Periampullary Diverticula: A Potential Source of Upper GI Bleeding

Abstract

Background: The duodenum is the most common location for small bowel diverticula. These diverticula are typically asymptomatic, and are often found incidentally or during post-mortem evaluations. When symptomatic, most periampullary diverticula result in pancreaticobiliary obstruction. We present a rare case of a periampullary diverticulum as a cause of upper GI bleeding, treated successfully with endoscopy. Case: A 69 year-old-male on dual antiplatelet therapy was admitted for an acute heart failure syndrome 2 weeks following a 4-vessel coronary artery bypass graft. During his hospitalization, he developed melenic stools with a subsequent drop in hemoglobin from 10.0 to 7.1 g/dL. Esophagogastroduodenoscopy (EGD) revealed a periampullary diverticulum that was found to be actively bleeding. Using a side-viewing endoscope, a vessel with visible arterial spurting was identified consistent with a Dieulafoy lesion. Hemostasis was achieved via combination therapy of endoscopic hemoclip and epinephrine injection at the site of the Dieulafoy lesion. His post procedural course was uneventful, and the patient was discharged within 48 hours of his procedure on a proton pump inhibitor.Figure 1Figure 2Discussion: Two to five percent of patients undergoing barium swallow studies, and up to 7% in patients undergoing endoscopic retrograde cholangiopancreatography, are found to have duodenal diverticula. Duodenal diverticula are not an uncommon finding, however they are generally asymptomatic. Most complications from these diverticula result in pancreaticobiliary pathology. This case demonstrates the ability of these more proximally located diverticula to cause upper GI bleeding, as with colonic diverticula. Whereas previous case reports describing treatment of diverticular bleeding have highlighted the ease of administering treatment with a forward-viewing scope, this case highlights the improved visibility and utility of the side-viewing endoscope. In the past, surgical diverticulectomy had been the main treatment for this pathology, however recent advances in endoscopic technique have made endoscopy the treatment of choice.Figure 3