23 year old female was presented with
postprandial epigastric fullness and vomiting since 4 months. Her barium meal
showed sack-like filling lesion in duodenum surrounded by radiolucent band
(Figure A). CECT abdomen revealed contrast
material–filled diverticulum (Figure B). She underwent duodenotomy and diverticulum excision.
http://imagejournals.org/unusual-cause-of-gastric-outlet-obstruction.pdf
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Discussion:
Duodenal diverticula can be extraluminal or intraluminal.
Extraluminal diverticula are seen in 5% of X Rays and 20 to 30% of ERCP.
Thought to be acquired; incidence increase with age typically after 50 years.
75% are located within 2cm of ampulla, called Juxtapapillary diverticula, which can pose difficulty in cannulation during ERCP.
It can be misinterpreted as pancreatic fluid collection, cystic pancreatic neoplasm or distal CBD stone.
Problems associated with extraluminal duodenal diverticula include perforation or diverticulitis, bleeding, acute pancreatitis, and bile duct stones.
Bleeding from diverticula can be controlled using various endoscopic techniques including bipolar cautery, epinephrine injection, and hemoclips.
Care should be taken to avoid injury to CBD or PD if surgical treatment of bleeding or perforation is contemplated.
Intraluminal diverticula - very rare,
Intraluminal duodenal diverticula (windsock diverticula) are single saccular structures that originate in the second portion of the duodenum.
Abnormal recanalization may lead to a duodenal diaphragm or web. Over time, peristaltic stretching may transform the diaphragm into an intraluminal diverticulum.
Barium studies typically shows globular structure of variable length, originating in the second portion of the duodenum, with its fundus extending into the third portion and outlined by a thin radiolucent line.
CT shows as a ring-like soft tissue density in the lumen of the second portion of the duodenum, outlined with oral contrast and containing oral contrast and a small amount of air (halo sign).
Endoscopy can demonstrate a sac like structure with an eccentric aperture or large soft polypoidal mass.
It can surgically or endoscopically resected.
References:
Sleisenger and Fordtran's gastrointestinal and liver disease; 10th edition, Philadelphia, PA : Saunders/Elsevier, [2016]