Surgical management of duodenal web in an adult presenting with melaena; Case report and literature review

Abstract

Introduction Duodenal web is a rare pathology presenting infrequently in adults. Diagnosis is challenging and definitive management is commonly delayed. We present a case of a patient with a late diagnosis of duodenal web, who underwent laparotomy, intraoperative gastroscopy and surgical removal of the web performed by two general surgeons. Case presentation A 32-year-old woman with a previous diagnosis of irritable bowel syndrome presented with a three day history of abdominal pain, nausea and anorexia, and a one day history of melaena and haematemesis. Investigations including a magnetic resonance enterography, barium swallow study and gastroscopy revealed the diagnosis. The patient underwent laparotomy and excision of duodenal web. Intraoperative gastroscopy assisted with identification of the web's anatomical location. A longitudinal duodenotomy was performed and this was closed in a transverse fashion using the Heineke-Mikulicz technique. Discussion This case reports successful application of intraoperative gastroscopy during laparotomy and duodenotomy. Longitudinal duodenotomy with excision of the web and transverse closure of the duodenum appears to be the best approach. There are no previous publications detailing gastroscopy at the time of laparotomy with duodenal web. This technique may be utilised in appropriate situations to improve operative accuracy. Conclusion Duodenal web is a rare entity in adults, and delayed diagnosis may lead to significant patient morbidity. Incorporating intraoperative endoscopy ensures accurate anatomical visualisation. This technique avoids duodenectomy, organ damage, bypass, or an unnecessarily large incision.

Duodenal Web in an Elderly Patient with Abdominal Discomfort and Vomiting: A Rare Case

“…Delayed diagnosis of this abnormality in adults is common, which can cause long-term complications such as malnutrition and weight loss. 7 It is suggested that on radiographic and endoscopic evaluation of patients at any age, the duodenal web should also be considered in order to prevent the long-term suffering of patients.…”

“… 5 , 6 In adults, it is usually diagnosed with a delay, due to non-specific symptoms and difficult visualization of the web on endoscopy, and this delayed diagnosis usually leads to significant complications for the patient. 7 Differentiating whether the duodenal web in adults is congenital or acquired (e.g. as a result of long-term non-steroidal anti-inflammatory drugs use, or secondary to pancreatitis, ulceration, obstruction or abdominal surgery) could be difficult.…”

Endoscopic Management of a Double Duodenal Web: A Case Report of a Rare Alimentary Anomaly

“…Typical management often includes diagnostic laparoscopy or open laparotomy with duodenoduodenostomy or duodenotomy with excision of the duodenal web. 10 , 11 Complications of these more invasive methods can include anastomotic leak and stenosis with open procedures, resulting in longer hospitalization, patient recovery time, and greater resource utilization. 12 Endoscopic management in our patient’s case avoided the morbidity and complication profile associated with surgical resection of duodenal webs.…”