Periampullary Duodenal Diverticula Research Articles

Pancreatic panniculitis associated with periampullary duodenal diverticulum

Introduction. Pancreatic panniculitis (PP) is a rare type of lobular panniculitis that manifests as painful erythematous nodules on the skin of the lower extremities. Subcutaneous fat necrosis caused by the release of pancreatic enzymes is the underlying cause of the disease, affecting around 2?3% of patients with pancreatic diseases. Case report. We present a case of a 58-year-old male patient who was admitted to our clinic due to the appearance of painful erythematous nodules on the lower extremities and trunk. Laboratory results revealed increased levels of pancreatic enzymes, amylase, and lipase, as well as heightened levels of glucose and inflammation markers. The histological analysis of the skin lesion biopsy revealed the presence of predominantly lobular panniculitis in the hypodermis, with areas of fatty tissue necrosis/saponification and remnants of adipocytes (?ghost cells?). Abdominal computed tomography scan demonstrated peri-ampullary diverticulum (PD) of the duodenum, with no signs of pancreatitis or other pancreatic abnormalities. Esophagogastroduodenoscopy showed a wide opening of PD in the D2 segment of the duodenum. The patient was successfully treated with pancreatin therapy, resulting in a significant reduction of skin lesions and decreased levels of pancreatic enzymes. Conclusion. Duodenal PDs can be the cause of PP, most likely due to the pressure they exert on the pancreatic duct, which can lead to elevated values of pancreatic enzymes. Depending on the individual characteristics of the patient, symptomatic duodenal PD may be treated with operative or non-operative measures. Treatment of PP primarily involves addressing any underlying medical condition.

S3439 Lemmel Syndrome Due to Periampullary Diverticular Food Impaction

Introduction: Lemmel Syndrome is a rare cause of mechanical biliary obstruction attributed to periampullary duodenal diverticula (PAD). It was first described in 1934 as obstructive jaundice in the absence of biliary stones or malignancy. The majority of PAD are asymptomatic, however, about 5% have symptomatic disease. We present a symptomatic case. Case Description/Methods: An 80-year-old woman with history of cholecystectomy, coronary artery disease, hypertension, and diabetes was transferred from a free-standing emergency room for acute pancreatitis. She had a one day history of postprandial epigastric pain with radiation to the back. Labs on presentation included lipase above 4000 U/L, BUN 27 mg/dL, AST 316 U/L, ALT 422 U/L, ALP 292 IU/L, total bilirubin 0.6 mg/dL. Abdominal ultrasound revealed 12mm common bile duct (CBD) with intrahepatic ductal dilatation. MRCP showed intra and extrahepatic biliary ductal dilatation with dilated pancreatic duct and a 3.6 cm fluid filled periampullary diverticulum. ERCP showed a large periampullary duodenal diverticulum with food impaction causing obstruction of the ampullary orifice which was removed with forceps. Cholangiogram revealed dilation of pancreatic, common bile, and intrahepatic ducts without any filling defects. Patient improved and was discharged home. (Figure) Discussion: The incidence of duodenal diverticula is approximately 17% with PAD being the most common type. PADs are pseudo-diverticula most commonly found in the second part of the duodenum and they pose a cannulation challenge during ERCP with an increased risk of complications. PAD in the setting of biliary obstruction is known as Lemmel Syndrome. It can cause biliary obstruction by sphincter of Oddi dysfunction, direct obstruction, or via external compression by fluid or material-filled PAD. In our case, there was biliary compression due to a food-filled PAD. Cross sectional imaging is critical for diagnosis, however, ERCP is the gold standard. Several therapeutic modalities including endoscopic extraction of entrapped food or stones, extracorporeal shock wave lithotripsy, and laparoscopic diverticulectomy have been used. Our case required endoscopic extraction of diverticular food debris and adds to the limited published cases to date. Lemmel Syndrome requires a high index of suspicion when a PAD is found in the setting of biliary obstruction.Figure 1.: A. MRCP image showing a large periampullary diverticulum packed with debris. B. ERCP image of food impacted inside periampullary diverticulum. C. MRCP image demonstrating a dilated common bile duct in absence of choledocholithiasis.

Endoscopic ultrasound examination of the intrapancreatic pancreatobiliary ducts using the gel immersion method in patients with periampullary duodenal diverticula.

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Biostatistics in Clinical Decision Making What can We Get from a 2×2 Contingency Table

Biostatistics is an essential part when making clinical decisions. Applications of 2×2 contingency tables playing a key role in conducting analysis involving binary variables. When it comes to analysis based on 2×2 contingency tables, most people are familiar with the concept of sensitivity and specificity for evaluating a new test, but predictive values and receiver operating characteristic (ROC) curves would also provide information. Besides, Odds Ratio (OR), Risk Ratio (RR), and Chi-square test are measures based on 2×2 tables and commonly applied in retrospective and prospective studies. This article will first review the two kinds of application of 2×2 contingency tables, evaluating a new test compared with a reference standard, and exploring the relationship of exposures and outcomes in retrospective or prospective studies. Two clinical examples are presented to demonstrate these basic biostatistical concepts: diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) to identify periampullary duodenal diverticula, and a randomized clinical trial (RCT) to examine the effectiveness of Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery. Correctly understanding these concepts will assist clinicians and medical researchers to analyze the data and interpret the results, and therefore make accurate decisions in clinical practice.

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.

S2146 Rare Presentation of a Bleeding Arteriovenous Malformation Within a Periampullary Duodenal Diverticulum

INTRODUCTION: The incidence of duodenal diverticula (DD) is reported between 0.16% and 23% in the literature, depending on the method of diagnosis, with more than 60% arising in the second part of the duodenum. Though typically asymptomatic, various complications including pancreatitis, diverticulitis, duodenal obstruction, and bleeding have rarely been reported in the literature. We present a case of melena that was initially thought to be due to epistaxis in the setting of a supra-therapeutic INR, and was later found to be secondary to an arteriovenous malformation (AVM) within a periampullary DD. CASE DESCRIPTION/METHODS: A 72-year-old male with a history of metastatic renal cell carcinoma status-post nephrectomy, aortic stenosis, end-stage renal disease on peritoneal dialysis, and atrial fibrillation on Coumadin presented with subacute epistaxis and melena. Abdominal exam was unremarkable, and labs were notable for a hemoglobin 7.1 g/dL, platelet 76 k/uL, sodium 121 mmol/L, and INR 4.5. Given a history of epistaxis requiring otolaryngology intervention on admission that could explain his melena, a gastroenterology consult was not at first pursued. However, 12 days into the hospitalization, he continued to have melena with blood transfusion requirements, despite no evidence of recurrent epistaxis. An EGD was then done and showed a 4-mm non-bleeding ulcer in the duodenal bulb, a bleeding 5-mm AVM in a large DD treated with argon plasma coagulation (APC) and clipping, and a bleeding AVM in the posterior duodenal bulb. Ongoing melena and persistent anemia later prompted an additional push enteroscopy, colonoscopy and capsule endoscopy, which showed no evidence of ongoing bleeding at the previously treated sites or new lesions with bleeding. To reduce the risk of rebleeding, the patient's medications were adjusted (Coumadin switched to Apixaban and his VEGF inhibitor was discontinued). DISCUSSION: Definitive treatment for bleeding arising from DD traditionally involves surgical removal, though there have been increasing reports of successful endoscopic therapy. In this case, we showed that APC and clipping of a bleeding AVM within a periampullary DD was a safe and effective approach. We also highlight the need to avoid the premature assumption that persistent melena in the setting of recent recurrent epistaxis precludes coexistent gastrointestinal bleeding.Figure 1.: Bleeding AVM within duodenal diverticulum, prior to treatment.Figure 2.: AVM within duodenal diverticulum after treatment with APC and clip.Figure 3.: A CT of the abdomen/pelvis demonstrating an air-filled diverticulum of the second portion of the duodenum.

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 (< 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.

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.

1362 A Rare Case of Obstructive Jaundice and Acute Pancreatitis

INTRODUCTION: Gallstones is the most common cause of both biliary pancreatitis and obstructive jaundice. Rarely, periampullary diverticula (PAD) and choledochal cysts can present with the same symptomatology. PAD is usually asymptomatic, but complications can occur in about 5% of cases. Among these, Lemmel's syndrome defined as obstructive jaundice in absence of choledocholithiasis or neoplasm and pancreatitis have been rarely reported. Choledochal cysts are abnormal dilatations of the biliary tree with type III (choledochocele) being the least common subtype, representing <5% of reported cysts. Pancreatitis is the most common clinical complication and is normally the inciting event that leads to identification of the choledochocele. We present a case of recurrent pancreatitis and obstructive jaundice secondary to Lemmel's syndrome and choledochocele. CASE DESCRIPTION/METHODS: Case of a 60-year-old male with history on uncomplicated pancreatitis, who presented with nausea, vomiting, epigastric pain and fever of 2 days of duration. Physical examination with diffuse abdominal tenderness. Laboratories with leukocytosis, alkaline phosphatase 202 U/L, total bilirubin 8.3 mg/L, lipase 700 U/L and amylase 1089 U/L. Abdominopelvic CT showed acute pancreatitis, no cholelithiasis or biliary tree dilation. Magnetic resonance cholangiopancreatography showed duodenal diverticulum and choledochocele. Endoscopic retrograde cholangiopancreatography revealed a large diverticuli next to the ampulla with debris and sacular appearance of the intraduodenal portion of the common bile duct (CBD) as seen in choledochocele. The pancreatic duct was normal. A pre-cut sphincterotomy was performed. There was normalization of laboratories for which he was discharge home. DISCUSSION: Lemmel's syndrome is caused by a periampullary duodenal diverticula causing extrinsic compression of the CBD and preventing secretion of the bile. In choledochocele, there is a dilatation of the intramural portion of the distal CBD within the duodenal wall. Both diagnoses should be included in the differential of benign biliary obstruction or pancreatitis when PAD or cyst are present in imaging. In both cases, symptomatic patients can be approach with sphincterotomy. As in our case, the patient had no further episode of pancreatitis or obstructive jaundice after successful sphincterotomy. Maintaining a high index of suspicion is required to establish an accurate diagnosis since they can mimic other cystic or solid lesions around the pancreas head.

Peri-ampullary duodenal diverticulum: effect on extrahepatic bile duct dilatation after cholecystectomy

To investigate the effect of peri-ampullary duodenal diverticula (PAD) on extrahepatic bile duct (EHBD) dilatation before and after cholecystectomy. During a 5-year period, a total of 860 consecutive patients with prior cholecystectomy were examined using abdominal computed tomography (CT). After exclusion of those with other obstructive EHBD lesions, 61 patients with PAD were recruited for evaluation of EHBD dilatation before and after cholecystectomy and were compared with a randomly sampled control group (n=113) without PAD. EHBD diameter was measured on coronal reconstruction CT using electronic callipers on the picture archiving and communication system monitors by two reviewers in consensus. There was no significant difference in EHBD diameter between PAD and non-PAD groups (8.2±2.8 versus 7.8±2.3 mm; p=0.276) before cholecystectomy. Compared with preoperative diameter, EHBD was significantly dilated after cholecystectomy (7.9±2.5 versus 9.8±3.4 mm, p<0.001), regardless of the presence of PAD; the degree of change was more prominent in the PAD group than in the non-PAD group (3.3±2.4 versus 1.1±1.6 mm; p<0.001) after surgery. The size of PAD did not affect the degree of EHBD dilatation after cholecystectomy (p=0.522). In the non-PAD group, the degree of EHBD dilatation was positively correlated with the follow-up interval after cholecystectomy (r=0.298; p=0.002), while the PAD group showed no significant correlation (r=-0.036; p=0.797). In patients with ≥2 mm postoperative EHBD dilatation, PAD incidence was higher than that in other patients (odds ratio, 8.739; p<0.001). Regardless of their size or postoperative follow-up duration, PAD induce marked post-cholecystectomy biliary dilatation.

Operation skills of endoscopic retrograde cholangiopancreatography in pancreaticobiliary patients with periampullary duodenal diverticula

Operation skills of endoscopic retrograde cholangiopancreatography in pancreaticobiliary patients with periampullary duodenal diverticula

Retained Common Bile Duct Lithiasis at a Pacient with Periampullary Duodenal Diverticulum

Periampullary duodenal diverticula are associated with the presence of common bile duct stones, being encountered more frequently with the increase of age. We present the case of a 76 years old female patient, who underwents emergency surgery for a perforated lithiasic gangrenous acute cholecystitis and for whom we perform a cholecystectomy and an external biliary drainage using a transcystic tube. Both preoperative and postoperative imaging and endoscopic examinations certify the presence of a periampullary duodenal diverticulum. Postoperative cholangiography performed on the transcystic tube raises the suspicion of retained common bile duct lithiasis. An endoscopic retrograde cholangiopancreatography is performed, initially failing to cannulate the common bile duct. A precut sphincterotomy fistula technnique is performed, using as reference a guide inserted on the transcystic tube, with the extraction of biliay sludge from the common bile duct, and with subsequently favorable development. Association between common bile duct lithiasis and a periampullary duodenal diverticulum may represent a therapeutic challenge because of the increased risk of failure of the endoscopic treatment.

A Periampullary Duodenal Diverticula in Patient with Choledocholithiasis - Single Endoscopic Center Experience.

The study group of 3788 patients who underwent ERCP between 1996 and 2016 at the 2nd Department of General Surgery Jagiellonian University Medical College in Kraków were analyzed. The group comprised of 2464 women (mean age 61.7 years) and 1324 men (mean age 61.8 years). The patients were divided into two groups. Group A included patients in whom there were no periampullary diverticula detected. Group B included patients in whom the opening of the bile duct was in the vicinity of a duodenal diverticulum. There were 3332 patients included in group A (2154 women and 1178 men) and 456 patients in group B (310 women and 146 men). The prevalence of periampullary duodenal diverticula in the analyzed group was 12.8%. The presence of stones or biliary sludge was diagnosed in 1542 patients (47.6%) in group A and 290 patients (68.1%) in group B. Recurrence of choledocholithiasis occurred in 4.5% of patients (70/1542) in group A and 10.3% of patients (30/290) in group B. Complications occurred in a total of 76 patients in group A (2.3%) and 22 patients in group B (4.8%). The presence of choledocholithiasis and the risk of ERCP related complications are significantly higher in the group with duodenal diverticula.

Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) performed in patients with Periampullary duodenal diverticula (PAD).

Periampullary diverticula (PAD) are found in 9-32% of patients who undergo endoscopic retrograde cholangiopancreatography (ERCP). PAD are acquired lesions which are rare in patients <40 years, but increasing with age. Several endoscopic studies have revealed an association between PAD and common bile duct (CBD) stones. The presence of a papilla located in the diverticula is also frequent (6.8-54.9%) and represents a restrictive factor for successful cannulation. A retrospective analysis has been made of data related to the patients with PAD treated at our GI Unit (small center with low case volume), who underwent ERCP in the period 1st January 2010 to 31st March 2014. For each patient were analyzed data regarding sex, age at diagnosis, indication to ERCP, cannulation rate, endoscopic treatment and complications. PAD were classified in 3 different types according to the position of the major papilla. A total of 647 ERCPs have been performed of which 77 (16.5%) in pts with PAD (48 F, 29 M, mean age: 78.3 years; range: 48-95). PAD type I (inside the diverticulum) were found in 22 pts (28.6 %), Type II (in the margin of the diverticulum or between two PADs) in 36 pts (46.7 %) of which 12 cases between two PADs, type III (near the diverticulm) in 19 pts (24.7 %). The indication for ERCP were: 72 CBD stones (93.5%), 3 cholangiocarcinoma (3.9%) and 2 pancreatic head cancer (2.6%). In cases of difficult cannulation, precut was performed in 12 pts (15.6%). Deep CBD cannulation and endoscopic sphincterotomy (ES) was achieved in 70 cases (90.9%). The other 7 case of failure were all in patients with CBD stones. Complete clearance of CBD stones was achieved in 57 patients (87.7%) (57/65 ERCP/ES). Stent placement was necessary in 8 cases (12.3%) (8/65 ERCP/ES), due to multiple large stones. The adverse events related to ERCP/ES included 4 intraprocedural bleeding (5.7%) (4/70 ERCP/ES) and 1 mild pancreatitis (1.4%) (1/70 ERCP/ES), all managed conservatively. Our data show that ERCP is a safe procedure also in patients with PAD, with a good success rate and low complications.

Sa1302 Size and Type of Periampullary Duodenal Diverticula Are Associated With Bile Duct Diameter and Recurrence of Bile Duct Stones

Sa1302 Size and Type of Periampullary Duodenal Diverticula Are Associated With Bile Duct Diameter and Recurrence of Bile Duct Stones

Active bleeding from a periampullary duodenal diverticulum that was difficult to diagnose but successfully treated using hemostatic forceps: a case report

IntroductionAlthough duodenal diverticula are common, periampullary duodenal diverticula are rare. Periampullary duodenal diverticula are usually asymptomatic and may be difficult to diagnose and treat. However, they may present with massive bleeding, requiring prompt diagnosis.Case presentationWe report the case of a 71-year-old Asian woman with bleeding from a periampullary duodenal diverticulum. She presented with severe anemia and tarry stools. Two examinations using a forward-viewing endoscope did not identify the source of the bleeding. However, examination using a side-viewing endoscope found an exposed bleeding vessel overlying the bile duct within a periampullary diverticulum of the descending part of the duodenum. The bleeding was successfully controlled by using hemostatic forceps.ConclusionsBleeding periampullary duodenal diverticula are rare, and a bleeding point in the mucosa overlying the bile duct within a large periampullary duodenal diverticulum is very rare. Identification of a bleeding point within a duodenal diverticulum often requires repeated examination and may require the use of a side-viewing endoscope. Use of hemostatic forceps to control bleeding from a periampullary duodenal diverticulum is very rare but, for bleeding lesions overlying the bile duct within a periampullary duodenal diverticulum, is the best way to prevent obstructive jaundice.

Safety of Endoscopic Sphincterotomy in Patients with Periampullary Diverticulum

Background: Periampullary duodenal diverticula (PAD) are generally an incidental finding in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). There is uncertainty about the increased risk of complications especially with endoscopic sphincterotomy (ES).

Technical Success of ERCP in Patients with Periampullary Duodenal Diverticulum

Background: Periampullary duodenal diverticula (PAD) are considered to be associated with high failure rate of endoscopic retrograde cholangiopancreatography (ERCP) especially in elderly patients.

The Relationship between Periampullary Duodenal Diverticula and Common Bile Duct Stones

The Relationship between Periampullary Duodenal Diverticula and Common Bile Duct Stones

Impact of Periampullary Duodenal Diverticula at Endoscopic Retrograde Cholangiopancreatography: A Proposed Classification of Periampullary Duodenal Diverticula

To propose a classification schema to describe periampullary duodenal diverticula (PDD) found at endoscopic retrograde cholangiopancreatography (ERCP), and to study the characteristics of these diverticula. Among 400 consecutive patients in whom an ERCP was performed, PDD were present in 131 (32.8%), being these patients significantly older than the remaining, served as controls. PDD were classified in 3 different types according to the position of the major duodenal papilla: type I (16.3%), inside the diverticulum; type II (10.2%), in the margin of the diverticulum; and type III (6.5%), near the diverticulum. PDD were not associated with a more difficult cannulation of the biliary tract. PDD are common, especially in older patients, and do not significantly increase the difficulty of deep cannulation.