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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Duodenal diverticula

, M.D. and , M.D.

Department of Surgery, Case Western University, Cleveland, OH, USA

Diverticula of the duodenum and small intestines rarely are clinical problems, but are fairly common anatomical entities (Eggert 1982) (Akhrass 1997). Diverticula of the small bowel are generally classified as congenital or acquired. The congenital diverticula (true diverticula) are best characterized by the Meckel's diverticulum, which contains all layers of the intestinal wall. Intraluminal duodenal diverticula are also true diverticula since they contain all layers of the duodenal wall (Adams 1986). These latter entities may represent congenital webs and are exceedingly rare. The standard acquired diverticula (false) of the duodenum and small bowel occur in small structural defects, probably around blood vessels; these defects allow protrusion of an outpouching containing only mucosa and submucosa. Whether these are due to pressure phenomena, suggested by the thick-walled jejunum where the diverticula occur, is not proven.

Clinical implications

The discovery of most duodenal diverticula is incidental (Brian, Jr. 1985). Upper gastrointestinal barium examinations show up to 5% of patients will have a duodenal diverticulum (Psathakis 1994). When upper gastrointestinal endoscopic examinations became frequent, ostia in the duodenum suggesting diverticula were seen in up to 20% of patients. Therefore, duodenal diverticulum can occur and not be seen on an upper GI series. The sac is not always entered by the barium flow. More than 90% of duodenal diverticula are asymptomatic and a very small percentage of the symptomatic patients would ever require an operation.

Unfortunately vague intestinal symptoms and pains have been attributed to duodenal diverticula since they are so commonly encountered during diagnostic examinations. These diverticula rarely turn out to be the cause of pain or intestinal distress. In general, duodenal diverticula should be left alone.

Surgical implications

The complications of duodenal diverticula include those same complications of diverticulosis any place in the GI tract including the colon. These outpouchings can be the source of bleeding, obstruction, infection, and perforation. In this author's series, 208 patients were identified that had clinically important small bowel diverticula: 79% of these were in the duodenum, 18% in the jejunum or ileum and 3% in all three areas (Akhrass 1996). Complications occurred in 42 patients. In 11 of 32 patients with duodenal complications, bleeding was the presenting problem. In jejunoileal diverticula, only 2 of 19 patients had bleeding. It was interesting that perforations and abscess occurred in three of 164 patients with duodenal diverticula and 9 of 37 patients with jejunoileal disease. Perforation is quite uncommon in diverticula of the duodenum in our experience and in the experience of others. There is a case report of traumatic perforation of a duodenal diverticulum (Pootstizadeh 1997). Fewer than 20 - cases have been reported of perforation of duodenal diverticula secondary to trauma. The perforated diverticulum from trauma is generally noted while exploring what was presumed to be a simple duodenal rupture. The diverticulum can be quite a surprise.

Obstruction of the duodenum from duodenal diverticula is uncommon, but it is much more common for the diverticula to obstruct the ampulla of Vater. The vast majority of duodenal diverticula are found in the periampullary region projecting from the medial wall of the duodenum (Eggert 1982). These not only can produce symptoms of obstruction, perforation or bleeding, but also can cause recurrent pancreatitis, cholangitis and common duct stones, even after cholecystectomy. Stenosis of the ampulla of Vater may contribute to the stones since such stones are bilirubinate stones. These stones appear to be primary within the bile ducts. It has been found that patients who have had remote cholecystectomies and have periampullary diverticula have a much higher recurrence rate of calculi than those who do not. Even though some authors have suggested that endoscopic sphincterotomy in patients with periampullary duodenal diverticula does not cause problems in patients who still retain their gallbladders (Shemesh 1989), this anatomic arrangement may make it very difficult for the endoscopist, particularly if the ampulla is situated well within the diverticulum. A Japanese group of authors noted that when endoscopic sphincterotomy is done for bile stones, the highest recurrence rates are in those with diverticula (Tanaka 1998). It was also noted that when one has recurrent stones, they are of the bilirubinate type in a significant number. Not only might there be restenosis of the ampulla resulting in these stones when a diverticulum is present, but bacterial overgrowth may also lead to bilirubinate common duct stones.

Surgical challenges

Aside from the difficult endoscopic procedures to evacuate common bile duct stones associated with duodenal diverticula (Shemesh 1987), the surgeon may be called upon to treat patients with complications of diverticula presenting as emergencies. The first of these is bleeding. The recommended evaluation of the patient with any upper gastrointestinal bleeding is by endoscopy. If no other source of bleeding can be found, and blood is present around the ampulla, then a bleeding diverticulum may be suspected. If the ostium is seen by an angled scope and the diverticulum entered, it may be possible to inject or coagulate the bleeding site. If the bleeding is close to the ampulla, then a stent should be placed before the endoscopic hemostatic procedures are used. If this fails to stop the bleeding in a duodenal diverticulum, the next approach to be considered would be a diagnostic intra-arterial angiographic study followed by placing of coils or foam to clot the offending vessel if found.

Only as a last resort should an exploration be performed. If the diverticulum does not include the ampulla, the sac can often be approached posteriorly after a generous Kocher maneuver (Brian, Jr. 1985) (Akhrass 1997). The diverticulum could then be directly excised and primarily closed taking care of the bleeding at the same time. If the diverticulum cannot be mobilized because of burrowing into the pancreas, then the lateral portion of the duodenum can be opened followed by direct suturing of the bleeding point; a bile duct stent is placed if the procedure is done near the ampulla. For massive bleeding, direct ligation of the pancreaticoduodenal artery should complement the open suture ligation of a bleeding vessel within a duodenal diverticulum. Obviously the extreme measure of pancreaticoduodenectomy would resolve the issue of significant hemorrhage, but there is scant literature to describe any experience with that procedure for diverticula.

Perforation with abscess will require an operative procedure. If the perforation is of traumatic origin, the planned operation is generally to repair the ruptured duodenum, while the diverticulum becomes a surprise finding. This rarest form of duodenal diverticular complication has been handled by excising the diverticulum and repairing the defect with single layer sutures. In the recent case report, the duodenal diverticulum was fortunately a centimeter distal to the ampulla (Pootstizadeh 1997). In trauma patients, the problem is acute and very little infection has been established. The more difficult challenging problem is the management of abscess with perforation. If a primary repair is tenuous or difficult, it may be necessary to do an exclusion of the duodenum utilizing a Roux-en-Y reconstruction bringing the divided proximal bile duct in the end of the jejunal loop and the pylorus distally on the same jejunal limb (Vassilakis 1997). The duodenum is then oversewn. Closed suction is recommended. The success of such an operation is dependent upon the condition of the pancreatic duct. A pancreatic fistula is a significant potential complication. If the infection surrounding a perforation is mild, it may be possible to repair with a jejunal serosal patch (Psathakis 1994). A Roux-en-Y can be placed directly over the debrided diverticulum as well. Such procedures are fortunately extremely rare, but will tax the judgment and ingenuity of the operating surgeon.

Supportive measures often will allow most complications of duodenal diverticula to resolve. Diverticulitis is obviously first managed with antibiotics and rest if no perforation has occurred. Bleeding will stop spontaneously in most patients, even though transfusions are required in the majority (Akhrass 1997).

Finally, regarding the true intraluminal diverticula, endoscopic snares have been used with success (Adams 1986). When this diverticulum functions as a web or obstructs, a duodenotomy with complete excision can also be performed. The ampulla of Vater is generally not within this weblike diverticulum, but it should have a stent if open excision is performed.

Conclusions

Duodenal diverticula are a rare cause of symptoms and there mere presence is not an indication for operation. Even though duodenal diverticula may be present in 20% of the population, such patients are generally asymptomatic. Duodenal diverticula will certainly complicate management of common bile duct stones. Surgical exploration should be very uncommon and limited to significant complications such as bleeding and infection which will not respond to supportive measures. Perforation will require operation and tax the ingenuity of the surgeon.

References

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Eggert A, Teichmann W, Wittman D H. The pathologic implication of duodenal diverticula. Surg Gyn Obst. (1982);154:62–64. [PubMed: 6797081]
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Poostizadeh A, Gow K W, Al-Mahmeed T, Allardyce D B. Traumatic perforation of duodenal diverticulum. J Trauma. (1997);43:370–371. [PubMed: 9291392]
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Shemesh E, Friedman E, Czerniak A, Bat L. The association of biliary and pancreatic anomalies with periampullary duodenal diverticula. Arch Surg. (1987);122:1055–1057. [PubMed: 3113400]
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Shemesh E, Klein E, Czerniak A, Loret A, Bat L. Endoscopic sphincterotomy in patients with gallbladder in situ: the influence of periampullary duodenal diverticula. Surgery. (1990);107:163–166. [PubMed: 2099745]
9.
Tanaka M, Takahata S, Konomi H, Matsunaga H, Yokohata K, Takeda T, Utsunomiya N, Ikeda S. Long term consequence of endoscopic sphincterotomy for bile duct stones. Gastro Endo. (1998);48:465–469. [PubMed: 9831833]
10.
Vassilakis J S, Tzovaras G, Chrysos E, Mouzas I, Manousos O, Xynos E. Roux-Y choledochojejunostomy and duodenojejunostomy for the complicated duodenal diverticulum. Amer J Surg. (1997);174:45–48. [PubMed: 9240951]
Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6891
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