of Severe Abdominal Pain

“…In other patients who present with choledocholithiasis due to juxtapapillary diverticula, management can be successfully done by the use of endoscopic retrograde cholangiopancreatography with sphincterotomy and stone removal followed by laparoscopic cholecystectomy [13]. Following a restricted diet and an antibiotic therapy are the mainstay of treatment in clinically stable patients with uncomplicated diverticulitis [1,[11][12][13][14][15][16]. Diverticulitis can be complicated by refractory gastrointestinal bleeding or infections [14].…”

“…DD can be the cause of a congenital or an acquired phenomenon. Furthermore, they can come in two forms either intramural or extramural [1][2][3][4]. The most common manifestation would be acquired and extramural [1].…”

“…Furthermore, they can come in two forms either intramural or extramural [1][2][3][4]. The most common manifestation would be acquired and extramural [1]. The majority are asymptomatic with less than 10% of the patients having nonspecific symptoms such as abdominal pain [1][2].…”