JUNE, 1974 GIANT DUODENAL DIVERTICULA* By JACK R. MILLARD, M.D., FRED M. H. ZITER, JR., M.D., and WILLIAM P. SLOVER, M.D. HARTFORD, D UODENAL diverticula are common incidental findings on barium examinations of the upper gastrointestinal tract, and their usual appearance has been well described previously. Occasionally, they may become very large and present diagnostic difficulties on plain abdominal roentgenograms. Four patients with giant duodenal diventicula are reported to illustrate their modes of presentation. REPORT OF CASES CASE I. O.A., a 69 year old woman, was first seen at Hartford Hospital in 1960 at which time a retropenitoneal fibrosarcoma was removed. In J anuary, 1971, the patient was re-admitted with complaints of episodic nausea. A gastrointestinal series showed an i I cm. diverticulum arising laterally from the fourth portion of the duodenum (Fig. IA). A side-to-side duodenojejunostomy was performed, as it was felt that the diverticulum was causing partial and intermittent obstruction of the duodenum. A follow-up examination obtained 10 months later, because of symptoms of high intestinal obstruction, showed that the diverticulum had increased in size to 20 cm. and lay in the right lower quadrant (Fig. i, B and C). CASE II. J.G., a 64 year old woman, was admitted in January, 1968, for hemorrhoidal bleeding. The patient gave a history of intermittent diarrhea for 2 years which was controlled with tincture of opium. A roentgenogram preliminary to a barium enema examination showed an abnormal air-fluid collection in the right upper quadrant (Fig. ia). The subsequent upper gastrointestinal series demonstrated a 10 cm. diverticulum located laterally in the third portion of the duodenum (Fig. 2B). A follow-up examination i years later showed no change in the appearance of the diverticulum. CASE III. I.G., a 70 year old woman with a CONNECTICUT known duodenal diverticulum for more than 20 years was admitted in August, 1970, with a history of fatigue, nausea and vomiting. Roentgenograms obtained during a barium enema examination showed a loculated gas collection in the right upper quadrant (Fig. 3A). A subsequent upper gastrointestinal series demonstrated the presence of a large septate duodenal diverticulum arising from the third portion of the duodenum (Fig. 3B). Further work-up revealed the presence of pancreatic carcinoma. The patient was treated with chemotherapy. CASE IV. E.C., an 88 year old woman, was admitted to Hartford Hospital in October, 1972, with symptoms offatigue, nausea, anxiety and cancerophobia. Physical examination revealed a mass in the right lower quadrant. Subsequent tests proved this mass to be a lowlying right kidney. An upper gastrointestinal series showed a large duodenal diverticulum arising from the third portion of the duodenum (Fig. 4, A and B). All additional tests were within normal limits. DISCUSSION Diverticula of the duodenum are mcidental findings in 1-5 per cent of barium examinations of the upper gastrointestinal tract and in approximately 20 per cent of autopsies. The so-called primary or congenital diverticula have no muscularis propnia and are found most frequently in the second and third portions of the duodenum. Secondary or acquired diverticula (pseudodiverticula) contain all layers of the duodenal wall and are usually sequelae of inflammatory disease. They are most frequent in the first portion of the duodenum. In one series, 88 per cent of diverticula were located on the medial wall of the duodenum, 4 per cent laterally- and 8 per cent posteriorly.7 Most diverticula are asymptomatic, but several complications have been reported.2 4 6 9 These include * From the Department of Radiology, Hartford Hospital, Hartford, Connecticut. 334
VOL. 121, No. 2 Giant Duodenal Diverticula 335 r - -- small bowel obstruction from pressure phenomena, hemorrhage from ulceration,9 perforation and fistula formation.3 Occasionally, the common bile duct may insert into #{149}-#{149}.: verticujum -.-- - measurtpproximatelv 11cm. in diameter. ( B) Supine C) decuhitus plain abdominal roentgi no- )W marked increase in size of the diverths a tr. Because of the u ii usti a I - #{149} -r quadrant, it could iim.-. - I-I- - - #{149}r --#{149} - - :i -.- --r the diverticulum with subsequent biliary tract obstruction.7 Our cases demonstrate additional impontan t points concerning these diventi cula. 4
336 J. R. Millard, F. M. H. Ziten, Jr., and \V. P. Sloven JUNE, 1974 FIG. 2. Case n. (A) Smooth, gas-filled collection in the right upper quadrant. (B) Gastrointestinal series shows presence of a 10 cm. smooth walled lateral diverticulum of the duodenum. First, they may become very large and present as confusing collections of air and/or fluid on plain roentgenograms of the abdomen. These collections may be in sites other than the right upper quadrant (Case i). Such a diverticulum may then be incorrectly interpreted as an abscess, dilated cecum, colonic diventiculum or pseudocyst of the pancreas. As shown in Case I, the giant duodenal diverticulum can also enlarge greatly in the interval between examinations. Case III demonstrates that oblique roentgenograms may be of value by demonstrating the neck of the diverticulum, thereby offering a clue to the correct diagnosis. Case iv demonstrates that such diverticula need not be smooth-walled, but may present as multilocular collections of gas. This appearance may be confused with an abscess, especially since the diventiculum max lie near Morrison s pouch.
VOL. 12!, No. 2 Giant Duodenal Diverticula 337 FIG. 4. Case iv. (A) Multiloculated gas-filled collection in the right mid-abdominal region. (B) Septate duodenal diverticulum shown on gastrointestinal series. As noted previously, the great majority ofduodenal diventicula occur on the medial aspect ofthe duodenum. In all ofoun cases, the giant diverticula arose laterally. Since medial diverticula are frequently sunrounded by pancreatic tissue, gross enlargement of the diverticula would seem unlikely. However, it appears possible that the lack of such containment of a laterallyoccurring diverticulum would account for their occasional large size. SUMMARY Four patients with giant duodenal diverticula are reported. The appearance of these diverticula on plain roentgenognams of the abdomen is discussed, as is a possible reason for their large size. Fred M. H. Ziter, Jr., M.D. Department of Radiology Hartford Hospital 8o Seymour Street Hartford, Connecticut o6i 15 REFERENCES I. ACKERMANN, \V. Diverticula and variations of duodenum. Ann. Surg., 1943, 117, 403-413. 2. CAVENAGH, J. E., JR. Enteroliths and perforation of duodenal diverticula. A.M.A. Arch. Surg., I970, /00, 614-618. 3. GALLIVAN, G. J., and PAINTER, R. W. Benign duodenocolic fistula. Hartford Hospital Bull., 1968,23, 86-98. 4. JULER, G. L., LIST, J. \V., STEMMER, E. A., and CosxoLLv, J. E. Perforating duodenal diverticulitis. A.M.A. Arch. Surg., 1969, 99, 572-578. 5. MARGULIS,.A. R., and BURHENNE, H. J. Editors. Alimentary Tract Roentgenology. C. V. Mosby Company, St. Louis, 1967, p. I 10. 6. MCSHERRY, C. W., and GLENN, F. Biliary tract obstruction and duodenal diverticula. Surg., Gvnec. & Obst., 1970, /30, 829-836. 7. MUNNELL, E. R., and PRESTON, W. J. Complications of duodenal diverticula. A.M.A. Arch. Surg., 1966, 92, 152-156. 8. NEILL, S. A., and THOMPSON, N. W. Complications ofduodenal diverticula and their management. Surg., Gynec. & Obst., 1965, 120, 125 I- 1258. 9. WOLFE, R. D., and PERAL, M. J. Acute perforation of duodenal diverticulum with roentgenographic demonstration of localized retroperitoneal emphysema. Radiology, 1972, 104, 30!- 302. FIG. 3. Case III. (A) Diverticulum seen as gas-filled structure on a barium enema roentgenogram. Oblique roentgenogram showed the neck of the diverticulum. (B) Gastrointestinal series confirms the presence of a Septate diverticulum arising laterally from the third portion of the duodenum.
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