Duodenal diverticulitis: a crossroad between conservative therapy and surgery: a case report

Abstract

Background

In total, 90% of patients with duodenal diverticulum are asymptomatic; 5% of patients present with symptoms due to its complications, as compression of neighboring organs, cholestasis (in cases of periampullary diverticulum), hemorrhage, inflammation (diverticulitis), or perforation. Duodenal diverticulitis represent a diagnostic challenge because of nonspecific symptoms and indeterminate computed tomography images, leading to diagnostic delay with possible complications such as perforation.

Case presentation

A 68-year-old Caucasian Italian female patient presented with large retroperitoneal fluid collection (5.5 × 5.6 × 4.8 cm) with air-fluid level around the second part of the duodenum, initially interpreted as localized duodenal perforation. An effective conservative management was performed with good outcomes.

Conclusion

With the exception of cases of peritonitis or frank sepsis, the treatment of duodenal diverticulitis, with or without retroperitoneal perforation, is based on the patient’s clinical manifestation, and in selected patients, conservative treatment may be a valid alternative to surgery, avoiding over-treatment and potential serious complications of a very difficult surgery.

Introduction

Duodenal diverticulum (DD) is the second most common type of gastrointestinal diverticulum after colonic tract. It is quite prevalent in the general population, seen in up to 5% of radiology studies and 22% of autopsy examinations. In addition, more than 90% of patients are asymptomatic; when symptoms do occur, patients often present with generalized abdominal pain, nausea, vomiting, diarrhea, constipation, or decreased appetite. The most frequent location is the second and third portions of the duodenum (D2–D3). There are two main types of duodenal diverticula: extraluminal diverticula, which are acquired lesions due to weakening of the muscular layer where large vascular vessels penetrate the wall, and intraluminal diverticula, which are congenital, less common, and due to an abnormality in foregut luminal canalization during embryological development. DD is rarely symptomatic and about 5% of patients present with symptoms due to its complications, such as compression of neighboring organs, cholestasis (in cases of periampullary diverticulum), hemorrhage, inflammation (diverticulitis), or perforation [1,2,3].

Case presentation

A 68-year-old Caucasian Italian female patient presented with 4-day history of epi-mesogastric abdominal pain and radiating back, with vomiting but no fever. On presentation in the emergency department, severe epi-mesogastric tenderness was observed upon physical examination. She was hemodynamically stable with no significant past medical or surgical history. A computed tomography (CT) of the abdomen (Fig. 1) revealed a large retroperitoneal fluid collection (5.5 × 5.6 × 4.8 cm) with air-fluid level around the second part of the duodenum, increased density, and thickening of surrounding fat, initially interpreted by the on-call radiology registrar as a collection related to localized duodenal perforation. Importantly, no extraluminal tracking of oral contrast into the retroperitoneum or intraperitoneal cavity was identified to indicate perforation, thus diagnosis of “not perforated duodenal diverticulitis” was made. Patient was found to have no leukocytosis white blood cells (WBC 9600 cells/μL), but increased C-reactive protein (CRP) (313.9 mg/dL); all other laboratory results were normal, except for gamma glutamic transferase of 120 U/L and amylase of 180 U/L. A conservative management with total parenteral nutrition, intravenous fluid, antibiotic therapy with piperacillin/tazobactam (4.5 g every 6 hours for 10 days) and metronidazole (500 mg every 8 hours for 5 days) and bowel rest was immediately started. A total of 5 days after recovery, a new CT abdomen showed improvement in edematous duodenal wall thickness, diverticulum diameter, and reduction of air bubbles (Fig. 2). A magnetic resonance imaging (MRI) performed on the same day confirmed the presence of a diverticulum of the superior wall of the second portion of the duodenum. A nasogastric tube was maintained for 10 days, until oral intake of food and drink started from day 11 after admission, with sips of water gradually proceeding to diet. Her clinical conditions improved day by day. On hospital day 15, follow-up CT scan showed a complete resolution of local inflammation (diameter 2.3 × 1.5 cm, Figure 3), thus patient was discharged with improved laboratory findings (WBC 4900 cells/μL, CRP 3.7 mg/dL). On day 21 after admission, on an outpatient CT abdomen, a second non-inflamed diverticulum of the fourth portion of the duodenum was detected (Fig. 4). Follow-up at 3 and 6 months after discharge showed that the patient was in good general condition and asymptomatic. Therefore, it was decided not to plan any surgical intervention and to consider surgery only in the event of a future recurrence of symptoms.

Fig. 1

Computed tomography on the day of admission demonstrating a large 5.5 × 5.6 × 4.8 cm fluid- and gas-containing focus adjacent to the duodenum (arrow) with associated fat stranding

Fig. 2

Healing duodenal diverticulitis (arrow)

Fig. 3

Complete resolution of local inflammation of diverticulum of the second portion of duodenum (arrow)

Fig. 4

Non-inflamed diverticulum 5 × 3 cm of the fourth portion of the duodenum (arrow)

Discussion

Despite the fact that only 5% of diverticula evolve into symptoms, potential complications can be severe. It represents a diagnostic challenge from the beginning of a diagnostic workup because of nonspecific symptoms and indeterminate CT images, which could first suggest pancreatitis, cystic pancreatic head neoplasms, duodenitis, cholecystitis, or duodenal neoplasms, leading to diagnostic delay with possible complications such as perforation, which carries a 30% mortality rate [2]. Our patient, in fact, referred generalized symptoms and pain in upper quadrants of the abdomen with vomiting, and CT images were interpreted initially as suspected duodenal perforation. In fact, as a further demonstration of the diagnostic difficulty of this type of pathology, Khan et al. reported a case of a giant duodenal diverticulum, initially misdiagnosed as a localized duodenal perforation on CT, and only additional ultrasound and fluoroscopic imaging demonstrated the final diagnosis of acute cholecystitis, avoiding in this way possible iatrogenic damages [4]. A total of 5 days after admission, our patient underwent an abdominal MRI that confirmed the presence of a diverticulum of the superior wall of the second portion of the duodenum, definitely excluding biliary tract or pancreatic disease, and especially perforated duodenal diverticulitis.

The most common complications of DD are biliopancreatic stasis and obstruction, ulceration with bleeding, and diverticulitis with a possible perforation. Patients with perforation typically present with upper abdominal pain associated with nausea and vomiting, such as our patient, who was not perforated; cholestasis and elevated lipase may be noted with inflammation and compression effects [5]. Duodenal diverticulitis could also be rarely associated with septic thrombophlebitis and portal vein thrombosis, as reported by Ryou et al. [6].

The treatment of duodenal diverticulitis is based on the patient’s clinical manifestation. Conservative treatments, such as fasting and empirical antibiotics, can be effective in absence of sepsis, while an upper endoscopic approach, in such cases that are equivocal or fail conservative management, in the absence of free perforation, is also indicated for diagnosis and allows for therapies including debridement, irrigation with normal saline, and stent placement in select cases. In these cases, in fact, endoscopic treatment may be a valid alternative to surgery [2, 7].

In case of detected perforated duodenal diverticulitis, the choice of treatment is often a function of the surgeon’s experience and control of the condition. In suspected retroperitoneal perforation, nonoperative management is also indicated; when conservative treatment is not well controlled, percutaneous retroperitoneal drainage can be selected at the right time, and when the patient shows clear signs of peritonitis or hemodynamic instability, surgery should be performed, as described by Zhong et al. in their treatment model [8].

There are reports in the literature that endoscopic drainage of the perforation by endoscopy may be a minimally invasive alternative to percutaneous drainage or exploratory laparotomy when CT scans suggest that the effusion is confined in clinically stable patients in the retroperitoneal space [9,10,11].

The attempt to treat conservatively, uncomplicated and complicated diverticulitis, derives from the possibly stabilizing patient prior to surgery and potential complications after surgery. The surgical approach involves a stapled or hand-sewn diverticulectomy, but more complex procedures, such as duodenal diversion, pyloric exclusion, gastroenteric anastomosis, duodenostomy tube, segmental duodenal resection, or even a pylorus-preserving Whipple procedure may be required in cases complicated by peritonitis, bile duct injury, pancreatitis, fistula, abscess, and persistent sepsis, but generally with inferior outcomes [12].

Management of perforated duodenal diverticulitis varies, as confirmed in literature. Nonoperative management is a valid alternative to surgery in selected patients [3, 13,14,15,16,17]; surgery, however, is still considered the main treatment in case of peritonitis and a free abdominal duodenal leak [18]. Moreover, surgical management can be adopted when the diagnosis is not clear before the operation [19]. In this contest, some authors express the need for a classification, similar to Hinchey’s for sigmoid diverticular perforation, to standardize treatment for each patient [15, 20].

Conclusion

Duodenal diverticulitis, with or without perforation, is an insidious pathology that can lead to diagnostic and therapeutic errors, especially in initial stages, with considerable risks to the patient. With the exception of cases of peritonitis or frank sepsis, a conservative approach, both in cases of uncomplicated duodenal diverticulitis and in perforated duodenal diverticulitis, may be successful, avoiding surgical over-treatment and potential serious complications.