Harlem Hospital Center New York, NY, United States
Angela Oduro-Afriyie, MD, Jeff C. Anucha, MD, Genoa Alvaro, MD, FACG, Joan Culpepper-Morgan, MD, FACG Harlem Hospital Center, New York, NY
Introduction: Duodenal diverticula are usually single or double and clinically silent. They are seen on up to 20% of upper endoscopies. Duodenal diverticulosis refers to finding up to five diverticula in the duodenum. Massive jejunal diverticulosis has been described. We report a case of massive duodeno-jejunal diverticulosis complicated by Superior Mesenteric Artery (SMA) Syndrome.
Case Description/Methods: An 88-year old female nursing home resident presented with advanced dementia, decreased oral intake, severe cachexia, and a BMI of 9.2. CBC revealed anemia (Hb 7.6). Chemistry was remarkable for azotemia (BUN/Cr= 38 /1.1). Albumin was 3.0 g/dl on admission. Abdominal CT done without oral contrast revealed a dilated fluid filled loops of small and large bowel with giant duodenum. Numerous diverticula of the large and small bowel were noted. Pneumobilia was present. Obstruction was not suspected. Percutaneous endoscopic gastrostomy (PEG) tube was placed to supplement nutrition. A massively dilated duodenum was seen honeycombed with enumerable diverticula within diverticula. Biopsies of the non-diverticular duodenum showed partial villous atrophy, which likely contributed to her malnutrition. Repeat CT of the abdomen with oral contrast confirmed massive duodenal diverticulosis, SMA syndrome, and choledochoduodenal fistula. Patient was transferred to ICU hospital day 9 for management of hypovolemic shock and acute anemia. No gross bleeding was seen. Patient was made DNR/DNI as per her family’s request and passed away on day 13 of admission.
Discussion: Duodenal diverticulosis is rare and most patients are asymptomatic. However, complications like inflammation, perforation, retroperitoneal abscess, sepsis, pancreatitis, bile duct obstruction, and bleeding can occur. Our patient had duodenal obstruction and choledochoduodenal fistula. She also had multiple diverticula of the small and large intestine. SMA syndrome is typically a disease of young females. Our patient was 88 years old. It is likely that the distention of her diverticula over time contributed to her obstructed duodenum.
Figure: Duodeno-Jejunal Diverticulosis and Superior Mesenteric Artery Syndrome
Angela Oduro-Afriyie indicated no relevant financial relationships.
Jeff Anucha indicated no relevant financial relationships.
Genoa Alvaro indicated no relevant financial relationships.
Joan Culpepper-Morgan indicated no relevant financial relationships.
Angela Oduro-Afriyie, MD, Jeff C. Anucha, MD, Genoa Alvaro, MD, FACG, Joan Culpepper-Morgan, MD, FACG. P1975 - Massive Duodeno-Jejunal Diverticulosis Leading to Fatal Superior Mesenteric Artery Syndrome, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.