1338 A Rare Case of Duodenal Windsock Diverticulum; Simultaneous Biliary, and Small Bowel Obstruction

Abstract

INTRODUCTION: Windsock intraluminal duodenal diverticulum (IDD) is rare congenital anomaly due to incomplete recanalization of foregut during embryogenesis. Most of the IDD are found incidentally and rarely cause symptoms. More common symptoms associated with IDD are nausea, abdominal pain and abdominal fullness. Rarely IDD can cause small bowel obstruction (SBO), pancreatitis and biliary obstruction. CASE DESCRIPTION/METHODS: This is the first reported case in literature of a windsock diverticulum causing SBO and biliary obstruction. A 44 year old man with no prior medical and surgical history presented to our hospital with acute onset abdominal pain, nausea, vomiting and inability to pass flatus or bowel movement for 3 days. Patient was clinically jaundiced and initial lab work up showed a total bilirubin level of 13.0 mg/dl. A CT abdomen and pelvis showed complete duodenal obstruction with suspected etiology of duodenal intussusception as well intra and extrahepatic biliary ductal dilatation (Figure 1). After NG decompression, patient underwent an upper endoscopy and small bowel enteroscopy with findings of a false lumen in second portion of duodenum showing focal areas of mucosal ulcerations but no intussusception was seen (Figure 2). An EUS was performed which did not show any intramural or extraluminal mass lesions. An ERCP was attempted for biliary obstruction but was unsuccessful due to lack of localization of ampulla of vater. Later during the endoscopic procedure, large amount of fresh bile flow was noted in the distal portion of duodenum. False lumen mucosal biopsies were reported negative for malignant cells. Patient's bilirubin level quickly and persistently trended down toward normal range post EGD. Clinically, his symptoms of bowel obstruction resolved completely. He underwent an upper GI series which showed contrast filling of large duodenal diverticulum which further confirmed the diagnosis of large windsock duodenal diverticulum (Figure 3). DISCUSSION: Windsock diverticulum is a true intraluminal diverticulum. In rare cases it can cause serious complications including SBO and biliary obstruction. ERCP can be challenging in case of ampullary proximity to diverticulum. Timely recognition and intervention is necessary for improved clinical outcomes. Endoscopic intervention for diagnosis and management is necessary. Endoscopic diverticulectomy can be a less invasive option for prevention of recurrence of IDD related complications especially especially in case of close proximity of ampulla to IDD.