Kelly Zucker, DO1, Nael Haddad, MD2, Joseph David, MD1 1University of Arizona College of Medicine, Phoenix, AZ; 2University of Arizona, Phoenix, AZ
Introduction: Diverticula are small, sac-like protrusions that can form throughout the lining of the digestive system. Diverticula most commonly occur in the colon. The duodenum is the second most common location. Complications such as diverticulitis or perforation will develop in less than 5% of patients with duodenal diverticula. We present a case of acute, symptomatic duodenal diverticulitis.
Case Description/Methods: A 72 year old female with past history of hypertension, overactive bladder, sacral neurostimulator presented with 2 days of epigastric pain, nausea, and bilious emesis. The pain was burning and radiated to the back. She endorsed chronic constipation. Vitals were within normal range, exam was notable for moderate tenderness in the epigastrium. Labs showed WBC count of 20.2, but otherwise normal CBC, CMP, lipase.
CT of the abdomen and pelvis with IV contrast showed a questionable abscess vs necrotic mass medial to the descending portion of the duodenum. Hepatobiliary surgery service (HBS) recommended GI consult for direct visualization. EGD revealed a large duodenal diverticulum impacted with fecalized material and copious pus, and was cleared with lavage, rat tooth forceps, biliary balloon, and a Roth net.
The following day she had improved pain, was tolerating oral intake and had a reduced WBC count. We recommended 14 days of antibiotics with close follow up as this was her first episode.
However, she proceeded with exploratory laparotomy and diverticulectomy as definitive management. The diverticulum was embedded in the head of the pancreas. HBS performed a diverting gastrojejunostomy rather than a Whipple procedure. This was complicated by intolerance to oral intake secondary to bowel edema. Initial gastrojejunostomy was converted to a Roux en Y gastrojejunostomy 4 weeks later. Her obstructive symptoms improved, but she developed nosocomial COVID-19. She required tracheostomy and eventually discharged to a long-term care facility.
Discussion: The prevalence of duodenal diverticula is rare and often asymptomatic. Besides diverticulitis, complications include pain, hemorrhage, biliary obstruction, and perforation. Our patient was successfully treated with endoscopy, however, she elected to undergo surgery. This was complicated by a non-functioning initial gastrojejunostomy and severe COVID-19 infection. This case demonstrates the need for careful consideration of the risks and benefits of surgery after successful endoscopic therapy for initial episode of duodenal diverticulitis.
Disclosures: Kelly Zucker indicated no relevant financial relationships. Nael Haddad indicated no relevant financial relationships. Joseph David indicated no relevant financial relationships.
Kelly Zucker, DO1, Nael Haddad, MD2, Joseph David, MD1. P1504 - Endoscopic Management of Acute Duodenal Diverticulitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.