A Rare Case of Bleeding from a Periampullary Diverticulum Diagnosed and Treated with a Side-Viewing Endoscope. Should Competency in Side-Viewing Endoscopy Be Mandated for GI Training Programs?

Abstract

Purpose: Bleeding from periampullary diverticula is uncommon and few cases have been reported in the literature. The optimal method of diagnosis and treatment is not well established, given the rarity of this lesion. We present a patient in whom both the diagnosis and treatment of a bleeding periampullary diverticulum could only be accomplished with the use a side-viewing endoscope. Results: A 74-year-old Caucasian man presented with melena, hypotension, and anemia. An upper endoscopy using a forward viewing endoscope revealed a periampullary diverticulum containing a large blood clot and fresh blood. A specific source of bleeding could not be identified. With evidence of recurrent bleeding, an upper endoscopy was repeated with a side-viewing endoscope. This revealed a periampullary diverticulum with a 7 mm cratered ulcer that was oozing blood from a visible vessel. It was successfully treated with epinephrine injection and a metal clip. The ampulla was normal without bloody extravasation. The patient was discharged with a stable hematocrit and no signs of further bleeding. Discussion: The incidence of duodenal diverticula ranges from 2.5-5% by upper GI series, to 23% by ERCP and autopsy series. Although 90% of duodenal diverticula occur within 1.5 cm of the papilla, most reported bleeding diverticula are in the third or fourth portions of the duodenum. In our case, a side-viewing endoscope was the only method to detect and treat the source of bleeding. Traditionally, training for the use of side-viewing endoscopes occurs in the context of elective training for endoscopic retrograde cholangiopancreatography (ERCP). Current guidelines from the accreditation council for graduate medical education (ACGME) do not require fellowship training to include competency in the use of side-viewing endoscopes. There are multiple diagnostic and therapeutic procedures that require a side-viewing endoscope in addition to ERCP such as the diagnosis and surveillance of periampullary adenomas in patients with familial adenomatous polyposis and difficult polyp removal during a colonoscopy. Conclusion: We report a rare case of a periampullary duodenal diverticular bleed. A side-viewing endoscope was employed to adequately diagnose and treat this lesion. Side-viewing endoscopes should be used in duodenal bleeding when a forward-viewing endoscope is unsuccessful in visualizing this lesion. Adequate training to demonstrate competency in the use of side-viewing endoscopes should be a standard part of a gastroenterology fellowship training curriculum.