Overview
Definition:
Duodenal diverticula are outpouchings or sac-like herniations of the duodenal wall, most commonly occurring at the junction of the second and third parts of the duodenum, close to the ampulla of Vater
Diverticulosis refers to the presence of multiple such diverticula, while diverticulitis signifies inflammation of a diverticulum.
Epidemiology:
Duodenal diverticula are found in 5-10% of the general population undergoing upper gastrointestinal imaging or endoscopy
They are more common in older individuals, with increasing prevalence after the age of 50
Most are asymptomatic.
Clinical Significance:
While often asymptomatic, duodenal diverticula can lead to significant morbidity due to complications like bleeding, perforation, obstruction, and inflammation, posing diagnostic and management challenges for surgeons
Their proximity to the ampulla of Vater can also lead to biliary and pancreatic issues.
Clinical Presentation
Symptoms:
Asymptomatic in most cases
Symptomatic presentations include vague abdominal pain, particularly in the epigastrium
Nausea and vomiting can occur with partial obstruction
Dyspepsia, early satiety, and bloating are also reported
Significant bleeding can manifest as hematemesis or melena
Perforation presents with sudden, severe abdominal pain and peritonitis.
Signs:
Physical examination may reveal epigastric tenderness
In cases of significant inflammation or perforation, signs of peritonitis such as guarding, rigidity, and rebound tenderness may be present
Evidence of anemia may be noted in patients with occult or overt gastrointestinal bleeding.
Diagnostic Criteria:
No specific diagnostic criteria exist for duodenal diverticulosis itself
Diagnosis is typically made incidentally during investigations for other gastrointestinal symptoms
Symptomatic diverticulitis is diagnosed based on clinical presentation, imaging findings, and exclusion of other causes.
Diagnostic Approach
History Taking:
Detailed history of abdominal pain (location, character, duration, exacerbating/relieving factors)
Assess for associated symptoms like nausea, vomiting, dyspepsia, early satiety, changes in bowel habits
Inquire about any history of gastrointestinal bleeding (hematemesis, melena)
Screen for risk factors like older age and NSAID use.
Physical Examination:
Thorough abdominal examination focusing on palpation for tenderness, masses, and signs of peritonitis
Assess for signs of anemia, such as pallor
Perform rectal examination to assess for melena.
Investigations:
Upper gastrointestinal endoscopy (EGD) is the gold standard for diagnosing duodenal diverticula, allowing direct visualization and biopsy if needed
Barium studies can also identify diverticula
CT scan of the abdomen is crucial for evaluating complications like perforation, abscess formation, or obstruction
Laboratory tests include CBC (for anemia), liver function tests, and amylase/lipase to rule out biliary or pancreatic involvement.
Differential Diagnosis:
Peptic ulcer disease, gastric or duodenal neoplasms, Crohn's disease of the duodenum, superior mesenteric artery syndrome, appendicitis (if pain migrates), cholecystitis, pancreatitis, and other causes of upper GI bleeding or perforation.
Management
Initial Management:
For asymptomatic diverticula, no specific treatment is required
For symptomatic diverticula, management is often conservative
For acute complications like perforation or significant bleeding, immediate surgical intervention is often necessary
Management involves resuscitation, IV fluids, antibiotics, and pain control.
Medical Management:
Symptomatic relief with antacids, proton pump inhibitors (PPIs) for dyspepsia or associated reflux
For diverticulitis, conservative management with bowel rest, IV fluids, and broad-spectrum antibiotics (e.g., ceftriaxone and metronidazole) is indicated for uncomplicated cases
Pain management is crucial.
Surgical Management:
Surgical intervention is reserved for complicated cases
Indications include recurrent or severe bleeding, perforation with peritonitis, abscess formation, or bowel obstruction
Procedures include: Diverticulectomy (excision of the diverticulum), which can be challenging due to location
Resection with anastomosis or a diversionary procedure like a Roux-en-Y duodenojejunostomy to bypass the diverticulum may be performed
Laparoscopic approaches are being increasingly utilized for elective cases.
Supportive Care:
Nutritional support, often with nasogastric decompression in cases of obstruction or ileus
Close monitoring of vital signs, fluid balance, and pain control
Postoperative care includes gradual resumption of oral intake and monitoring for surgical site infections or anastomotic leaks.
Complications
Early Complications:
Hemorrhage (ranging from occult to massive), perforation leading to peritonitis, abscess formation, duodenal fistula, and pancreatitis or cholangitis due to ampullary involvement
Postoperative complications include anastomotic leak, ileus, and wound infection.
Late Complications:
Chronic abdominal pain, partial or complete gastric outlet obstruction due to inflammation or scarring, and recurrent episodes of diverticulitis
Malabsorption syndromes are rare but possible with extensive disease.
Prevention Strategies:
There are no specific preventative strategies for the development of duodenal diverticula
For symptomatic patients, managing comorbidities like GERD and avoiding irritants such as NSAIDs may help reduce symptomatic episodes
Prompt recognition and management of complications are key to minimizing morbidity.
Prognosis
Factors Affecting Prognosis:
The prognosis for asymptomatic duodenal diverticula is excellent
For symptomatic or complicated diverticula, prognosis depends on the nature and severity of the complication, the chosen management strategy, and the patient's overall health status
Prompt surgical intervention in acute complications generally leads to better outcomes.
Outcomes:
Most patients with asymptomatic duodenal diverticula require no treatment and have normal outcomes
For those requiring surgery for complications, successful management leads to resolution of symptoms and prevention of further morbidity, though some long-term sequelae may persist.
Follow Up:
Asymptomatic patients with duodenal diverticula require no specific follow-up
Patients who have undergone surgery for complicated diverticula should have regular follow-up appointments to monitor for any recurrence of symptoms, assess nutritional status, and evaluate for long-term complications
Imaging may be performed based on clinical suspicion.
Key Points
Exam Focus:
DNB/NEET SS aspirants must know that duodenal diverticula are often asymptomatic and found incidentally
Key complications include bleeding, perforation, and obstruction
Management is usually conservative for asymptomatic cases, but surgery is indicated for complications
Understand the surgical options: diverticulectomy vs
bypass procedures.
Clinical Pearls:
Remember the triad of symptoms for complicated diverticulitis: abdominal pain, fever, and leukocytosis
Diverticula near the ampulla of Vater are particularly important due to potential for biliary or pancreatic complications
CT scan is essential for diagnosing complications like perforation and abscess.
Common Mistakes:
Over-treatment of asymptomatic diverticula
Underestimating the risk of bleeding or perforation in symptomatic cases
Inadequate workup to rule out other causes of similar symptoms, especially malignancy
Inappropriate surgical approach without considering the diverticulum's location and patient factors.