Duodenal Diverticular Bleeding: Multidisciplinary Management for an Uncommon Cause of Upper Gl Bleeding

Abstract

Duodenal diverticular bleeding (DDB) represents an uncommon cause of upper GI bleeding, accounting for less than 0.25 % of cases. Most cases of DDB are located near the ampulla, so called juxtapapillary diverticula. Diverticula of the third and fourth portions of the duodenum are exceedingly rare, accounting for 10% of duodenal diverticula, and are more difficult to visualize endoscopically. A 70-year-old Caucasian man presented to an outside hospital with melena; he was hypotensive, tachycardic and anemic on presentation. Emergent esophagogastroduodenoscopy (EGD) was performed, which revealed dark blood in the stomach; the endoscope was advanced to the second portion of the duodenum without evidence of blood in the examined duodenum. Following the EGD, the patient continued to have evidence of rapid GI blood loss with a high transfusion requirement. The patient was transferred to our institution on hospital day 2. Resuscitation to maintain adequate blood pressure continued, and an EGD was repeated. The endoscope was advanced to the third portion of the duodenum, where a diverticulum with active, brisk bleeding was identified. An endoscopic clip was placed near the bleeding diverticulum to serve as a radiographic marker for angiography. Angiography identified active hemorrhage from a branching vessel of the inferior pancreaticoduodenal artery. Selective embolization with vascular coils to the hemorrhaging branch vessel and to the inferior pancreaticoduodenal artery achieved hemostasis. This case underscores the utility of second-look endoscopy, as recommended in the literature. Due to the brisk nature of bleeding, endoscopic intervention seemed unlikely to achieve hemostasis in our case. This case also highlights the value of coordinated care with an interventional radiologist to successfully manage an uncommon cause of upper GI bleeding. Though active extravasation was present on angiography in this case, endoscopic clips can be helpful to guide embolization when active bleeding is not apparent on angiography. Three cases were found in the literature of endoscopic diagnosis or management of DDB in the third portion of the duodenum. To our knowledge, this is the first case in which the diagnosis was made endoscopically and immediate intravascular embolization was performed.Figure 1Figure 2Figure 3