Periampullary Diverticular Food Impaction: A Rare Cause of Obstructive Jaundice

Abstract

Periampullary diverticula (PAD) are extra-luminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. The prevalence of PAD increases with age and reaches up to 27% in elderly patients. We present a case where food impaction of a PAD caused biliary obstruction and its subsequent management. 86-year-old male with no significant gastrointestinal history presented with a 4 day history of painless jaundice. Physical exam revealed scleral icterus and cutaneous jaundice but was negative for hepatosplenomegaly or abdominal tenderness. Labs revealed AST 98, ALT 133, ALP 1204, total bilirubin 7.6 and direct bilirubin 6.9. CT abdomen revealed biliary ductal dilatation up to 2 centimeters with tapering at the ampulla and distal obstruction. MRCP revealed severe intra- and extrahepatic biliary ductal dilation and a T2 hypointense and T1 hyperintense mass adjacent to the distal common bile duct (CBD) near the pancreatic head. The patient underwent EGD with a side-viewing duodenoscope and EUS which revealed a dilated CBD without stones or hypoechoic mass. Instead, he was noted to have a large PAD with its lumen completely occluded by retained food. This was visualized as a round hyperechoic lesion on EUS. The major papilla could not be located, presumably located inside the PAD. A variety of endoscopic methods were then used to disimpact the debris, including rat tooth forceps, sphinctertome and water irrigation without much success. Eventually, carbonated beverage was injected through a sphinctertome into the diverticulum allowing for successful removal of debris and subsequent bilious drainage from the CBD. Following the procedure, the patient's transaminases and bilirubin normalized and he was safely discharged home. He continued to do well 3 months after treatment.Figure 1Figure 2Periampullary diverticula are associated with age and can be found in up to 27% of elderly patients. The clinical importance of these usually stems from the fact that cannulation during ERCP can be difficult in patients with anatomical distortion due to large PAD or when the papilla is located inside a diverticulum. Patients with PAD also have a higher incidence of choledocholithiasis. Our case demonstrates a rare cause of biliary obstruction where a PAD became occluded by food debris, eventually leading to painless jaundice mimicking malignancy. The case also highlights the utility of carbonated beverage in successfully resolving the occlusion.