Endoscopic diagnosis of upper gastrointestinal tract bleeding from a duodenal diverticulum

Endoscopic diagnosis of upper gastrointestinal tract bleeding from a duodenal diverticulum Dido Franceschi, William Castillo, Jen-Nan Yuh, Peter F. Chen,

MD MD MD MD

The clinical significance of duodenal diverticula has been a matter of controversy for many years. Although most diverticula are innocuous, over the last two decades various studies have established an association with biliary tract and pancreatic disease. I - 4 Also, multiple reports have appeared describing life-threatening situations related to duodenal diverticula, e.g., perforation, cholecystitis, intestinal obstruction, and massive hemorrhage. 5-8 Bleeding from a duodenal diverticulum can be caused by erosion into a vessel such as the aorta or a mesenteric vessel, by bleeding ectopic gastric mucosa, or from a local inflammatory process. 9 - 12 A rare case of bleeding from an intradiverticular polyp has also been documented. 13 This potentially lethal complication is usually diagnosed only at laparotomy. We report a case in which the diagnosis of upper gastrointestinal tract bleeding from a duodenal diverticulum was made preoperatively with endoscopy. Considerations regarding management and surgical approach are discussed. CASE REPORT

An 81-year-old white male was admitted to the hospital on August 6, 1985, because of an episode of melena on the day of admission. He also had nausea, postprandial coffeeground emesis, anorexia, weakness, dizziness, and dull, low grade bilateral lower abdominal pain throughout that day. He gave a previous history of cholecystectomy, hypertension, and a stroke and had been hospitalized 14 years ago for "colitis." On admission he was in no distress and vital signs were stable. Examination revealed a soft abdomen, no tenderness or peritoneal signs, and active bowel sounds. Stool was black and guaiac positive. Hemoglobin was 11.8 gjdl, hematocrit 33.3%, and white blood count 13,700jdl with 87 polymorphonuclear leukocytes. Amylase was 47 units. Other tests were normal including prothrombin, bleeding, and clotting times. Initial management consisted of intravenous hydration, nasogastric suction, and gastric lavage. Twelve hours after admission the patient had an episode of massive hematemesis and hematochezia. Stabilization was achieved with transfusion of 3 units of packed red blood cells and adequate fluids. An upper gastrointestinal endoscopy was done. Blood was found in the stomach; however, no active source of bleeding was identified. The endoscope was advanced into From the Departments of Surgery, Fairview General Hospital, Cleveland, Ohio, and Robinson Memorial Hospital, Ravenna, Ohio. Reprint requests: Peter F. Chen, MD, Department of Surgery, Robinson Memorial Hospital, 6847 N. Chestnut Street, Ravenna, Ohio 44266. VOLUME 33, NO.5, 1987

Figure 1. Diverticulum in third portion of duodenum. Multiple outpouchings and actively bleeding ulcer are noted.

the duodenum where at the 80-cm level a large diverticulum was identified (Fig. 1). Multiple outpouchings and an actively bleeding ulcer were within the diverticulum. The patient was taken promptly to surgery where a 2.5 X 2 cm diverticula was readily exposed in the antimesenteric border of the third portion of the duodenum. The diverticulum was excised, and the defect was repaired transversely by a 2-layer catgut and silk closure. The patient required transfusion of another unit of packed red blood cells postoperatively. Recovery was uneventful and the patient was discharged on the 12th postoperative day.

DISCUSSION

Duodenal diverticula, initially a surgical curiosity, are interesting lesions with controversial pathologic and surgical implications. They are classified into congenital, primary or acquired, and secondary or pseudodiverticula. 14 Most are found incidentally during an upper gastrointestinal roentgenographic examination with an incidence varying from 1% to 5%. However, Ackerman l5 reported a 22% incidence at autopsy and Osnes et aU 6 a 23% incidence during ERCP. Most diverticula are peri-Vaterian in the mesenteric border of the duodenum. 2,14 These are associated with biliary tract disease and have been implicated by Lotveit and Osnesl 7 as an important factor in the pathogenesis of pigmented biliary calculi. Interestingly, many of the reported cases of hemorrhage from duodenal diverticula have been from diverticula located away from the peri-Vaterian region. Clinical presentation varies greatly. Most of them are asymptomatic. Some present with nonspecific epi383

gastric symptoms or with signs and symptoms of the complications they cause, Le., gastrointestinal hemorrhage, perforation, cholangitis, pancreatitis, or biliary calculous disease. They have also been considered as etiologic factors in "postcholecystectomy syndromes."1,18 Ryan et al.,19 in the only other reported case of endoscopic diagnosis of a bleeding ulcer localized in a duodenal diverticulum, initially managed the patient conservatively with antiacids and sucrulfate, a management which contrasts with our approach. Management depends on the location of the duodenal diverticulum and the existing complication. Donald20 proposes excision or partial excision for bleeding duodenal diverticula; choledochoduodenostomy for common duct obstruction; and excision or partial excision, closure, and drainage for perforated duodenal diverticulum. However, he does suggest that consideration be given to complete diversion of intestinal stream from the duodenum in the latter situation. Critchlow et al. 21 report good results with duodenojejunostomy in three patients with pancreatobiliary complications. Whether or not to remove uncomplicated duodenal diverticula remains an unsettled issue. Cattell and Mudge ll report an 8% mortality during elective excision of duodenal diverticula. Iida 22 had no complications in 14 patients in which he did transduodenal diverticulectomy for periampullar diverticula associated with cholelithiasis. Most of the recent literature on this subject agrees in not recommending routine diverticulectomy but suggests that, due to the high incidence of morbidity and mortality of patients with complications from duodenal diverticula, an aggressive surgical approach should be considered when these complications occur. 2 ,2Q-25

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GASTROINTESTINAL ENDOSCOPY