Retroperitoneal Duodenal Diverticulum Microperforation: The Role of Computed Tomography.

Duodenal diverticula are relatively common, but perforations are rare and therapy has not yet been standardized. The most common location of diverticula is the descending duodenum, usually on the lateral side next to the pancreas, so perforations present with an atypical clinical course. We present a case of a 73-year-old female patient with epigastric pain and nausea. Abdominal CT revealed an air-fluid collection near the laterocaudal border of the descending duodenum, suggestive of duodenal microperforation and incipient abscess formation. During the operation, a diverticulectomy was performed with primary duodenal closure and abdominal drainage. A diverticulum microperforation contains some extraduodenal air bubbles, no evidence of abscess, and free air in the subdiaphragmatic region. It is an imaging entity with distinct clinical and biochemical features, and radiological findings often determine the final decision on treatment.

Traumatic perforated duodenal diverticulum after a fight, a case report.

INTRODUCTION: Fewer than 200 cases of Perforated Duodenal Diverticulum ("PDD") have been reported in the literature. The percentage of caused by trauma is generally very low and similar to rates recorded for duodenal injuries caused by trauma in the absence of diverticula (3 %-5 %). As a rare cause of abdominal pain after trauma, perforated duodenal diverticula are seldom diagnosed preoperatively. Despite preoperative CT scan demonstrating duodenal perforation, a diverticular origin is often only identified intraoperatively. PRESENTATION OF CASE: A 36-year-old man was admitted to the emergency department with severe upper abdominal pain that began after blunt trauma by a kick to his upper abdomen during a fight. A duodenal injury was identified by CT. Exploratory laparotomy then revealed a retroperitoneal perforation of a diverticulum located at the second segment of the duodenum. DISCUSSION: A review of the literature found few cases reporting perforated duodenal diverticulum secondary to trauma. Most cases identified the diverticulum at intraoperative exploration, with most approaches being through open surgery. CONCLUSION: Perforation of a duodenal diverticulum secondary to trauma is an extremely rare event, which is why it is often overlooked in the differential diagnosis of acute abdomen. As the presenting signs are often suggestive of duodenal perforation without a clear notion of duodenal diverticula at CT scan, a surgical approach and exploration is most frequently described. In our experience, the management of traumatic PDD aligns with the literature favoring the open surgical approach.

Beyond the Usual Suspects: A Pictorial Case Report of Lemmel Syndrome Emphasizing the Role of Multimodality Imaging.

Lemmel syndrome, characterized by biliary and pancreatic duct obstruction secondary to a periampullary duodenal diverticulum (PAD), remains a rare and often overlooked diagnosis. Although duodenal diverticula are found in approximately 23% of the population, only about 5% of these cases lead to complications such as obstructions. A new case of Lemmel syndrome is demonstrated in the article about a middle-aged woman with chronic epigastric pain and right upper abdominal quadrant initially misdiagnosed as cholelithiasis. The accuracy of diagnosis was made possible by multimodal imaging methods, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) with oral contrast when a diffuse common bile duct was compressed by a PAD. Additionally, it highlights the necessity of including Lemmel syndrome in cases where patients have dilated bile ducts without calculi or mass lesions while emphasizing advanced imaging techniques for the revelation of structural malformations that underlay these conditions. The endoscopic intervention was minimally invasive but effective in relieving symptoms through sphincterotomy followed by laparoscopic cholecystectomy and biliary stent placement, thus making a point of the need for multiple disciplinary approaches toward treatment rare phenomenon like this one. This case report not only sheds light on the diagnostic and therapeutic avenues for Lemmel syndrome but also serves as a valuable educational resource for healthcare professionals. It emphasizes the need for heightened clinical vigilance and the adept use of imaging modalities in cases of biliary obstruction with obscure etiology. By contributing to the growing knowledge of this rare condition, we aim to facilitate timely diagnosis and optimize patient outcomes.

Concomitant Sigmoid Diverticulitis and Periampullary Duodenal Diverticulitis Complicated by Lemmel Syndrome: A Case Report.

Diverticular disease is a major cause of hospitalizations, especially in the elderly. Although diverticulosis and its complications predominately affect the colon, the formation of diverticula in the small intestine, most commonly in the duodenum, is well characterized in the literature. Although small bowel diverticula are typically asymptomatic, and diagnosed incidentally, a complication of periampullary duodenal diverticulum is Lemmel syndrome. Lemmel syndrome is an extremely rare condition whereby periampullary duodenal diverticula, most commonly without diverticulitis, leads to obstruction of the common bile duct due to mass effect and associated complications including acute cholangitis and pancreatitis. Here, we present the first case, to our knowledge, of periampullary duodenal diverticulitis complicated by Lemmel syndrome with concomitant colonic diverticulitis with colovesical fistula. Our case and literature review emphasizes that Lemmel syndrome can present with or without suggestions of obstructive jaundice and can most often be managed conservatively if caught early, except in the setting of emergent complications.

Multi-slice spiral computed tomography diagnosis of juxta-papillary duodenal diverticulum and its relationship with biliopancreatic diseases.

BACKGROUND: Juxta-papillary duodenal diverticula (JPDD) are common but are usually asymptomatic, and they are often diagnosed by coincidence. OBJECTIVE: To analyse the anatomy and classification of JPDD and its relationship with biliary and pancreatic disorders, and to explore the diagnostic value of multi-slice spiral computed tomography (MSCT) in patients with JPDD. METHODS: The imaging data of patients with JPDD, which was obtained via abdominal computed tomography examination and confirmed via gastroscopy and/or upper gastrointestinal barium enema, in our hospital from 1 January 2019 to 31 December 2020 were retrospectively analysed. All patients were scanned using MSCT, and the imaging findings, classification and grading were analysed. RESULTS: A total of 119 duodenal diverticula were detected in 96 patients, including 73 single diverticula and 23 multiple diverticula. The imaging findings were mainly cystic lesions of the inner wall of the duodenum protruding to the outside of the cavity. The thin layer showed a narrow neck connected with the duodenal cavity, and the shape and size of the diverticula were different: 67 central-type cases and 29 peripheral-type cases. There were 50 cases of type I, 33 cases of type II, 19 cases of type III and six cases of type IV. Furthermore, there were seven small, 87 medium and 14 large diverticula. The differences in the location and size of the JPDD in MSCT grading were statistically significant (P< 0.05). CONCLUSION: The MSCT method has an important diagnostic value for the classification of JPDD, and MSCT images are helpful in the clinical evaluation of patients with JPDD and the selection of treatment options.

A Tale of 2 Tics: Endoscopic Treatment of Perforated Periampullary Diverticulum Within a Giant Duodenal Diverticulum.

Periampullary diverticulum presenting with severe complications, such as perforations, is associated with high morbidity and mortality. Traditionally, only surgical or conservative management has been warranted. In this case, we present a 76-year-old woman with a spontaneously perforated periampullary diverticulum, located within a larger duodenal diverticulum, who achieved complete recovery with endoscopic closure after an initial unsuccessful attempt at surgical management. This case report highlights the role of endoscopy in the treatment of complicated diverticulum perforation.

Dieulafoy's Lesion in a Duodenal Diverticulum: A Case Report and Literature Review.

This report presents a case of Dieulafoy's lesion (DL), a rare and serious gastrointestinal condition, which occurred unusually in a duodenal diverticulum and highlights the diagnostic and management complexities associated with it. A literature review of six similar cases revealed commonalities in presentation, diagnosis, and management, emphasizing the complexities in identifying and handling this rare manifestation of DL. The findings emphasize the need for clinical vigilance and further research into optimizing strategies for diagnosing and managing this rare condition.

Combination of Cattell-Braasch and Kocher maneuver in laparotomy for diverticular resection in the third part of the duodenum: a case report.

A duodenal diverticulum is an outpouching of all or partial layers of the duodenal wall. Duodenal diverticulum complications such as bleeding, diverticulitis, pancreatitis, choledochal occlusion, and perforation can develop. Localization of the diverticulum in the third part of the duodenum is rare. Surgical intervention with a combination of Cattell-Braasch and Kocher maneuvers in laparotomy is currently emerging as a viable option. Case presentation: The authors report a case of a 68-year-old male with chief complaints of black stool and recurring epigastric pain. Barium follow-through showed diverticulum at the third part of the duodenum. Surgery with a combination of Cattell-Braasch and Kocher's maneuvers using a linear stapler was successful, and there were no intraoperative or postoperative complications. Postoperative barium follow-through showed no diverticulum residue. The patient had no more complaints of black stools nor epigastric pain. Clinical discussion: Symptomatic duodenal diverticulum is a rare case with a very small chance of complications. Due to its lack of specific symptoms, imaging examinations play a better role in diagnosis. Surgical intervention is also rarely performed due to the small chance of complications. Diverticulectomy with the use of Cattell-Braasch and the extended Kocher maneuver results in better duodenum exposure, and the usage of a linear stapler also made the surgery safer and quicker to perform. Conclusion: The authors propose that a diverticulectomy of the third part of the duodenum performed with a combination of the Cattell-Braasch and Kocher maneuvers with the use of a linear stapler as a safe procedure.

Lemmel syndrome, a rare cause of obstructive jaundice by periampullary duodenal diverticulum: Case report and review of the literature.

Lemmel syndrome is a pancreaticoduodenal disease caused by compression of the mid or distal common bile duct by a periampullary diverticulum. This condition should be considered a rare complication of a duodenal diverticulum and an unusual cause of obstructive jaundice. Because of its infrequent occurrence and non-specific clinical presentation, Lemmel syndrome can mimic other conditions. We herein report the clinical and imaging findings (computed tomography, magnetic resonance imaging) of a patient who presented with intermittent abdominal pain and jaundice. Large air-filled outpouching lesions of the duodenum compressed the biliary duct, resulting in upstream biliary ductal dilatation that led to the diagnosis of Lemmel syndrome.

Duodenal Diverticular Bleeding Treated with Endoscopy or Transcatheter Arterial Embolization: A Report of Two Cases and a Literature Review.

Duodenal diverticular bleeding (DDB) is extremely rare. We herein report 2 life-threatening cases of DDB successfully treated with endoscopy or transcatheter arterial embolization (TAE) and review 13 cases of DDB reported from Japan. When upper gastrointestinal bleeding of unknown origin is encountered in middle-aged or older adults, DDB should be included in the differential diagnosis. DDB often causes massive bleeding. It is therefore important to judge which is safer and more effective, endoscopy or TAE, based on the general condition of the patient. In addition, it is critical to attempt hemostasis via various strategies, including different gastroscopes and hemostatic devices.

Periampullary diverticulitis (Lemmel's syndrome) misdiagnosed as pancreatic head tumor: A report of two cases.

INTRODUCTION AND IMPORTANCE: Lemmel's syndrome is a rare condition caused by a periampullary duodenal diverticulum that compresses the ampulla, causing jaundice. Two cases of misdiagnosis as pancreatic tumors are presented, both confirmed as Lemmel's syndrome with MRCP. Conservative therapy is the main treatment, with invasive procedures reserved for rare cases. CASE PRESENTATION: Case 1: An 82-year-old patient presented with abdominal pain, vomiting, fever, weight loss, and jaundice. MRCP showed a pancreatic head tumor, but multiple scans and procedures confirmed the diagnosis of Lemmel's syndrome caused by a periampullary duodenal diverticulum. Case 2: A 48-year-old patient had abdominal pain, vomiting, temperature, acholic feces, and jaundice. MRI with MRCP suggested a pancreatic tumor, and the patient underwent ERCP, papillotomy, and biliary stent placement. However, after three failed stent changes, MRCP revealed Lemmel's syndrome. CLINICAL DISCUSSION: Lemmel's syndrome can be diagnostically challenging for physicians as it mimics pancreatic tumors. MRCP is the primary diagnostic tool, and conservative therapy is the primary treatment, with invasive procedures being uncommon. CONCLUSION: Consider Lemmel's syndrome as a possible differential diagnosis in obstructive jaundice cases. Comprehensive diagnostic methods and repeated imaging are crucial to prevent misdiagnosis. Early detection and appropriate treatment can improve patient outcomes.

Bezoar in a periampullary duodenal diverticulum causing pancreaticobiliary obstruction and ascending cholangitis.

Ascending cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain. It is caused by stasis and infection in the biliary tract with severity ranging from mild to life threatening. The most frequent causes of biliary obstruction and ascending cholangitis are choledocholithiasis, benign biliary stricture, and obstructing malignancy. In this report, we describe a rare case of a large periampullary duodenal diverticulum impacted with a food bezoar, causing pancreaticobiliary obstruction and ascending cholangitis.

Duodenal Diverticular Perforation Treated Conservatively: Reassessing Indications for Treatment.

A 59-year-old woman presented with a chief complaint of melena. She had no abdominal findings, such as tenderness or tapping pain. Laboratory tests revealed a white blood cell count of 5,300 cells/µL and C-reactive protein level of 0.07 mg/dL. Inflammation and anemia (hemoglobin 12.4 g/dL) were denied. Contrast-enhanced computed tomography (CT) revealed multiple duodenal diverticula and air surrounding a descending duodenal diverticulum. Based on these findings, duodenal diverticular perforation (DDP) was suspected. Oral food intake was stopped, and nasogastric tube feeding and conservative treatment with cefmetazole, lansoprazole, and ulinastatin were begun. On day 8 of hospitalization, follow-up CT revealed the disappearance of the air surrounding the duodenum, and the patient was discharged on day 19 after the resumption of oral feeding.

A Rare Presentation of Duodenal Diverticulum Causing Obstructive Jaundice: Lemmel's Syndrome.

Lemmel syndrome is an uncommon pancreaticobiliary consequence of duodenal diverticula. We herein present a case of an 80-year-old male who presented with upper abdominal discomfort. Based on lab values and relevant clinical history, a diagnosis of obstructive jaundice was made. A contrast-enhanced CT scan of the abdomen revealed gross dilatation of intra-hepatic and extra-hepatic bile duct, cystic duct, common bile duct, major and minor pancreatic duct. A contrast-filled outpouching was seen from the medial wall of the second part of the duodenum with duodenal diverticulum and papilla within it. The abrupt termination of the common bile duct and main pancreatic duct adjacent to the thickened wall of the diverticulum was the cause of the patient's pancreaticobiliary obstruction. In the absence of cholelithiasis or tumor, the duodenal diverticulum that manifests as obstructive jaundice is known as Lemmel syndrome. Prompt identification of Lemmel syndrome can avoid dangerous complications and unnecessary investigations. Gallstones, cholangitis, and bile duct stones are more common in patients with duodenal diverticula. Treatment depends on patient presentation and may involve conservative management, surgical procedures in the form of excision of the diverticulum, or even endoscopic sphincterotomy or stenting.

Lemmel syndrome: an unusual cause of biliary obstruction secondary to a duodenal juxta-ampullary diverticulum: a report of two cases.

Lemmel's syndrome is a rare cause of obstructive jaundice caused by a periampullary duodenal diverticulum compressing the intrapancreatic common bile duct with resultant bile duct dilatation, patients with Lemmel's syndrome usually present with abdominal pain or jaundice. Cross-sectional imaging is beneficial in making the diagnosis noninvasively, thus eliminating other pathologies of the peri-ampullary region. Although rare, we recognize the importance of considering this syndrome to be able to make a diagnosis and offer timely treatment. We present 2 cases of Lemmel's syndrome whose diagnosis is retained based on a CT scan and magnetic resonance cholangiopancreatography.

Acute hypotensive hematochezia due to jejunal diverticular bleed.

Small bowel diverticulum, though rare, can result in complications including diverticulitis, hemorrhage, intussusception, fistula, perforation, or bacterial overgrowth. Here, we present a case of gastrointestinal bleeding as a complication of jejunal diverticulum, resulting in hemorrhagic shock. The patient had a negative endoscopy and colonoscopy, prompting computed tomography angiogram, which identified one jejunal diverticulum with active contrast extravasation into the lumen of the small bowel. She underwent successful coil embolization, resulting in cessation of bleeding. This case demonstrates the difficult but successful identification of nonsteroidal antiinflammatory drug-induced jejunal diverticular bleeding in the acute emergent setting.

Duodenal diverticulum metastasis from pulmonary squamous cell carcinoma diagnosed by EUS-FNA.

A 76-year-old male with pulmonary squamous cell carcinoma achieved complete response by chemoradiotherapy and subsequent systemic chemotherapy. During follow-up, fluorodeoxyglucose positron emission tomography/computed tomography showed strong fluorodeoxyglucose accumulation near the duodenal papilla. Elevated lesions were observed in the duodenal diverticulum upon lateral-viewing endoscopy, and a curved linear array echoendoscope showed a hypoechoic mass. Since it was difficult to obtain adequate tissue samples by endoscopic biopsy, endoscopic ultrasound-guided fine needle aspiration was performed for the hypoechoic mass. The pathological findings were squamous cell carcinoma, which was similar to the past histology of primary lung cancer. These findings indicated the diagnosis of duodenal diverticulum metastasis from pulmonary squamous cell carcinoma. Duodenal metastasis of pulmonary squamous cell carcinoma is a rare disease, and there have been no reports of duodenal diverticulum metastasis.

Debris-Filled Duodenal Diverticulum and Lemmel's Syndrome.

We report a case of a 73-year-old woman affected by Lemmel's syndrome, a rare type of obstructive jaundice caused by a periampullary duodenal diverticulum. The patient was admitted to the Emergency Department for pneumonia associated with mild epigastric pain and vomiting. While hospitalized for antibiotic treatment, the appearance of jaundice led us to discover a periampullary duodenal diverticulum by endoscopy and CT scan. The jaundice was successfully managed endoscopically with removal of food debris from the diverticulum.