Intraluminal duodenal diverticulum: An unusual cause of acute pancreatitis

Abstract

Case reportscarries a high degree of morbidity. Distal or subtotal pancreatectomy has also had mixed results, although patients 1 and 2 in this family experienced complete relief of pain after operation. While not advocating distal pancreatectomy for all patients, it is proposed that the procedure be considered when conservative therapy is failing. References I .Comfort Standard surgical texts list several rare causes of acute pancreatitis that should be considered when gallstones and alcohol have been excluded. This list should now also include intraluminal duodenal diverticulum, a congenital abnormality first described by Boyd' in 1845. Case reportA 27-year-old woman was admitted to hospital with acute pancreatitis. During the preceding 7 months she had experienced several less severe episodes of epigastric pain. She did not drink alcohol, had normal serum lipid levels and a normal abdominal ultrasonography scan. Symptoms settled with conservative treatment. Some 2 months later she was readmitted after a more severe attack. Endoscopic retrograde cholangiopancreatography (ERCP) during this admission appeared to show a large polyp in the second part of the duodenum that obscured the papilla, preventing cannulation of the ampulla of Vater. A subsequent duodenogram supported the endoscopic findings (Figure 1 ).At laparotomy 3 weeks later the duodenum was palpably normal but duodenotomy revealed a 7 x 2 cm duodenal diverticulum resembling a 'windsock' and which could be completely invaginated. The neck of the diverticulum was attached to 120" of the circumference of the duodenal wall at the level of the papilla and on the same side of the duodenum. Although the diverticulum was not causing luminal obstruction, when it was collapsed its free edge lay directly over the papilla. The diverticulum was excised along its mural attachment. Microscopically it comprised two layers of duodenal mucosa separated by muscularis mucosa. The patient made an uneventful recovery and after 6 months remains asymptomatic. DiscussionAn intraluminal diverticulum, which is usually found in the second or occasionally the third part of the duodenum, is one of the least common forms of congenital duodenal abnormality. It occurs equally in both sexes. Approximately 50 cases have been reported in the world literature, 40 per cent of which have had coexistent anatomical abnormalities including choledochocele and annular pancreas'. In the 7-week-old normal embryo the duodenum becomes occluded and then recanalized. Incomplete recanalization causes either duodenal atresia, stenosis or a diaphragm3. A duodenal diverticulum, attached to all or part of the circumference of the duodenum, may be caused by ballooning of a diaphragm or may represent the remnant of dual recanalization, a theory postulated to explain its rare occurrence in neonates4.Intraluminal duodenal diverticula most commonly present in the third to fifth decades with abdominal pain and obstructive speculated that reflux of duodenal contents into the pancreatic duct might occur if the am...

Intraluminal Duodenal Diverticulum Causing Acute Pancreatitis: CT Scan Diagnosis and Review of the Literature

“…The reported cases of pancreatitis associated with IDD are summarized in table 1 [7, 12, 14, 16, 19, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37]. All cases were diagnosed preoperatively: by contrast study (11 cases) till 1986 and by endoscopy thereafter.…”

Ampullary but Not Periampullary Duodenal Diverticula Are an Etiologic Factor for Chronic Pancreatitis

“…Suggested mechanisms for this association include biliary and pancreatic stasis, bacterial overgrowth with ascending infection and mechanical pressure elevation in the pancreatic and biliary duct system [24, 32, 33, 34, 35]. Biliary and pancreatic diseases associated with duodenal diverticula were reported in up to 86 and 37.5%, respectively [24], while others find duodenal diverticula associated significantly more often with chronic pancreatitis than with chronic cholecystitis or ulcer disease of the duodenum [33, 36, 37].…”

Recurrent pancreatitis due to an intraluminal duodenal diverticulum: report of a case

“…The big black arrow points to the original lumen of the distal part of the duodenum stenosis of the duodenum account for the majority of congenital anomalies, duplication cysts or an intraluminal duodenal diverticulum (IDD) are rarely reported [3,4]. Eventually, pancreatitis is singularly reported as a sequela of these malformations [4][5][6].…”

“…As the septum is constantly stretched due to duodenal peristalsis, it might be transformed into a pulsion-type diverticulum, rarely projecting into the proximal jejunum [4,6,10]. The pouch may contain an aperture or fenestration [4][5][6]. Food or ingested foreign bodies may enlarge the diverticulum.…”

“…Since then, about 120 cases have been described in the published medical literature [4][5][6][7][8]. An IDD is considered to be an incomplete mucosal septum, probably resulting from the failure of recanalization in the 7-week-old human embryo [9].…”