Intraluminal Duodenal Diverticulum Research Articles

Imaging Findings of an Intraluminal Duodenal Diverticulum Associated with Adult Duodeno-Duodenal Intussusception and Recurrent Pancreatitis: A Case Report

Intraluminal duodenal diverticulum (IDD) is a rare congenital abnormality, consisting of a sac-like mucosal lesion in the duodenum. Cases of IDD can present with gastrointestinal bleeding, duodenal obstruction, or pancreatitis. Here, we report a rare case of a 25-year-old female presenting with IDD complicated by duodeno-duodenal intussusception and recurrent pancreatitis. The diagnosis was based on findings from radiologic examinations (CT and MRI), upper gastrointestinal series (barium swallow), and gastroduodenofiberscopy. Laparoscopic excision of the presumed duodenal duplication was performed. The subsequent histopathologic evaluation of the excised sac revealed normal mucosa on both sides, but the absence of a proper muscle layer confirmed the diagnosis of IDD. Radiologic detection of a saccular structure in the second portion of the duodenum can indicate IDD with duodeno-duodenal intussusception as the lead point.

Intraluminal duodenal “windsock” diverticulum

Intraluminal duodenal diverticulum (IDD) is a rare developmental anomaly usually found in the second portion of the duodenum. The cause appears to be a failure of recanalization of the occluded foregut lumen of the human embryo, resulting in a fenestrated mucosal membrane [1]. A small aperture in this diaphragm will gradually cause it to elongate caudally in response to duodenal peristalsis to form the so called “wind-sock” configuration. Symptoms are nonspecific and generally depend on the degree of duodenal obstruction; 25% of cases are associated with GI bleeding. In most documented cases, IDD was diagnosed radiologically, but the value of endoscopy for diagnosis and treatment has been amply demonstrated

Intraluminal duodenal “windsock” diverticulum; Case Report and discussion

Intraluminal duodenal diverticulum (IDD) is a rare developmental anomaly usually found in the second portion of the duodenum. The cause appears to be a failure of recanalization of the occluded foregut lumen of the human embryo, resulting in a fenestrated mucosal membrane [1]. A small aperture in this diaphragm will gradually cause it to elongate caudally in response to duodenal peristalsis to form the so called “wind-sock” configuration. Symptoms are nonspecific and generally depend on the degree of duodenal obstruction; 25% of cases are associated with GI bleeding. In most documented cases, IDD was diagnosed radiologically, but the value of endoscopy for diagnosis and treatment has been amply demonstrated.

A Case of Intraluminal Duodenal Diverticulum Treated by Curative Surgical Resection

A Case of Intraluminal Duodenal Diverticulum Treated by Curative Surgical Resection

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.

1338 A Rare Case of Duodenal Windsock Diverticulum; Simultaneous Biliary, and Small Bowel Obstruction

INTRODUCTION: Windsock intraluminal duodenal diverticulum (IDD) is rare congenital anomaly due to incomplete recanalization of foregut during embryogenesis. Most of the IDD are found incidentally and rarely cause symptoms. More common symptoms associated with IDD are nausea, abdominal pain and abdominal fullness. Rarely IDD can cause small bowel obstruction (SBO), pancreatitis and biliary obstruction. CASE DESCRIPTION/METHODS: This is the first reported case in literature of a windsock diverticulum causing SBO and biliary obstruction. A 44 year old man with no prior medical and surgical history presented to our hospital with acute onset abdominal pain, nausea, vomiting and inability to pass flatus or bowel movement for 3 days. Patient was clinically jaundiced and initial lab work up showed a total bilirubin level of 13.0 mg/dl. A CT abdomen and pelvis showed complete duodenal obstruction with suspected etiology of duodenal intussusception as well intra and extrahepatic biliary ductal dilatation (Figure 1). After NG decompression, patient underwent an upper endoscopy and small bowel enteroscopy with findings of a false lumen in second portion of duodenum showing focal areas of mucosal ulcerations but no intussusception was seen (Figure 2). An EUS was performed which did not show any intramural or extraluminal mass lesions. An ERCP was attempted for biliary obstruction but was unsuccessful due to lack of localization of ampulla of vater. Later during the endoscopic procedure, large amount of fresh bile flow was noted in the distal portion of duodenum. False lumen mucosal biopsies were reported negative for malignant cells. Patient's bilirubin level quickly and persistently trended down toward normal range post EGD. Clinically, his symptoms of bowel obstruction resolved completely. He underwent an upper GI series which showed contrast filling of large duodenal diverticulum which further confirmed the diagnosis of large windsock duodenal diverticulum (Figure 3). DISCUSSION: Windsock diverticulum is a true intraluminal diverticulum. In rare cases it can cause serious complications including SBO and biliary obstruction. ERCP can be challenging in case of ampullary proximity to diverticulum. Timely recognition and intervention is necessary for improved clinical outcomes. Endoscopic intervention for diagnosis and management is necessary. Endoscopic diverticulectomy can be a less invasive option for prevention of recurrence of IDD related complications especially especially in case of close proximity of ampulla to IDD.

1406 “Windsock” Duodenal Diverticulum Resulted in Recurrent Pancreatitis and Gastric Outlet Obstruction

INTRODUCTION: “Windsock” or intraluminal duodenal diverticulum (IDD) is a rare congenital abnormality caused by an improper luminal recanalization of the foregut during embryological development. Most patients are asymptomatic. We present a case of recurrent pancreatitis and gastric outlet obstruction (GOO) caused by IDD in a young man with chronic alcohol use. CASE DESCRIPTION/METHODS: A 30-year-old man presented with severe nausea, vomiting and abdominal pain and found to have a third episode of acute pancreatitis in one month. Medical history was notable for alcohol abuse. However the patient stated that his last drink was more than a month ago. Lipase on admission was 130 U/L and he was found to have acute kidney injury (AKI) with creatinine 4.1 mg/dL. Magnetic resonance imaging without contrast revealed severe gastroduodenal obstruction and acute pancreatitis with pancreatic head pseudocysts. Esophagogastroduodenoscopy revealed nearly complete obstruction of the second portion of duodenum that the scope could not traverse. The patient was managed for acute pancreatitis, resulting most likely from paraduodenal pancreatitis causing GOO. After 10 days of aggressive treatment, the patient's pancreatitis has clinically much improved with better relief of the abdominal pain and resolution of the AKI. However he remained obstructed as large volume was drained from the nasogastric tube. A subsequent abdomen and pelvis computed tomography (CT) revealed interval decrease of the cluster pseudocysts previously seen by the pancreatic head but showed a “windsock” duodenal diverticulum. With conservative management, parental nutrition, intravenous fluids and pain control, the patient was able to tolerate frequent small portions of regular diet on hospital day 23. He was then discharged for elective surgery and resection of the IDD. DISCUSSION: Patients with IDD may present with chronic non-specific symptoms such as epigastric pain, nausea, vomiting, post-prandial fullness or rarely acute complications such as obstruction, hemorrhage, or pancreatitis. Radiologic diagnosis by CT or upper gastrointestinal series shows a typical “windsock” appearance hence the name. Endoscopic diagnosis may be challenging as the diverticulum can collapse and be unnoticed, or be mistaken for a polyp or a mass. Surgery has been the mainstay of treatment. However endoscopic techniques have been described in recent literature. IDD should be considered in the context of unexplained duodenal obstruction or recurrent pancreatitis.

An incidental windsock diverticulum.

Key Clinical MessageWindsock diverticulum is a rare anomalous finding of a true intraluminal duodenal diverticulum. While complications of bowel obstruction, bleeding, and pancreatitis may occur, most patients are asymptomatic. Surgical or endoscopic management may be pursued when complications develop.

A Case of Intraluminal Duodenal Diverticulum Accompanied by Recurrent Pancreatitis

A Case of Intraluminal Duodenal Diverticulum Accompanied by Recurrent Pancreatitis

Surgical Management of Symptomatic Intraluminal Duodenal Diverticulum in an Adolescent.

Surgical Management of Symptomatic Intraluminal Duodenal Diverticulum in an Adolescent.

Novel endoscopic approach for a large intraluminal duodenal (“windsock”) diverticulum

Novel endoscopic approach for a large intraluminal duodenal (“windsock”) diverticulum

Pancreatic and biliary obstruction years after retention of a swallowed coin in a duodenal diverticulum: a case report

IntroductionCongenital duodenal diverticula are a rare anomaly. The discovery of one in association with an ingested foreign body has only been reported on one previous occasion. In this challenging presentation, the presence of the coin led to the correct diagnosis. Patients with congenital duodenal anomalies may present a number of associated abnormalities. Interestingly, after the discovery of his intraluminal duodenal diverticulum, we searched and found that our patient presented a number of associated pathologies, as described in the literature.Case presentationOur patient was a 36-year-old man, Caucasian, a kidney transplant recipient who presented with abdominal pain, vomiting and fever after an episode of pancreatitis. Because of a history of behavioral problems associated with intellectual impairment, including a compulsion to swallow coins during childhood, an abdominal radiograph was performed. Surprisingly, the radiograph revealed a radiopaque shadow in the central abdominal area. The findings of the ultrasound examination and computed tomography scan were suggestive of dilated biliary and pancreatic ducts. We performed an endoscopic retrograde cholangiopancreatography, which led to confirmation of the suspected coin above an obstructing intraluminal duodenal diverticulum with associated biliary ductal dilation. Upon retrieval of the coin, it was found to be a 1975 copper two-cent piece out of circulation in Australia for a large number of years.ConclusionsForeign body retention in the gastrointestinal tract in an adult could be a sign of underlying mechanical pathology. Intraluminal duodenal diverticulitis can have a varied presentation, including life-threatening complications. Awareness should be raised of the conditions associated with congenital duodenal anomalies in adults, including renal, hepatobiliary and cardiac defects, many of which were present in our case.

1007 Novel Endoscopic Approach for a Large Intraluminal Duodenal (“Windsock”) Diverticulum

A 59 yr-old female presents for evaluation of recurrent acute pancreatitis. She has had three documented episodes over 8 yrs and is status post cholecystectomy. She has a longstanding history of foregut symptoms. She had undergone multiple EGDs and no abnormality was identified. Investigations demonstrated a dilated CBD with no mass lesion. We arranged an EUS and if no abnormality was seen, an ERCP with biliary sphincterotomy would be performed for papillary stenosis. At attempted ERCP, a structure was identified that was in the correct location for the major papilla but was odd in appearance. This was subsequently found to be a large intraluminal duodenal diverticulum, otherwise known as a “windsock” diverticulum. This is a congenital abnormality characterized by a septum across the duodenal lumen and can be missed at endoscopy. This has been known to cause pancreatitis. In this patient, the apex of the duodenum had an opening and this is not uncommon in those with a longstanding diverticulum. Management approaches include a surgical or endoscopic strategy. With regards to an endoscopic approach, multiple modalities are available with no consensus as to which accessory is best. The objectives of this video are to demonstrate a novel endoscopic technique to obliterate a symptomatic intraluminal duodenal septum.

Intraluminal Duodenal Diverticulum: CT and Gadoxetic Acid-Enhanced MRI Findings

Intraluminal duodenal diverticulum (IDD) is a rare congenital abnormality consisting of a sac-like mucosal projection in the second portion of the duodenum, in close proximity to the ampulla of Vater. Although the majority of cases are asymptomatic, symptomatic IDD may result in pancreatitis, cholangitis, peptic ulcer disease, gastrointestinal bleeding, and intestinal obstruction (1). We present a case of IDD mimicking duodenoduodenal intussusception, diagnosed by computed tomography (CT) and gadoxetic acid-enhanced magnetic resonance imaging (MRI) without surgical correction.

Intraluminal duodenal diverticulum in a child concomitant with an entrapped coin and a duodenal polyp

Summary Intraluminal duodenal diverticulum (IDD) is a rare congenital anomaly. We present the report of an 8-year-old girl who had an entrapped coin in an IDD for 3 years that was associated with recurrent pancreatitis. Besides, a duodenoduodenal intussusception was found during the course of investigation and it seemed that a concomitant duodenal polyp contributed to the development of the intussusception. In view of the rarity of each of the aforementioned situations and the improbability of these conditions occurring together, this unusual and possibly unique case is therefore reported here.

Intraluminal duodenal diverticulum treated with an endoscopic procedure

Intraluminal duodenal diverticulum treated with an endoscopic procedure

Impaction of food material wrapped in a plastic sheet in a huge intraluminal duodenal diverticulum

Journal of Advances in Internal Medicine 2013;02(01):14-15 DOI: http://dx.doi.org/10.3126/jaim.v2i1.7631

Intraluminal duodenal diverticulum with refractory pancreatitis successfully treated by endoscopic diverticulectomy

Figure S1 Duodenographic findings of intraluminal duodenal diverticulum (IDD). Duodenography revealed a 4-cm barium stagnation framed by a clear and smooth translucent line, suggesting no dysplastic change in the pocket-like lesion (arrowheads). Figure S2 Histological findings. The histological findings of the removed specimen showed a sandwich-like appearance with a submucosal layer between two mucosal layers. Table S1 Reported cases of intraluminal duodenal diverticulum treated by endoscopic procedure. Video S1 Endoscopic diverticulectomy using a two-channel endoscope. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Intraluminal Duodenal Diverticula: Collective Review with Report of a Laparoscopic Excision

A comprehensive review of intraluminal duodenal diverticulum (IDD) is presented, along with a report of a completely laparoscopic excision of this duodenal abnormality as well as a report of magnetic resonance cholangiopancreatography demonstrating the classic fluoroscopic "wind sock sign" pathognomonic appearance of IDD. IDD may easily be missed unless one specifically considers this entity in patients presenting with symptoms of foregut disease. Patients with IDD typically present in the fourth decade of life with duration of symptoms less than 5 years that typically include pain, nausea and vomiting, pancreatitis, and gastrointestinal bleeding. Diagnosis usually requires imaging studies and upper gastrointestinal endoscopy. Laparoscopic excision is recommended because of superior visualization of significant intestinal anatomic abnormalities, the need for accurate ampullary localization, and the ability to facilitate complete diverticular excision while maintaining biliary and pancreatic ductal integrity. Review of surgical literature suggests that IDD results from congenital duodenal developmental abnormalities matured by long-term duodenal peristalsis.

Endoscopic treatment of intraluminal duodenal (“windsock”) diverticulum: varying techniques from five cases

The optimal endoscopic approach to intraluminal duodenal diverticulum (IDD) has not been established. We report on our experience of endoscopic resection of symptomatic IDD in five patients (three men, two women; mean age 37 years) who were treated between August 2004 and April 2012. Four patients underwent endoscopic diverticulectomy using a standard polypectomy snare. Following diverticulectomy, the remaining duodenal septum was incised using a needle-knife in two patients. The fifth patient underwent endoscopic diverticulotomy using a needle-knife. In four cases the IDD was resected and reviewed histologically and demonstrated substantial vascularity. All patients developed clinically significant, post-procedural bleeding, which was managed endoscopically. Endoscopic management of symptomatic IDD can be achieved using various approaches. Post-procedural bleeding appears to be a common adverse event, but this complication can be managed endoscopically.