Perforation of a Duodenal Diverticulum. Elective Student S. C.

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1 Perforation of a Duodenal Diverticulum Elective Student S. C.

2 Case History An elderly male presented to the Emergency Department with abdominal pain. Chief Complaint: Worsening, diffuse abdominal pain that began the previous day. History of Present Illness: Appetite loss for one day. No nausea, vomiting or diarrhea.

3 Case History No Significant Past Medical History No past surgeries No medications except a trial of laxatives No known drug allergies Social History Drinks 1-21 go of sake / day No smoking

4 Physical Exam General: - Conscious, awake, alert and oriented Abdominal Exam: - Hyporesonant Bowel Sounds - Diffuse tenderness to palpation in abdomen - Positive McBurney point tenderness - Positive rebound tenderness Heart and Lungs: -Unremarkable

5 Vitals Blood Blood Pressure: 144/68 Temperature: 37.8 degrees celcius Blood Blood Sugar: 88 SPO2: SPO2: 95 Heart Heart rate: Not reported Respiratory Rate: Not reported

6 Lab Data WBC 10.6, RBC 3.99, Hb 13.2, Ht 38.6, Plt 221 AST 20, ALT 10, LDH 182 T-bilirubin 1.7, TP 6.9, Alb 3.7 Amylase 122, BUN 23, Cr 0.7 Na 139, K 3.9, Cl 104, Ca 7.1 CRP 4.99

7 Differential Diagnoses of Acute Abdomen Perforated peptic ulcer Acute cholecystitis Acute pancreatitis Acute appendicitis Diverticulitis of large intestine Bowel obstruction Etc.

8 Abdominal X-Ray X (Upright) No evidence of intestinal obstruction No evidence of intraperitoneal free air No abnormal calcification Bone structure is normal

9 Chest X-Ray X (PA) No pleural effusion No consolidation in lungs Cardiovascular silhouette appears normal No free air in sub- phrenic area

10 Abdominal CT Pertinent Negatives Normal Pancreas Normal size No pancreatic fluid in pararenal space Normal Gallbladder No wall thickening No gallstones Nonedematous Appendix

11 Abdominal CT Third portion of duodenum (red arrows) No free air around bowel Possible dilation and wall thickening

air Adipose tissue around unusual air space is higher

12 Abdominal CT Unusual air space (red arrows) inferior to 3 rd portion of duodenum No intraperitoneal free air Adipose tissue around unusual air space is higher in density suggestive of inflammation around the duodenum

13 Abdominal CT Air within the mesentery (red arrows) Suggestive of perforation of the 3 rd portion of the duodenum into the retroperitoneum No ascites, no free air in the peritoneal cavity

14 Diagnosis: Perforation of a Duodenal Diverticulum

15 Air Within the Mesentery Intestine Visceral peritoneum Vein and artery Nerve and lymph Mesenteric peritoneum Air tracks down between the peritoneal reflection, around vasculature structures

16 Treatment: Emergent Surgical Partial Duodenectomy Surgical Note: Repair was done to a perforated diverticulum located in the 3 rd portion of the duodenum. There was also a small abscess in the retroperitoneum cavity which continued to the diverticulum. Edema and hypertrophy of mesentery near the third portion of the duodenum. No ascites/inflammation of ascending colon or appendix

17 Duodenal Diverticulum with Perforation 1) Definition: Aquired lesion consisting of a sac of mucousal and submucousal layers herniated through a muscular defect in the bowel wall. 75% occur within 2 cm of the ampulla of Vater. Perforation is a very rare complication and can be fatal unless diagnosed and treated quickly.

18 Duodenal Diverticulum with Perforation 2) Signs and Symptoms: Duodenal diverticula: Usually asymptomatic and usually discovered incidentally. In perforation of duodenal diverticulum: Non-specific abdominal pain or abdominal fullness Fever Nausea, vomiting Hyporesonant bowel sounds

19 Duodenal Diverticulum with Perforation 3) Epidemiology/Incidence: Duodenum is the second most common site of diverticula in the digestive tract. 5-15% of the population over age 50 have acquired duodenal diverticula Only about 100 reported cases of doudenal diverticulum perforation in the past 20 years Most common location of duodenal diverticula is inner medial wall or pancreatic border of the duodenal curve.

20 Duodenal Diverticulum with Perforation 4) Diagnosis: Plain radiographs often cannot detect free air in the retroperitoneal space. CT may show perforated diverticulum and abnormal air collection. Surgical exploration often needed to confirm diagnosis.

21 Duodenal Diverticulum with Perforation 5) Treatment: Duodenal diverticula are usually asymptomatic. Upon perforation, early emergency surgery is required. Post-operative operative antibiotics are essential.

22 References Duarte B, Nagy KK, Cintron J (1992) Perforated duodenal diverticulum.. Br J Surg 79(9): Glazer GM, Buy JN (1981) CT detection of duodenal perforation. AJR Am J Roenrgenol 137: Sakurai Y, Miura H, Matsubara T (2004) Perforated duodenal diverticulum successfully diagnosed peroperatively with abdominal CT scan associated with upper gastrointestinal series. J Gastroenterol 39(4):

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