Westchester Medical Center at New York Medical College Tarrytown, NY
Anila Kumar, DO1, Tracey Kenneally, FNP2, Mehtap Canastar, MD2, Shireen Pais, MD2; 1Westchester Medical Center at New York Medical College, Tarrytown, NY; 2Westchester Medical Center at New York Medical College, Valhalla, NY
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.
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.
Cholangiogram showing stricture spanning the distal half of the CBD.