Duodenal Diverticulum Research Articles

S1416 A Not so Simple Case of Obstructive Jaundice

INTRODUCTION: Lemmel syndrome is a rare cause of obstructive jaundice caused by a duodenal diverticulum compressing the intra-pancreatic part of the common bile duct with resultant dilation of the extra-and intrahepatic bile ducts. In our case, we present a patient with suspected Lemmel syndrome after a difficult diagnostic workup, demonstrating the importance of a broad differential when approaching jaundice. CASE DESCRIPTION/METHODS: We present a 50-year-old Caucasian male with a history of EtOH abuse, necrotizing pancreatitis s/p laparoscopic cystogastrostomy, obesity, and cholecystectomy. The patient presented with a four-day history of sharp, epigastric pain associated with nausea, non-bloody vomiting, and lethargy. The patient stated the symptoms were similar to those related to prior episodes of necrotizing pancreatitis and admitted to drinking 16 cans of beer per day for the past four months. Physical examination revealed diffuse jaundice, scleral icterus, and right upper quadrant tenderness. Initial laboratory findings included platelets 86 × 109/L., total bilirubin 13.52 mg/ dL, AST 900 U/L, ALT 266 U/L, ALP 456 U/L and GGT 11180 U/L. Right upper quadrant ultrasound noted patent portal and hepatic veins. Magnetic resonance cholangiopancreatography (MRCP) was performed. It noted a 1.7 cm mildly high T1 lesion medial and contiguous with the second portion of the duodenum, possibly representing a duodenal diverticulum. The common bile duct was dilated with abrupt narrowing/cut off at the level of the second portion of the duodenum. The findings were suggestive of Lemmel syndrome, and to be confirmed by ERCP. DISCUSSION: This case illustrates the importance of maintaining a broad differential diagnosis and also brings awareness to a rare potential etiology of jaundice. The patient's excessive alcohol intake made acute alcoholic hepatitis the most likely initial suspected etiology of the patient’s jaundice. However, the continued elevation of transaminases and hyperbilirubinemia necessitated additional investigative studies. Imaging suggested the rare disorder known as Lemmel syndrome. Lemmel syndrome is caused by a periampullary duodenal diverticulum compressing the intra-pancreatic part of the common bile duct. This disorder should be considered in patients presenting with obstructive jaundice without malignancy or choledocholithiasis. Delayed identification can lead to unnecessary diagnostic testing, recurring symptoms, frequent hospital visits, and an increase in morbidity and mortality.Figure 1.: MRCP Findings.

S3379 Acute Renal Failure in a Patient With Salmonella Gastroenteritis

INTRODUCTION: Salmonella is a common cause of gastroenteritis worldwide. Typically, this condition is self-limited, and resolves within seven to ten days without severe complications. However, patients with CKD are susceptible to developing acute renal failure. This has been attributed to shock, dehydration, or rhabdomyolysis as well as immunologic mechanisms. Our case follows a patient who developed Salmonella gastroenteritis prior to hospital admission and presented with severe dehydration and decreasing urinary output. Although the patient’s renal function and diarrhea resolved after aggressive fluid resuscitation, it is crucial to initiate early treatment and to be cognizant of the potential of co-morbidities associated with Salmonella gastroenteritis. CASE DESCRIPTION/METHODS: A 77 year old female with a past medical history of CKD IV, type II DM, HTN presented to the emergency department with a chief complaint of abdominal pain along with 5 to 6 diarrheal episodes for the preceding week. Symptoms started after eating a hamburger at a restaurant. The patient also endorsed a fever, decreased oral intake and urinary output for the three days prior to the emergency department visit. At admission, labs revealed a BUN/Cr of 86/10.63 with a GFR of 3. CT abd/pelv w/out contrast revealed a distended gallbladder with a small gallstone, duodenal diverticulum, and fluid in the colon reflecting a diarrheal state. Aggressive rehydration was initiated and stool studies were obtained. Nephrology consultation was placed for further evaluation. During the first two days of admission, the patient remained oliguric with < 1L of output. A temporary trialysis catheter was placed in preparation for hemodialysis on day two of admission, however the patient was unable to undergo dialysis due to clot formation in the catheter. At that time, the patient’s diarrhea continued and she was treated with Lomotil along with continued hydration with renal function steadily improving. On day six of admission, stool studies resulted revealing Salmonella enterica. As the patient was afebrile and showed clinical improvement, no antibiotics were initiated. On day eight, the patient was discharged, with plan for outpatient Nephrology follow up. Labs revealed a BUN/Cr of 49/2.16 with a GFR of 23.0 on day of discharge. DISCUSSION: Initiating early aggressive rehydration may help to reduce significant co-morbidities associated with the development of renal pathology in Salmonella infection and to avoid the need for hemodialysis and further workup.

S1849 Intraluminal Duodenal Diverticulum: Double Barrel Lumen Treated With Water Immersion Septotomy and Endoscopic Mucosal Resection

INTRODUCTION: Intraluminal duodenal diverticulum (IDD) is a rare congenital condition caused by incomplete recanalization of the foregut. Surgical diverticulotomy was historically used to treat patients with symptomatic IDD. Underwater septotomy and endoscopic mucosal resection (EMR) present a minimally invasive approach to relieve an obstructing IDD lesion. Our case report demonstrates effective management of IDD with underwater septotomy and EMR. CASE DESCRIPTION/METHODS: A 78-year-old male presented with progressive chronic post-prandial nausea and bloating associated with early satiety and substernal heartburn that was only moderately relieved with proton pump inhibitor therapy. Initial esophagogastroduodenoscopy (EGD) revealed post-bulbar duodenal stricture and symptoms persisted following balloon dilation. Repeat EGD showed IDD with double barrel lumen of the duodenal mucosa. Due to persistent symptoms, the decision was made to intervene on the obstructive IDD. The IDD was visualized in the second part of the duodenum. The obstructing lesion was tented back to visualize the septum, which was injected with saline-methylene blue lifting agent. Initial limited EMR was performed via snare excision to debulk diverticular tissue. Next, underwater septotomy was performed with a 20-mm snare tip. EMR of the lesion was then completed and the lesion was removed by snare. The mucosal defect closed with six endoscopic clips to achieve hemostasis. The next day, the patient developed gastrointestinal bleeding due to a visible vessel and hemostasis was again achieved with 7 French gold probe cautery and one additional endoscopic clip. DISCUSSION: Underwater septotomy and EMR successfully relieved obstruction due to IDD. Snare tip for septotomy was an effective alternative to needle knife and preserved resources by employing tools already being used for EMR. Underwater approach allowed for clear visualization due to minimal electrosurgical smoke production and potentially reduced risk of perforation compared to insufflation. This case highlights the use of underwater septotomy and EMR as minimally invasive management for obstructing IDD lesions.

S1580 Gallstone Ileus in a 67-Year-Old Male

INTRODUCTION: There are several causes of small bowel obstructions. About 4% of all cases of mechanical intestinal obstructions are caused by gallstones. This increases to 25% in the elderly (age > 65 years) with a heavy female predominance (male:female ratio 3.5:6.0). This clinical vignette presents a case of gallstone ileus in a 67 year old male and aims to increase the priority of gallstone ileus on the differential list due to suspicion of an increase in prevalence of this condition. CASE DESCRIPTION/METHODS: 67M presents with 4.5 hours of sharp periumbilical and epigastric pain that has been progressively worsening and associated with intermittent spasms. Pt denies previous abdominal surgeries and no reported history of gallbladder issues. Physical exam revealed generalized tenderness most prominent in the epigastric, RUQ and periumbilical region with rebound tenderness. No distension, rigidity or guarding were noted. Abdominal CT revealed mild small bowel dilatation and inflammation. Pt was admitted for an SBO and initially managed conservatively. Pt's symptoms continued to worsen such that he vomited 4000 cc of bilious emesis and NGT output was 2600cc in 24 hours. He was not passing flatus or having BMs. Surgery decided to proceed with an exploratory laparotomy. Intraoperatively, pt was found to have a loop of bowel in the mid jejunum that was twisted, dilated and associated with patchy necrosis. A 3 cm stone was noted just distal to this segment and was causing a complete SBO with transition zone. The source of the stone was felt to be of gallbladder origin. However, gallbladder was contracted and firm without inflammation. No portal vein gas was noted on CT, but there was not another source seen for the stone. No large duodenal diverticulum based on CT. GI recommended a CT enterography, which revealed intraluminal gallbladder air that may relate to a biliary enteric fistula. Thickening of the first portion of the duodenum that made contact with the gallbladder was also noted. DISCUSSION: Prevalence of gallstone ileus may be increasing, and the ratio between males and females may be more evenly distributed than prior. Two subsequent cases of gallstone ileus in males were seen at the same hospital in the following months. It will be beneficial to have this condition higher on the differential list in patients presenting with a bowel obstruction. Patients over the age of 65 found to have asymptomatic gallstones may benefit from elective cholecystectomy to prevent gallstone ileus and its complications.Figure 1.: Three centimeter gallstone with segment of mid-jejunum removed intra-operatively.Figure 2.: Intraluminal gallbladder air noted on CT enterography.Figure 3.: Thickened first portion of the duodenum along the right lateral aspect which contacts the gallbladder.

S1386 Periampullary Duodenal Diverticulitis and Common Bile Duct Stricture

INTRODUCTION: Periampullary duodenal diverticula (PAD) are frequently asymptomatic but in rare cases can cause diverticulitis, diverticular bleed, obstructive jaundice, cholangitis, acute pancreatitis or recurrent acute pancreatitis. We present a case of periampullary diverticulitis with common bile duct (CBD) stricture. CASE DESCRIPTION/METHODS: A 45-year-old woman with no past history presented with nausea, vomiting and post-prandial upper abdominal pain. Her physical exam was significant for right upper quadrant tenderness. Initial labs showed WBC 15.6 k/mm3, lipase 436 U/L, AST 64 U/L, ALT 246 U/L, alkaline phosphatase 244 U/L and total bilirubin 2.8 mg/dL. Imaging of the abdomen revealed a dilated biliary tree of 1.2 cm, duodenal wall thickening and adjacent fat stranding. She was started on antibiotics. Endoscopic retrograde cholangiopancreatography (ERCP) showed periampullary duodenal diverticulitis with large amounts of pus extruding adjacent to the ampulla. Cholangiogram revealed distal CBD stricture, and dilated common, left and right hepatic ducts. Biliary sphincterotomy was performed, the stricture was brushed and a plastic CBD stent was placed. Her symptoms resolved and her abnormal lab parameters resolved. Cytology from the brushing was negative for malignancy. Magnetic resonance imaging was done and showed normal pancreas. Repeat ERCP seven months later revealed a persistent stricture spanning the distal half of the CBD - brushings were obtained and a stent was placed. Repeat brushings were negative for malignancy, her tumor markers were within normal limits and the patient is waiting for hepatobiliary surgery intervention for the stricture. DISCUSSION: PADs are frequently found during endoscopic evaluation and studies suggest a prevalence of up to 23%. PAD can be a hindrance to cannulation with reported cannulation rates of 61-95% and complications of ERCP did not differ between patients with and without PAD. Our case highlights the importance of recognizing duodenal diverticulitis in the differential diagnosis of cholangitis. In most cases of diverticulitis, antibiotics and sphincterotomy are sufficient to relieve the obstruction and treat the infection. The case presented highlights a persistent stricture as a consequence of extensive scarring from periampullary duodenal diverticulitis. Despite initial management with antibiotics, sphincterotomy and stent placement, some cases require surgical intervention.Figure 1.: Cholangiogram showing stricture spanning the distal half of the CBD.Figure 2.: ERCP showing periampullary duodenal diverticulitis.

Small bowel obstruction secondary to gallstone migration from duodenal diverticulum after gastric bypass.

Small bowel obstruction secondary to gallstone migration from duodenal diverticulum after gastric bypass.

Precautionary Measures: Performing ERCP on a Patient With Juxtapapillary Duodenal Diverticula (JPDD)-Related Biliary Stone After COVID-19 Lockdown Restriction Lifted in Wuhan, China

On April 8, 2020, after nearly 3 months of battling against the outbreak of COVID-19, Wuhan, where the pandemic began, began easing lockdown restrictions. However, given that asymptomatic carriers could continue to lead to transmission of COVID-19 during the very early stages, the endoscopists have taken precautions and conduct risk assessments to perform endoscopic intervention in this transition stage. Here, we have reported an urgent ERCP in a patient with acute pancreatitis secondary to JPDD-related biliary stone. Based on our experiences, the objective is to provide practical suggestions for the safe resumption of ERCP procedures in the setting of the COVID-19 pandemic with specific focus on patient risk assessment, personal protection equipment (PPE), and dress code modalities, all of which have been implemented in our hospital to reduce the risk of viral transmission.

Proposed Classification of Periampullary Diverticulum and its Role on Performing ERCP and Post ERCP Complication

Introduction: Duodenal diverticula are pouches of the mucosa, submucosa, and scattered muscle cells that extend through the intestinal wall. In this study, we aimed to classify the papilla position according to presence of PAD and evaluate the impact of papilla position on the success rate and post ERCP complication in the patients with PAD. Methods: This cross-sectional study was performed on 1260 patients with bile duct problems underwent ERCP. Patients with diverticulum were considered as the first group and the patients without diverticulum as the second group. In this study, SPSS Version 18 software, Chi-square and Students T-test were used, respectively. Results: 239 patients had peripheral diverticula. The mean age of participants was 68.9±10.3. In 239 patients with diverticulum Type 1=48.2%, Type 2 =37.6%, Type 3 =5.1%, Type 4 =9.1% the success rate in Type 1 was 97% (p-value: 0.003). In the patients with type 3, the cannulation was difficult and had a low success rate, with more complications. Conclusion: Classification of PAD can predict success rate in the patients with PDA, and can predict post ERCP complication rates.

Acute duodenal obstruction secondary to intussusception caused by the duodenal diverticulum: a case report

BackgroundThe duodenal intussusception is rarely reported and usually occurs secondary to organic diseases of the duodenum such as polyps, tumors and duplication cysts. Herein we report a case of duodenal intussusception caused by duodenal diverticulum.Case presentationA 21-year old male patient presented with abdominal pain and vomiting for one day. A contrast enhanced computed tomography of the abdomen revealed duodenal intussusception. On emergency laparotomy, the intussusception had reduced spontaneously while an invaginated diverticulum was seen at the junction of the descending and horizontal segments of the duodenum. The diverticulum was resected and the patient had uneventful recovery.ConclusionDuodenal intussusception is a rare complication of duodenal diverticulum. Being aware of this complication of diverticulum can help in timely diagnosis and treatment.

Hemorragia digestiva alta y divertículo duodenal. Reporte de un caso

Bleeding duodenal diverticulum is an infrequent pathology in need of emergency treatment due to its high mortality. We present the clinical case of a 72-year-old patient with multiple comorbidities, who was admitted with upper gastrointestinal bleeding, abdominal pain and hemodynamic instability. Once hemodynamic stability was achieved, upper digestive endoscopy was performed, showing duodenal diverticulum in the upper knee with bleeding in the fundus, performing hemostatic control. CT was requested: at the level of the upper duodenal knee, wide base diverticulum. Surgery was scheduled for the high risk of new bleeding. In surgery, cholecystectomy and diverticulectomy were performed laparoscopically with mechanical suture. Anatomopathological report: duodenal wall with parietal thinning of the duodenum, suggestive of diverticulum by pulsion. The discharge was granted with radiological control on the 3rd postoperative day. The aim of this case is to show the importance of endoscopic resolution of urgency and subsequent laparoscopic management in a patient with important risk factors, evidencing the short hospital stay without postoperative complications.

Perforated duodenal diverticulum successfully treated with a combination of surgical drainage and endoscopic nasobiliary and nasopancreatic drainage: a case report

BackgroundPerforation of a duodenal diverticulum is a rare complication that may become fatal with a delay in appropriate treatment. However, the optimal treatment for perforated duodenal diverticulum remains controversial, ranging from conservative therapy to surgery including pancreatoduodenectomy.Case presentationThe patient was a 60-year-old woman with no particular medical history who visited our hospital with chief complaints of continuous fever and right dorsal pain. Upon arrival, she had tenderness in the right upper quadrant of the abdomen. Laboratory data showed the elevation of inflammatory markers. Computed tomography revealed free air with abscess formation around the duodenum, which was diagnosed as duodenal perforation with abdominal abscess. We decided on emergent surgery, and we identified the perforation site on the dorsal side of the second portion of the duodenum intraoperatively. However, the inflammation around the perforation site was severe, and it was difficult to perform primary closure or dissection of the perforated diverticulum. Therefore, we finished surgery by placing four indwelling intra-abdominal tubes. Since postoperative day (POD) 1, the elevation of inflammation markers appeared to be uncontrollable, owing to the leakage of bile and pancreatic juice. We decided to perform endoscopic retrograde cholangiopancreatography on POD 2, and inserted endoscopic nasobiliary drainage and nasopancreatic drainage tubes. The patient showed a good postoperative course and was discharged on POD 57.ConclusionsEndoscopic nasobiliary and nasopancreatic drainage in combination with surgical drainage may be an effective treatment for perforated duodenal diverticulum.

Evaluation of juxtapapillary duodenal diverticula using multiplanar reformation in MDCT: correlation with ERCP findings.

To determine the ability of multidetector computed tomography (MPR-MDCT) to identify and classify the juxtapapillary duodenal diverticulum (JPDD), with ERCP findings as the gold standard. We retrospectively reviewed all ERCP examinations (n: 455) performed between January 2010 to December 2018 and selected 105 patients with JPDD as the inclusion criteria. Of those, 28 patients were excluded because of advanced pancreatic carcinoma, incomplete MDCT examinations and biliary catheter insertion. Finally, MDCT examinations of 77 patients with JPDD were assessed for the presence and type of JPDD. MPR-MDCT was able to identify 71 (92.2%) JPDD in 77 cases with 88.9% accuracy, 83.3% sensitivity, and 91.6% specificity in classifying the type of JPDD. MPR-MDCT performed best in determining type 1 JPDD, with accuracy of 95.4% compared with type 2 (83.3%) and type 3 (87.8%). There was no significant difference between age, gender, incidence of biliary stones and pancreatitis between each type of JPDD. No correlation of sizes with types of JPDD was found. MPR-MDCT can accurately identify and classify JPDD. This information will be useful in determining the difficulty of ERCP.

Endovascular treatment of bleeding ulcer in a duodenal diverticulum fed by right hepatic artery

Endovascular treatment of bleeding ulcer in a duodenal diverticulum fed by right hepatic artery

The challenging diagnosis and treatment of duodenal diverticulum perforation: a report of two cases

BackgroundThe duodenum is a common site for diverticulum formation. Most of the duodenal diverticula are asymptomatic, incidental findings. Perforation is a rare but potentially lethal complication of duodenal diverticular disease. Surgery remains the mainstay of treatment for perforated duodenal diverticula. In recent years, a few cases were successfully managed either conservatively or with endoscopy.Case presentationWe present two cases of female patients treated in our department for duodenal diverticulum perforation. The first case was treated surgically with a diverticulectomy. The second case was managed conservatively with bowel rest and intravenous antibiotics. Both patients had an uncomplicated postoperative course and were discharged home.ConclusionsBoth surgical and conservative treatments are viable options for a perforated duodenal diverticulum in selected patients. Patients with a contained duodenal diverticular perforation can be managed conservatively at the outset. Possibly, the introduction of a classification system for duodenal diverticulum perforation may help clinicians in making essential therapeutic decisions.

DIAGNOSTIC ACCURACY OF MRCP IN EVALUATION OF PERIAMPULLARY DUODENAL DIVERTICULA – PROSPECTIVE STUDY

Background and Objectives: Duodenal diverticula are a common finding in patients with biliary tract disorders. The objective of this study is to assess the diagnostic value of the magnetic resonance cholangiopancreatography (MRCP) in case of periampullary duodenal diverticula (PAD) using endoscopic cholangiopancreatography (ERCP) as a reference method. Methods: The study population included 350 patients with known or suspected diseases of the biliary tract, liver, and pancreas. Two radiologists interpreted the image quality and the presence of PAD in agreement . Results: In cases with a single PAD, MRCP had sensitivity 81.2%, specificity 98.6%, positive predictive value 90.9%, and negative predictive value 97%, compared to ERCP. In the case with two PAD, MRCP had sensitivity 40%, specificity 99.7%, positive predictive value 66.7% and negative predictive value 98.9%. The average volume of PAD was 3.25 cm3. In this study group patients with PAD were on average 10 years older than those without PAD (&lt; 0.001). There was also found a significant association of PAD with choledocholithiasis (p = 0.009) and cholecystitis (p = 0.002). Interpretation and Conclusions: In conclusion, MRCP could be used as a non-invasive diagnostic modality with acceptable sensitivity and specificity in patients with suspected PAD and biliary tract diseases.

Duodenal diverticulum causing obstructive jaundice - Lemmel's syndrome.

The duodenum is the second most common location of intestinal diverticula. Periampullary duodenal diverticulum rarely causes obstructive jaundice and this condition was first described by German surgeon Gerhard Lemmel in 1934. Lemmel's syndrome is defined as obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledocholithiasis or a neoplasm.

Endoskopik Stentleme Yöntemi ile Tedavi Edilen Duodenal Divertikül Perforasyonu: Olgu Sunumu

Endoskopik Stentleme Yöntemi ile Tedavi Edilen Duodenal Divertikül Perforasyonu: Olgu Sunumu

Lemmel syndrome: an uncommon complication of periampular duodenal diverticulum.

Lemmel's syndrome consists of obstructive jaundice due to compression of a periampular duodenal diverticulum (DDP), in the absence of choledocholithiasis or tumor. DDP are pseudodiverticula without a muscle layer within a radius of 2-3 centimeters from the ampulla of Vater. They rarely cause obstructive jaundice, although the prevalence is estimated at up to 22 % according to the sensitivity of the diagnostic test. They are usually incidental findings, but up to 1-5 % can be complicated with diverticulitis, bleeding, perforation, obstructive jaundice (Lemmel syndrome), choledocholithiasis, pancreatitis or cholangitis.

Diagnostic performance of 64-MDCT in detecting ERCP-proven periampullary duodenal diverticula.

To determine the diagnostic performance of 64-slice multidetector computed tomography (64-MDCT) in detecting periampullary duodenal diverticula. Medical profiles of 120 endoscopic retrograde cholangiopancreatography (ERCP)-proven patients with (n = 100) and without (n = 20) periampullary duodenal diverticula who had undergone 64-MDCT were retrospectively reviewed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 64-MDCT in detecting periampullary duodenal diverticula were calculated. Potential factors that might influence the diagnostic performance of 64-MDCT in such patients were also examined. Patients were 60 males and 60 females with the mean age of 68.8 ± 12.7 (27-93) years. Indications of ERCP were common bile duct stricture (n = 62) or stone (n = 41), biliary cholestasis (n = 16) and acute cholangitis (n = 1). The sensitivity, specificity, PPV, and NPV of 64-MDCT in detecting periampullary duodenal diverticula were 76%, 100%, 100%, and 45.5%, respectively. The size of diverticula was the only predictor of 64-MDCT performance, with better results observed in larger (> 20mm) diverticula. 64-MDCT is a highly specific imaging modality in detecting periampullary duodenal diverticula. The diagnostic performance of 64-MDCT increases for larger diverticula.

Assessment of Duodenal Diverticula: Computed Tomography Findings.

To demonstrate the prevalence, accompanying pathologies, imaging and follow up findings of Duodenal Diverticula (DD) with Multidetector Computed Tomography (MDCT). Consecutive 2910 abdominal MDCTs were retrospectively reviewed on axial, coronal and sagittal planes. DD were evaluated for prevalence, location, number, size, contents, diverticular neck, accompanying pancreaticobiliary pathologies, jejunal and colonic diverticula, respectively. DD were diagnosed in 157 cases (5.4%) and found mostly in the second part of the duodenum. Juxta-ampullary DD was the most common type (78.3%) and mostly located ventral (n:86, 69.9%) to the ampulla of Vater. DD was solitary in 123 patients (78.3%) and more than one in 34 patients (21.7%). The median diameter of DD was 2.5 cm (range 1.5-3.6 cm) in the long-axis. The lumen of DD contains air and contrast agent (n:96, 61.1%); air, contrast agent and debris (n:42, 26.7%) in most cases. Colonic diverticula (n:36, 22.9%), cholelithiasis (n:32, 20.4%), choledocholithiasis (n:7, 4.4%), and biliary dilatation (n:8, 5.1%) were the most common additional findings. Median follow-up time was 23 months (range 11 to 41 months). In three cases, new findings (cholelithiasis, n:3, choledocholithiasis, n:1) were detected. Accompanying pathologies with DD diagnosis are valuable for physicians in order to manage the patients. Following clinical and radiological features of well-diagnosed DD might reduce the possible complications.