Discussion
Duodenal diverticula are found in 5–10% of patients undergoing
radiological or endoscopic procedures and in 15–23% of patients at
autopsy 1. The duodenum is the most common site for
gastrointestinal diverticula after the colon, especially in the
parapapillary region of Vater and the horizontal and ascending portions
of the duodenum 4, 5. Unlike colon diverticulum,
duodenal diverticulum is relatively asymptomatic. However, the risk of
perforation should be kept in mind 6. Most of these
perforations were seen within the second portion of the duodenum, mainly
along the medial wall, within 2 cm of the ampulla of Vater. Duodenal
diverticulitis was the most common cause of DDP, representing 69% of
total associated cases 7. As perforation often occurs
in the retroperitoneum, typical signs of peritonitis are often absent.
Due to the lack of pathognomonic signs or symptoms, DDP is often
clinically mistaken for acute cholecystitis, appendicitis, and
perforated duodenal or gastric ulcers. Shimada et al. evaluated all 202
cases of DDP reported worldwide between 1907 and 2020. A total of 83%
of all reported cases underwent surgical treatment 8.
Simple closure of the perforated site is anatomically difficult when a
duodenal diverticulum perforates the retroperitoneum. A
pancreaticoduodenectomy must be performed to resect the duodenum that
has the perforated site. However, this treatment appears to be highly
invasive. Indeed, several cases in which surgical treatment was chosen
reportedly involved only drainage for retroperitoneal perforation9, 10. In addition, these patients required a longer
time to achieve postoperative cure. The morbidity and mortality rate for
surgical options are reaching as high as 30% 11,
including duodenal leak and fistulization; the option of conservative
treatment has become more common. The success rate of conservative
treatment, initially with broad-spectrum antibiotics, is very low. Given
these facts, nonsurgical drainage from a retroperitoneal abscess is an
option for treating perforated diverticula. However, percutaneous
drainage can be technically challenging. Therefore, if the symptoms
improve with endoscopic drainage, it is a valuable option.
Bezoars are composed of vegetable matter (phytobezoar), hair
(trichobezoar), or other unusual materials. Previous gastric surgery
(disturbance of pyloric function, gastric emptying, and hypoacidity),
poor mastication, or overindulgence with foods with high fiber content
are common predisposing factors for bezoar formation. There is only one
report of laparoscopic resection of a bezoar in a duodenal diverticulum12, but duodenal diverticular perforation due to
phytobezoar is rare.
We used the keywords “DDP” and “Endoscopic treatment” to conduct a
PubMed search, there were several reports of endoscopic treatment of
DDP. The information regarding the reported 7 patients and our case is
summarized in Table 1 10, 13–17. Endoscopic treatment
of DDP has increased since 2015. An ENBD catheter 17,
stent 15, and endoscopic negative pressure16 were used for treatment. In all the cases,
antibiotics were administered on admission, and endoscopic treatment was
performed concurrently or secondarily. These reports demonstrated food
debris and enteroliths in the duodenal diverticulum, which were removed
using lithotomy 10 or a combination of a balloon
catheter, Dormia basket, and an endoscopic retrograde
cholangiopancreatography (ERCP) injection catheter 13.
The symptoms improved immediately after endoscopic treatment. In this
case, the retroperitoneal abscess was cleaned with the placement of an
ENBD catheter in the diverticulum and endoscopic lithotripsy and was
significantly effective. However, the bezoar was so hard and sticky that
three endoscopic treatments were required to remove it. Flushing the
ENBD catheter with saline was particularly useful because now the bezoar
was smaller and softer. It has been reported that DDP can sometimes be
relieved with fasting and antibiotics. However, in this case, there was
no improvement in inflammatory findings or abdominal symptoms after
starting antibiotics; therefore, endoscopy was performed. Endoscopic
treatment was effective because the patient’s condition did not improve
until the phytobezoar of the duodenal diverticulum was removed.
Endoscopy can provide a more appropriate diagnosis, drainage, tube
washing, and even stone removal. Endoscopic therapy, due to its
therapeutic diversity, is valuable for the treatment of DDP.
In the current case, a previous CT scan revealed a duodenal
diverticulum, which helped in the diagnosis of DDP. It remains difficult
to distinguish DDP from duodenal perforation based on image studies and
clinical findings. However, even if the presence of a duodenal
diverticulum was not evident and CT showed a localized fluid collection
around the duodenum and no peritoneal irritation symptoms; DDP should be
suspected and endoscopic treatment considered.