clinical analysis and literature review of massive...

World J. Surg. 25, 848–855, 2001DOI: 10.1007/s00268-001-0039-y WORLD

Journal ofSURGERY© 2001 by the Société

Internationale de Chirurgie

Clinical Analysis and Literature Review of Massive Duodenal DiverticularBleeding

Wen-Yao Yin, M.D.,1 Hwa-Tzong Chen, M.D.,1 Shih-Ming Huang, M.D.,1 Hsien-Hong Lin, M.D.,2

Tzu-Ming Chang, M.D.1

1Department of Surgery, Tzu-Chi Dalin General Hospital, No. 2, Min-Sheng Road, Dalintown, Chia-Yi, Taiwan, Republic of China2Department of Medicine, Buddhist Tzu-Chi Medical Center, No. 707, Section 3, Chung-Yang Road, Hualien, Taiwan, Republic of China

Abstract. A duodenal diverticulum (DD) appears in 2.5% of upper gas-trointestinal (UGI) examinations and up to 22% of endoscopic retrogradecholangiopancreaticographies (ERCP) and autopsies. Most of these pa-tients are asymptomatic, but the lesion is occasionally associated withbleeding, inflammation, perforation, obstruction of the duodenum orbiliary-pancreatic duct (or both), fistula formation in the bile duct, andbezoar formation inside the diverticulum. A total of 816 patients haveundergone ERCP examination at our institution since January 1987, and100 (12.25%) of them have DD. Seven (7%) patients presented with bloodyor tarry stools from massive UGI bleeding followed by shock. Only twocould be diagnosed by UGI endoscopy preoperatively. The lesions weredemonstrated in angiographic studies in another four cases. However,only one was correctly interpreted and one required reoperation after acorrect repeat endoscopic finding. The lesions in the other two patientswere identified by thorough exploration during laparotomy. The remain-ing case was diagnosed by intraoperative endoscopy via pyloroduodeno-tomy. Six underwent surgical intervention, and one was successfullytreated by expectant treatment. Three (50%) had leakage from the duo-denotomy but recovered uneventfully with conservative treatment. Inconclusion, we believe that DD bleeding is more frequent than usuallythought. A high index of suspicion should be raised in cases of UGIbleeding when more obvious and common causes have been excluded byroutine endoscopy. Aggressive but careful endoscopic examination com-bined with accurate angiography can help us diagnose most of the casespreoperatively. Diverticulectomy is an effective surgical procedure,though it is associated with a considerable leakage rate. The morbidity isminimal if we can identify the lesion earlier and evacuate the lesionwithout delay.

Duodenal diverticula were described by Chromel in 1710. Hem-orrhage from diverticula is a rare complication [1]. In 1951 Patter-son and Bromberg described the first, well documented case ofbleeding from a duodenal diverticulum [2]. Only a few docu-mented cases have been reported in the literature [3–12]; and theexperience of any surgeon or group relative to the sequence ofdiagnosis, surgical treatment, and subsequent relief of the symp-toms remains limited. We report seven consecutive cases of duo-denal diverticular bleeding treated by us during a 5-year period.To our knowledge, this should be the first and largest series ofmassive duodenal diverticular bleeding experienced by the samegroup of surgeons over a relatively short time. As it is rarely

encountered, understanding its pathogenesis and management isessential if the occasional patient is to be successfully treated. Theaim of this paper is to share our experience with this disease entityto fulfill the above objective.

Patients and Methods

We retrospectively reviewed the cases of duodenal diverticulumdetected by endoscopic retrograde cholangiopancreaticography(ERCP) in our hospital from January 1987 through June 1999.Clinical analysis was focused on patients with documented mas-sive gastrointestinal bleeding. A total 816 patients underwentERCP for various abdominal symptoms, and 100 (12.25%) ofthem had duodenal diverticula. Among them, seven cases (7%)were complicated with massive life-threatening bleeding. Allseven cases were encountered during the recent 5-year periodbetween January 1994 and March 1999. This group consisted offive women and two men with an age range of 46 to 91 years(mean 63.14 years). To better understand this problem, threerepresentative cases with different clinical courses are reportedhere in detail. Patients were followed up in the outpatient clinicfor periods ranging from 5 to 65 months.

Case 1

A 61-year-old woman was admitted to our hospital in May 1994with a chief complaint of tarry stool for 1 day. On arrival her bloodpressure was 80/50 mmHg, pulse rate 120/min, and hemoglobin6.4 g/dl. Other hematologic and biochemical data were withinnormal limits. After initial resuscitation, she was submitted togastroduodenoscopy, and a large diverticulum with blood clot wasfound in the third portion of the duodenum (Fig. 1). The uppergastrointestinal series also revealed the diverticulum at the thirdportion of the duodenum (Fig. 2). The vital signs were stable afterresuscitation (which included 2 units of blood), and she wasdischarged within 1 week. There has been no recurrent bleedingup to the most recent follow-up.Correspondence to: W.-Y. Yin, M.D., e-mail: [email protected]

Comment. This is the first patient in our series, and she re-sponded well to conservative treatment. Such measures were alsoattempted in cases 2 and 6, but they failed and surgical interven-tion was undertaken.

Case 4

A 55-year-old woman was referred to our emergency room inDecember 1995 after 3 days of bloody stool. She had been treatedconservatively in another hospital during the previous 3 days andrequired 2 units of blood a day to stabilize her vital signs after theinitial resuscitation. She gave a history of partial gastrectomy forupper gastrointestinal (UGI) bleeding 10 years ago. Endoscopicexamination in that hospital revealed a marginal ulcer withoutactive bleeding. On arrival, she was in sinus tachycardia (heartrate 108 beats/min) and anemic (hemoglobin 8.7 g/dl), but herblood pressure of 130/90 mmHg. Other laboratory data wereapparently normal. Colonoscopy at our hospital and repeat gas-troduodenoscopy showed a large amount of blood and clots in thestomach. No active bleeder was detected. As she continued tohave bloody stool and tachycardia, angiography was arrangedurgently. Fortunately, extravasation from the pancreaticoduode-nal artery was identified, and laparotomy was performed with theimpression of active bleeding from the second portion of theduodenum (Fig. 3). During operation, a solitary diverticulum withactive bleeding was found at the concavity of the second portionof the duodenum. The diverticulum was then inverted, and suture-ligation was done transduodenally. The papilla of Vater andorifice of the accessory pancreatic ducts were carefully identifiedto avoid iatrogenic injury during suture-ligation. The bleedingstopped dramatically, and the postoperative course was unevent-ful.

Comment. Cases 2, 3, and 4 were patients who had bleeding fromthe perivaterian diverticula. Two were diagnosed by angiography,but the angiographic findings were misinterpreted in one. Endos-copy revealed a diverticulum with bleeding in case 3. We used thetransduodenal approach in all of them, and diverticulectomy orsimple inversion with suture-ligation was performed. In case 3,choledochojejunostomy was needed for biliary drainage.

Case 6

A 46-year-old man was brought to the emergency room with achief problem of severe anal bleeding for 5 hours. He was in theshock state with blood pressure 83/41 mmHg, heart rate 97 beats/min, and hemoglobin 8.8 g/dl. He was admitted after resuscitation,and the gastroduodenal endoscopic examination was negative.Colonoscopy 10 hours later showed massive bloody stool in thecolon, but no source of bleeding could be identified. Angiographywas arranged shortly after colonoscopy, as the bloody stool con-tinued. Fortunately, a diagnosis for the extravasation was straight-forward, and it was reported by the radiologist as bleeding fromthe transverse colon (Fig. 4). Interestingly, the condition im-proved dramatically after right hemicolectomy. Although wecould not definitively identify the lesion in the resected specimen,we decided to terminate the operation after observation in theoperating room for an hour, as we did not see any marked lesionin the remaining colon and small bowel, and the bleeding seemedto be stopped (based on his stable vital signs).

Sixty hours after the initial laparotomy, the patient sustained afainting attack concomitant with bloody intestinal content comingout of the ileostomy. An emergent red blood cell (RBC) scanrevealed a positive finding in the left upper quadrant, but angiog-raphy failed to prove it. The angiocatheter was left in the superior

Fig. 1. Endoscopic finding of active bleeding with clot in the diverticulum (case 1).

Fig. 2. Large diverticulum at the third portion of duodenum was demonstrated by upper gastrointestinal (UGI) series in case 1.

Yin et al.: Duodenal Diverticular Bleeding 849

mesenteric artery, and pitressin was given via catheter to controlthe bleeding. Repeated angiography the next day also could notidentify the bleeder, though the patient was still passing bloodyintestinal content and needed at least 3 to 4 units of blood tostabilize his condition for the next 48 hours. Reevaluation of theUGI endoscopy was considered then, as some coffee-ground sub-stance was detected in the nasogastric tube. In contrast to the firsttime, we found fresh blood in the second part of the duodenum.More aggressive endoscopy, down to the distal end of duodenum,clearly highlighted the actively bleeding point in the pouch of thediverticulum. He was brought back to the operating room forreoperation, which showed a 5 3 4 cm extraluminal diverticulumat the fourth portion of the duodenum in the retroperitoneum(Fig. 5). Diverculectomy was done, and a jejunostomy tube wasinserted for early enteral feeding. The patient recovered unevent-fully and was discharged 2 weeks later.

Comment. In four cases duodenal diverticular bleeding was foundat a site other than the second portion. Three of the sites were inthe third portion and one was in the fourth portion of the duo-denum. Only one of them could be seen by the initial UGIendoscopy. Two of the sites (one in the third portion and theother in the fourth portion of the duodenum) could be shown onangiography. Misinterpretation in both cases (cases 6 and 7) led toresection of the right colon or a segment of proximal jejunum—ineach case by mistake. One patient had to undergo reoperation for

rebleeding after a correct repeat endoscopy. The fourth case wasdiagnosed by intraoperative endoscopy via pyloroduodenotomy.

Results

All of the patients presented with bleeding per rectum. Five of theseven complained of passing bloody stools, and the remaining twopatients had tarry stools. Only three presented with hematemesis,and four showed blood in the nasogastric drainage. All of themwent to the emergency room with marked signs and symptoms ofshock (with or without prior resuscitation) and profound anemia.Three patients had a history of partial gastrectomy for peptic ulcerbleeding 1 year, 10 years, and 20 years previously, respectively.The data are summarized in Table 1. Preoperative endoscopyrevealed blood with or without clots in all cases except case 6, andthe bleeders were identified in cases 1 and 3 (Table 2). Colonos-copy was performed in cases 6 and 2; only blood was seen in theircolons. Angiography was undertaken in all patients with negativepreoperative endoscopic findings (cases 2, 4, 6, 7) except case 5, inwhom intraoperative endoscopy through a pyloroduodenotomywas used to identify the diverticulum with active bleeding in thethird portion of the duodenum. All the angiographic studiesshowed positive findings with radiologic reports of artifacts in theright abdomen and extravasation from the pancreaticoduodenalartery, transverse colon, and proximal jejunum, respectively (Ta-ble 3). Therefore only one patient was correctly diagnosed during

Fig. 3. Extravasation of contrast at the junction of the superior andinferior pancreaticoduodenal artery (arrows) in case 4.

Fig. 4. Positive findings at superior mesenteric artery angiography weremisinterpreted as transverse colon bleeding instead of having a duodenalorigin (arrow) in case 6.

850 World J. Surg. Vol. 25, No. 7, July 2001

the preoperative period (case 4). In two other cases the rightcolon (case 6) and proximal jejunum (case 7) with innocent di-verticulum were mistaken for the source of the gastrointestinalbleeding at the beginning and were resected. Case 6 had to bereoperated for recurrent bleeding from the duodenal diverticulumafter repeat endoscopy. In case 2, the diagnosis was made duringthe exploratory laparotomy by identifying the tense and dilatedsecond portion of duodenum (due to active bleeding with clotformation).

All of the patients, except case 1, required 3 to 7 days (mean 5

days) for a definitive diagnosis. Regarding the treatment, theamount of transfusion ranged from 4 to 15 units (average 10 units)for the preoperative period and 2 to 18 units (average 5 units) forthe intraoperative period. Three bleeding sites were found in thesecond portion of the duodenum, and another three were de-tected in the third portion. Only one bleeding site was found in thefourth portion of the duodenum. Six patients were operated onfor cessation of the bleeding. Excision was done in all of thesecases except case 4, where only simple inversion and suture-ligation was carried out. Among the three cases of perivaterian

Table 1. Clinical manifestations of patients at admission.

Parameter

Results in cases 1–7

1 2 3 4 5 6 7

Stool Tarry Bloody Tarry Bloody Bloody Bloody BloodyHematemesis – 1 1 – 1 – –Blood in NG tube 1 1 – – 1 – 1Blood pressure (mmHg) 80/50 50/30 70/60 70/30 60/30 83/41 80/56Hemoglobin (g/dl) 6.4 7.2 4.1 5.1 5.7 8.8 9.9Prior gastrectomy – BI (1 year) – BII (10 years) – – BI (20 years)Associated findings Gastric ulcer – – Marginal ulcer Gastric ulcer – Jejunal diverticulum

NG tube: nasogastric tube; BI, BII: Billroth I or II gastrectomy.

Table 2. Results of various diagnostic methods in each patient.


1 2 3 4 5 6 7

UGI endoscopy 1 Blood 1 Blood Blood Clear BloodColonoscopy ND Blood ND ND ND Blood NDRBC scan ND ND ND ND ND 1 NDAngiographic reading ND Artifact ND PDA bleeding ND T. colon bleeding Jejunal bleedingUGI series 3rd Part ND ND ND ND ND ND

1: bleeder was found; ND: not done; T. colon: transverse colon; PDA: pancreaticoduodenal artery; UGI: upper gastrointestinal; RBC: red bloodcell.

Fig. 5. Extraluminal type of duodenaldiverticulum (arrow) occupying theascending portion of the duodenum justproximal to Trietz’s ligament.


diverticula treated by excision via the transduodenal approach,two were complicated by leakage from the duodenal wound; bothpatients recovered uneventfully with conservative treatment. An-other DD in the third portion treated by diverticulectomy (case 5)was complicated by a duodenal fistula but responded well toconservative treatment. We obtained five specimens from the sixoperated patients, all of which revealed various signs of recenthemorrhage, including erosion, ulceration, subserosal hemor-rhage, or a ruptured blood vessel. They all showed characteristicsof a primary acquired diverticulum with protrusion of the mucosathrough the duodenal wall with a scant amount of muscle layerand covered by thin serosa (Fig. 6A). All of the patients are stillalive at the most recent follow-up except the 91-year-old woman(case 3), who died of acute heart failure during the second post-operative month.

Discussion

The incidence of DD depends on the mode of diagnosis and theintent of the investigator. The reported incidence ranges fromabout 5% in the UGI series to 23% in the ERCP series [13] andup to 22% at autopsy (average 8.6%) [14, 15]. Most of theliterature describes a less than 10% incidence in the generalpopulation [3, 15]. The prevailing age varies from 26 to 69 years(average 50 years), and there is no gender predilection [16]. Ourseries revealed an incidence comparable to that in the literature.DD can be classified according to their pathologic etiology intoprimary acquired diverticula and secondary diverticula caused bypeptic ulceration. The former type, which occurs in the second,third, and fourth portions of the duodenum grow out mostly fromthe concave aspect of the duodenum and may be multiple. Theirdistributions are 62% in the second part, 30% in the third part,and 8% in the fourth part of the duodenum [5]. They are thoughtto be caused by herniation of the mucous membrane through themuscular coat at sites where the latter is weakened by the passageof blood vessels or aberrant growth of pancreatic tissue into thewall of the duodenum. The diverticula seen within 2.5 cm of theampula of Vater have been assigned a separate descriptive term,perivaterian, and are due to a weak muscular coat caused by

piercing of the ducts. Secondary diverticula are associated withpeptic ulceration and are due to ballooning of the gut wall sec-ondary to fibrotic contraction of a healing ulcer [7].

Generally, DDs seldom cause hemorrhage, but when they dobleed it is difficult to make the diagnosis in time, so they are oftenfatal. Although there is a considerable number of DDs, the inci-dence of their bleeding is not known. There are various reportedetiologies for DD bleeding: peptic ulcer disease within the pouch[2, 7, 17], traumatic irritation by a bezoar [8], perforation orerosion into the major vessels [6, 18], neoplastic growth [19],angiodysplasia involving the diverticular mucosa [9], and usingdrugs that produce a bleeding tendency [10, 12]. Among our cases,we found no ectopic mucosa, neoplastic growth, or angiodysplasia.All of the patients showed erosion or ulceration with signs ofhemorrhage by microscopy (Fig. 6B). Fewer than 10% of suchpatients are symptomatic, and 1% may require operation [3]. Thesymptoms vary from nonspecific to those associated with thecomplications. Before the development of endoscopic technique,this potentially lethal complication was usually diagnosed at lap-arotomy. A preoperative impression was reached only by exclud-ing other possible causes together with retention of barium for atleast 6 hours during the UGI series [9, 16, 20].

Accurate preoperative imaging is helpful to the surgeon, asintraoperative localization of the lesion in the retroperitoneummay otherwise be difficult. Herrington and Team in 1958 de-scribed the first case in the literature in which the definitivediagnosis was made properly by radiologic demonstration of anulcer in the diverticulum [17]. The first case diagnosed by endos-copy was reported by Ryan et al. in 1984 [8], who were followedby other groups [21, 22]. Nevertheless, this is not always possibleif the bleeding is profuse or the bleeding point is situated in thedistal parts of duodenum [9, 11, 12]. UGI endoscopy was firstcarried out in all of them, and only two cases were diagnosed bythis method preoperatively; and one required a repeat examina-tion. Although another two patients were diagnosed by the samemethod, they were detected only by intraoperative endoscopy orrepeat endoscopic examination before reoperation for the recur-rent bleeding. Angiography may be helpful in patients in whom

Table 3. Data for the entire course of treatment.

Parameter


1 2 3 4 5 6 7

Preoperative transfusion (cc) 2000 5500 4250 3750 4500 6250 7500Intraoperative transfusion (cc) — 1000 1000 1500 9000 (1) 2000, 600 2000

Blood (500 cc/pack) 1200 600 300 2700 (2) 1000, 600 600Plasma (150/pack)

Days for diagnosis 1 7 7 7 3 7 3Location of bleeding in

duodenum (portion)3rd 2nd 2nd 2nd 3rd 4th 3rd

Operating time (hr) ND 2.5 7.5 4.0 8.0 5.5, 5.0 4.0No. of operation ND 2 1 1 1 2 1Operative procedure ND Excision Excision,

choledochojejunostomyInversion 1 suture

ligationExcision Excision

colectomyExcision

enterectomyOutcome Survived Survived, leakage Died of AHF

in second monthSurvived, leakage Survived, leakage Survived Survived

AHF: acute heart failure; leakage: leakage of duodenotomy.Reoperation was done in cases 2 and 6, but the amount of blood transfusion for both operations was described only in case 6 because the first

operation of case 2 was performed in another hospital. Colectomy and enterectomy were mistakenly done in cases 6 and 7, respectively, for suspicionof the source of gastrointestinal bleeding.


endoscopy (as the first choice of diagnostic tool) cannot find theUGI bleeder.

The first case of DD bleeding diagnosed by arteriography wasreported by Miller et al in 1970 [4]. Angiography was done in fourof our cases after negative endoscopic findings, and all of themhad positive results. However, the correct diagnosis was obtainedin only one patient, who had had a prior Billroth II gastrectomy.In another three cases, they were mistaken as artifact, bleedingfrom the transverse colon, or proximal jejunal diverticular bleed-ing for DD bleeding, respectively. Two were diagnosed intraop-eratively by palpation of a tense duodenum with blood clots.

Misinterpretation of the angiographic findings in three cases ledto delayed operation in one case (case 2), resection of the non-diseased part of colon or jejunum mistakenly in two cases (cases6 and 7), and reoperation for recurrent bleeding in one case (case6). Hence careful interpretation of the angiographic findings isfundamental for the definitive diagnosis and appropriate surgicaltreatment.

We needed a total of 5 days (mean) to diagnosis the DDbleeding correctly. This duration is much longer than that of thecommonly seen etiologies of UGI bleeding (e.g., peptic ulcerbleeding). The reasons for this delay are multifactorial. Based onour series, possible causes are difficult access to the location of theDD especially for the distal duodenum (third and fourth parts),interference with endoscopic viewing by the gush of blood fromthe active bleeding area, the intermittent nature of the bleeding,

misinterpretation of the angiographic findings, and lack of a highindex of suspicion. Correcting these factors should improve thepreoperative and intraoperative diagnosis and therefore give bet-ter results in these patients.

Regarding exploration during laparotomy, there are severaltechniques we can use to assess the continuing bleeding andlocation of the lesions. They include careful inspection and pal-pation of the gut with or without external bright light transillumi-nation, segmental clamping of the bowel to demonstrate rapidfilling after milking out the blood from bowel [23], enteroscopythrough multiple enterotomies [24], video-panendoscopy by trans-oral and transanal routes [25], and segmental irrigation of thebowel and evaluation of the flushed fluid. These methods arehelpful in some instances, but each has limitations. Thereforeobtaining a correct diagnosis preoperatively is the only way toobtain the better results in such patients. A high index of suspicionwith an aggressive, skillful endoscopic examination supplementedwith expert angiographic evaluation can give us the best resultswith less blood transfusion, early surgical intervention, and lowmorbidity.

Temporary control of hemorrhage with infusion of vasopressin[6] or electrocoagulation [10] of the bleeding point may allowbetter preparation before surgery. However, it was not that effec-tive for one of our patients, who had more than 16 hours ofintraarterial vasopressin infusion through the indwelling angio-catheter. Surgery therefore was used as a life-saving procedure in

Fig. 6. Microscopic finding of a bleeding duodenal diverticulum with (A) protrusion of mucosa through the duodenal wall with a scant muscle layer andthin, intact serosa (arrow). B. Submucosal hemorrhage and ulcer crater on the mucosa (arrow).


all patients with massive bleeding although conservative treatmentin one patient stabilized the condition quickly and no recurrenceoccurred during the follow-up period.

Excision of the diverticulum is the treatment of choice and hasbeen shown to be effective in many reports [2, 5, 8–12, 17, 19–22].This procedure may be technically difficult, however, with a risk ofdamage to the pancreas and biliary and pancreatic ducts in pa-tients with perivaterian diverticula. A survey in 1964 revealed 20%postoperative mortality among patients with (1) duodenal diver-ticulitis; (2) diverticular perforation, fistula, or hemorrhage; or (3)biliary or pancreatic duct obstruction [3]. Excision of the mucosalpouch only [26] or inversion of the diverticular sac with [27] orwithout [18] amputation of the sac were reported to be safe,simple procedures. We believe that total excision of the divertic-ulum or partial excision with suture-ligation of the bleeder is anexcellent treatment for the bleeding diverticulum; inversion of thediverticulum with suture-ligation may be a suitable method forpatients with marked edematous changes in the duodenal wall.For diverticula located near the ampulla of Vater, every attemptshould be made to avoid injury to the biliary and pancreatic duct.It is safer to approach these diverticula through an anteriorduodenotomy when introducing a guided probe through the cho-ledochotomy down to the lumen of the second portion of theduodenum. We used the transduodenal approach in all threepatients with perivaterian DD bleeding, and they were all freefrom iatrogenic injury to the pancreatic or bile ducts. However, westill encountered leakage from the duodenotomy in three cases(50%), including two perivaterian diverticula among those oper-ated cases. This incidence is quite high, with significant morbidityduring the postoperative period. Such a high rate of leakage maybe related to poor tissue condition as a consequence of the shockstate, fluid resuscitation for massive and prolonged blood loss, andthe natural high fluid content in the duodenum. All of these cases,though, were successfully and simply managed by restricting oralintake, enteral feeding through a jejunostomy tube, and supple-mentary fluid therapy.

Conclusions

We have reported seven cases of DD presenting as hemorrhagicshock due to passage of bloody or tarry stool from massive UGIbleeding. Among them, UGI endoscopy diagnosed the bleeder intwo patients during the preoperative period and in another pa-tient during the intraoperative period. Although the superiormesenteric artery (SMA) or celiac angiography was positive in theremaining four patients, only one correctly localized the bleedingpoint. In two patients the proximal jejunum and transverse colonwere mistakenly resected as the suspected source of the bleeding.Six cases were successfully treated by surgical intervention, butthree were complicated by a duodenocutaneous fistula; they weresuccessfully managed by conservative treatment. One of the pa-tients responded well to conservative treatment. All but one of thepatients survived, the exception being an elderly woman who diedduring the second postoperative month unrelated to the opera-tion.

We concluded that for a patient in whom the site of UGIbleeding is not readily apparent on routine endoscopic examina-tion a duodenal diverticulum should be sought with a deeper butcareful endoscopic examination down to the fourth part of theduodenum. A systemic diagnostic approach such as scanning with

technetium 99-labeled red blood cells and angiography with ac-curate interpretation is helpful for avoiding the morbidity of apoorly planned surgical exploration. Aggressive investigationswith skillful technique and careful reading of the imaging studiespre- and intraoperatively, coupled with perseverance, is funda-mental for the correct diagnosis and successful treatment.

Résumé

Le diverticule duodénal (DD) se voit dans 2,5% des examens dutube gastrointestinal supérieur et dans 22% des examens parcholangiopancréatographie rétrograde endoscopique (CPRE) oud’autopsie. La plupart de ces patients sont asymptomatiques maisde temps à autre, le DD est responsable d’hémorragie,d’inflammation, de perforation, d’obstruction duodénale ou descanaux biliopancréatiques, de formation de fistule biliaire et/ou debézoard à l’intérieur du diverticule. Un DD a été observé chez 100des 816 (12,15%) CPRE effectuées depuis janvier 1987. Dans septcas (7%), les selles étaient hémorragiques ou mélaniques,secondaires à une hémorragie massive suivie de choc. Seulementdeux de ces DD pouvaient être diagnostiqués par fibroscopiepréopératoire. Les lésions ont été démontrées par l’angiographiedans quatre autres cas. Cependant, seulement un cas a étéinterprété correctement et un autre avait besoin d’uneréopération après une deuxième endoscopie. Les lésions chez lesdeux autres patients ont été identifiées par laparotomieexploratrice. Le dernier cas a été diagnostiqué par une endoscopieperopératoire à travers une pyloroduodénotomie. Six patients onteu besoin d’une intervention chirurgicale alors qu’un autre a ététraité par l’expectative. Trois cas (50%) ont été compliqués parfistule de la duodénotomie mais ont guéri après un traitementconservateur. En conclusion, nous croyons que l’hémorragie àpartir du diverticule duodénal serait plus fréquente que l’oncroyait autrefois. Il faut toujours penser à la possibilité d’unehémorragie à partir d’un DD lorsque les causes les plus évidenteset les plus fréquentes ont été éliminées par une endoscopie deroutine. Un examen agressif mais soigneux, combiné àl’angiographie, pourraient aider dans le diagnostic préopératoiredans la plupart des cas. La diverticulectomie est efficace mais letaux de fistule est élevé. Cette morbidité peut être minimisée sil’on peut identifier la lésion tôt.

Resumen

El divertı́culo duodenal (DD) se detecta en un 2.5% de losexámenes del tracto gastrointestinal superior (UGI) y en el 22%de las colangiopancreatografias retrógradas endoscópicas(ERCP), ası́ como en los estudios necrópsicos. En la mayorı́a delos casos los pacientes no presentan sintomatologı́a alguna, peroen ocasiones el divertı́culo puede sangrar, inflamarse, perforarse,provocar una obstrucción duodenal o del conducto bilio-pancreático, fistulizarse a las vı́as biliares extrahepáticas y, enrarı́simos casos, originar un benzoar. 816 pacientes fueronsometidos a una ERCP desde enero de 1987, encontrándose en100 (12.25%) un DD. Siete casos (7%) cursaron con hemorragiasmasivas del tracto gastrointestinal superior (UGI) que originaronun shock; sólo dos pacientes pudieron diagnosticarsepreoperatoriamente mediante endoscopia del UGI. La lesión, enotros 4 casos, se diagnosticó mediante angiografia. Sin embargo,los hallazgos sólo fueron interpretados correctamente en 1 caso y


otro, requirió una reintervención tras repetir e interpretarcorrectamente los hallazgos endoscópicos. La lesión, en otros 2pacientes, fue identificada en el transcurso de una exploracióntras laparotomia. Los restantes casos se diagnosticaron gracias aun endoscopia intraoperatoria realizada a través de unapiloroduodenostomı́a. 6 fueron intervenidos quirúrgicamente yuno fue tratado, con éxito, con medidas conservadoras. De los 6,tres (50%) desarrollaron como complicación una fı́stula a nivel dela duodenotomı́a, que se curó, sin secuela alguna, mediantetratamiento conservador. En conclusión, pensamos que elsangramiento de un DD es más frecuente de lo que parece. Encasos de hemorragia alta del UGI y cuando otras etiologı́a másfrecuentes han sido descartadas mediante la endoscopia rutinaria,debe de sospecharse esta patologı́a. En la mayorı́a de los casos, eldiagnóstico preoperatorio puede efectuarse merced a unaagresiva pero cuidadosa endoscopia, asociada a una angiografia.La diverticulectomı́a es la técnica quirúrgica de elección, pero hade tenerse muy en cuenta que se acompaña de un alto porcentajede fistulas. La morbilidad puede minimizarse si se hace undiagnóstico y tratamiento precoz.

References

1. Chromel, J.B.L.: Historie de l’ Academie Royale, Paris, Institut deFrance, Academie des Sciences, 171:33, 1710

2. Patterson, R.H., Bromberg, B.: Surgical significance of duodenal di-verticula. Ann. Surg. 134:834, 1951

3. Munnel, E.R., Preston., W.J.: Complications of duodenal diverticula.Arch. Surg. 92:152, 1966

4. Miller, R.E., McCabe, R.E., Salmon, P.F., Knox, W.G.: Surgical com-plications of small bowel diverticula exclusive of Meckel’s. Ann. Surg.171:202, 1970

5. Lapin, R., Kamath, M.L., Engler, J., Friedman, H.: Massive gastroin-testinal hemorrhage from duodenal diverticula. Am. J. Gastroenterol.610:185, 1974

6. Ghahremani, G. G., Hietala, S. O.: Arteriography of a bleedingduodenal diverticulum. Dig. Dis. 22:445, 1977

7. Rowlands, B.C., King, P.A.: Duodenal diverticulum perforating intoabdominal aorta causing fatal hemorrhage. Br. J. Surg. 41:415, 1954

8. Ryan, M.E., Hamilton, J.W., Morrissey, J.F.: Gastrointestinal hemor-rhage from a duodenal diverticulum. Gastrointest. Endosc. 30:84,1984

9. Balkissoon, J., Balkissoon, B., Leffall, L.D., Posey, D.A.: Massiveupper gastrointestinal bleeding in a patient with a duodenal divertic-

ulum: a case report and review of the literature. J. Nat. Med. Assoc.84:365, 1992

10. Callery, M.P., Aliperti, G., Soper, N.J.: Laparoscopic duodenal divert-iculectomy following hemorrhage. Surg. Laparosc. Endosc. 4:134,1994

11. Rioux, L., Groseilliers, S.D., Fortin, M., Mutch, D.O.: Massive uppergastrointestinal bleeding originating from a fourth-stage duodenaldiverticulum: a case report and review of the literature. J. C. C. 39:510,1996

12. Mosimann, F., Bronnimann, B.: The duodenal diverticulum: an ex-ceptional site of massive bleeding. Hepatogastroenterology 45:603,1998

13. Osnes, M., Lotveit, T., Larsen, S., Aune, S.: Duodenal diverticula andtheir relation to age, sex, and biliary calculi. Scand. J. Gastroenterol.16:103, 1981

14. Ackermann, W.: Diverticula and variations of the duodenum. Ann.Surg. 13:403, 1943

15. Jones, T.W., Merendino, K.A.: The perplexing duodenal diverticulum.Surgery 48:1068, 1960

16. Catell, R.B., Mudge, T.J.: The surgical significance of duodenal di-verticula. N. Engl. J. Med. 246:317, 1952

17. Herrington, J.L., Tenn, N.: Massive hemorrhage resulting from benignulceration in a primary duodenal diverticulum. Surgery 43:340, 1958

18. Neill, S.A., Thompson, N.W.: The complications of duodenal diver-ticula and their management. Surg. Gynecol. Obstet. 120:1251, 1965

19. Bradham, G.B., Martin, J.B.: Massive bleeding from a polyp in aduodenal diverticulum. Ann. Surg. 156:81, 1962

20. Pises, P.: Bleeding duodenal diverticula. Am. J. Gastroenterol. 43:121,1965

21. Franceschi, D., Castillo, W., Yuh, J.N., Chen, P.F.: Endoscopic diag-nosis of upper gastrointestinal tract bleeding from a duodenal diver-ticulum. Gastrointest. Endosc. 33:383, 1987

22. Sim, E.K.W., Goh, P.M.Y., Isaac, J.R., Kang, J.Y., Gangaraju, C.R.,Ti, T.K.: Endoscopic management of a bleeding duodenal diverticu-lum. Gastrointest. Endosc. 37:634, 1991

23. Rosenberg, I.K., Rosenberg, B.F.: Massive bleeding from diverticulaof the colon, with demonstration of the source of bleeding. Ann. Surg.159:570, 1964

24. Sweeting, J. G.: Fiberoptic examination of the small intestine in a caseof familiar telangiectasia. Gastrointest. Endosc. 14:152, 1968

25. Flickinger, E.G., Stanforth, A.C., Sinar, D.R., MacDonald, K.G.,Lannin, D.R., Gibson, J. H.: Intraoperative video panendoscopy fordiagnosing sites of chronic intestinal bleeding. Am. J. Surg. 157:137,1989

26. Slater, R.B.: Duodenal diverticulum treated by excision of mucosalpouch only. Br. J. Surg. 58:198, 1971

27. Wilkinson, G., Greaney, E.M.: Perforated perivaterian duodenal di-verticulitis. Am. J. Surg. 111:351, 1966


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