Diagnostic Radiology
Association of Intraluminal Duodenal Diverticulum with Acute Pancreatitis 1 John L. Nosher, M.D. and William B. Seaman, M.D. A case of acute pancreatitis is reported in a patient with an intraluminal duodenal diverticulum. Five previous reportsof thisassociation are cited, andthe mechanisms through which the intraluminal duodenal diverticulum maycause pancreatitis are reviewed. INDEX TERMS:
Duodenum, diverticula. Pancreatitis
Radiology 115:21-22, April 1975
• HE
MUCOSAL
SAC
or
intraluminal
diverticulum
Twhich occurs within the lumen of the duodenum is usually an incidental finding of no clinical significance. The sacs are always attached to the duodenal wall near the papilla of Vater. The sixth case associated with acute pancreatitis is reported, with the suggestion that these two conditions may be etiologically related.
Fig. 1. Intraluminal duodenal diverticulum filled with barium is in the third portion of the duodenum and appears as an oval sac (arrows) outlined by a thin radiolucent band which represents the mucosa of the diverticulum.
CASE REPORT This 42-year-old woman had had intermittent episodes of epigastric pain for as long as she could remember. Four years before, an intraluminal duodenal diverticulum was detected. One month prior to admission, she noted the onset of severe upper abdominal pain. There was no history of alcohol consumption or medication use. At the time of hospital admission the serum amylase was 1720 Myers and Killian units (normal less than 55 Myers and Killian units). On conservative management the symptoms subsided and the amylase level returned to normal. Upper gastrointestinal examination again revealed an intraluminal duodenal diverticulum originating in the second portion of the duodenum and extending to five centimeters proximal to the ligament of Treitz (Fig. 1). The ligament of Treitz was inferiorly displaced by an enlarged pancreas which also indented the greater curvature of the distal stomach. An oral cholecystogram visualized a normal gallbladder.
The radiographic appearance of the intraluminal duodenal diverticulum is a fingerlike sac filled with barium and surrounded by barium so that the mucosa appears as a radiolucent band. When empty of barium it may look like a pedunculated polyp. In this patient there. is no cause for pancreatitis except the presence of an intraluminal duodenal diverticulum. This association has been reported five times previously (2-6). The proximity of the attachment of the diverticulum to the papilla of Vater suggests the possibility of partial obstruction of the duodenum by the diverticulum which may allow reflux of duodenal contents into the pancreatic ducts causing pancreatitis in a manner similar to the experimental model of Pfeffer (7). Nance (2) proposes two mechanisms for induction of pancreatitis in a patient with an intraluminal diverticulum; either intermittent obstruction as the diverticulum distends, acutely raising the intraluminal pressure and forcing duodenal contents into the pancreatic ducts, or deformation of the papilla of Vater by traction from the diverticular attachment allowlnq reflux at normal duodenal pressures.
DISCUSSION An intraluminal duodenal diverticulum is a sac of duodenal mucosa and incomplete muscularis mucosa originating in the second portion of the duodenum. Its proximal portion is always attached to the wall of the duodenum near the papilla of Vater. It has been described in all age groups. Richardson and Martin (1) call attention to the fact that the windsock diaphragm of the duodenum in children and the intraluminal duodenal diverticulum in adults are probably the same entity, Most authorities now feel that the diverticulum occurs as the result of pulsion forces on a duodenal diaphragm. The most commonly observed symptoms are epigastric pain, postprandial fullness and vomiting. One-fourth of the patients exhibit evidence of gastrointestinal blood loss.
REFERENCES 1. Richardson WR, Martin LW: Pitfalls in the surgical management of the incomplete duodenal diaphragm. J Pediat Surg 4:303312, Jun 1969 2. Nance FC, Cocchiara J, Kinder JL: Acute pancreatitis associated with an intraluminal duodenal diverticulum. Gastroenterology 52:544-547, Mar 1967
1 From the Department of Radiology (J. LN.,. Chief Resident: W. B. S., Professor and Chairman), Columbia-Presbyterian Medical Center, New York, N. Y. Accepted for publication in November 1974. dk
21
22
JOHN
L. NOSHER AND WILLIAM B. SEAMAN
3. Buisseret E, Van Den Eynde P: Un type particular de diverticule duodenal. Acta Gastroent Belg 25:129-132, Feb 1962 4. Pergola F, Willemin A, Levy C: Diverticule interne de duodenum. Arch Mal Appar Dig 53:844-846, Jul-Aug 1964 5. Martinotti A, Di Carlo V, Bevilacqua G: Su un raro caso di diverticolo intraluminale del duodeno complicato da pancreatite acuta. Minerva Chir 24:1267-1271,15 Nov 1969 6. Lawson TL: Intraluminal duodenal diverticulum. A rare cause
April 1975
of acute pancreatitis. Am J Dig Dis 19:673-677, Jul1974 7. Pfeffer RB, Stasior 0, Hinton JW: The clinical picture of the sequential development of acute hemorrhagic pancreatitis in the dog. Surg Forum 8:248-251,1957 Department of Radiology Columbia-Presbyterian Medical Center New York, N. Y. 10032
Association of Intraluminal Duodenal Diverticulum with Acute Pancreatitis 1 John L. Nosher, M.D. and William B. Seaman, M.D. A case of acute pancreatitis is reported in a patient with an intraluminal duodenal diverticulum. Five previous reportsof thisassociation are cited, andthe mechanisms through which the intraluminal duodenal diverticulum maycause pancreatitis are reviewed. INDEX TERMS:
Duodenum, diverticula. Pancreatitis
Radiology 115:21-22, April 1975
• HE
MUCOSAL
SAC
or
intraluminal
diverticulum
Twhich occurs within the lumen of the duodenum is usually an incidental finding of no clinical significance. The sacs are always attached to the duodenal wall near the papilla of Vater. The sixth case associated with acute pancreatitis is reported, with the suggestion that these two conditions may be etiologically related.
Fig. 1. Intraluminal duodenal diverticulum filled with barium is in the third portion of the duodenum and appears as an oval sac (arrows) outlined by a thin radiolucent band which represents the mucosa of the diverticulum.
CASE REPORT This 42-year-old woman had had intermittent episodes of epigastric pain for as long as she could remember. Four years before, an intraluminal duodenal diverticulum was detected. One month prior to admission, she noted the onset of severe upper abdominal pain. There was no history of alcohol consumption or medication use. At the time of hospital admission the serum amylase was 1720 Myers and Killian units (normal less than 55 Myers and Killian units). On conservative management the symptoms subsided and the amylase level returned to normal. Upper gastrointestinal examination again revealed an intraluminal duodenal diverticulum originating in the second portion of the duodenum and extending to five centimeters proximal to the ligament of Treitz (Fig. 1). The ligament of Treitz was inferiorly displaced by an enlarged pancreas which also indented the greater curvature of the distal stomach. An oral cholecystogram visualized a normal gallbladder.
The radiographic appearance of the intraluminal duodenal diverticulum is a fingerlike sac filled with barium and surrounded by barium so that the mucosa appears as a radiolucent band. When empty of barium it may look like a pedunculated polyp. In this patient there. is no cause for pancreatitis except the presence of an intraluminal duodenal diverticulum. This association has been reported five times previously (2-6). The proximity of the attachment of the diverticulum to the papilla of Vater suggests the possibility of partial obstruction of the duodenum by the diverticulum which may allow reflux of duodenal contents into the pancreatic ducts causing pancreatitis in a manner similar to the experimental model of Pfeffer (7). Nance (2) proposes two mechanisms for induction of pancreatitis in a patient with an intraluminal diverticulum; either intermittent obstruction as the diverticulum distends, acutely raising the intraluminal pressure and forcing duodenal contents into the pancreatic ducts, or deformation of the papilla of Vater by traction from the diverticular attachment allowlnq reflux at normal duodenal pressures.
DISCUSSION An intraluminal duodenal diverticulum is a sac of duodenal mucosa and incomplete muscularis mucosa originating in the second portion of the duodenum. Its proximal portion is always attached to the wall of the duodenum near the papilla of Vater. It has been described in all age groups. Richardson and Martin (1) call attention to the fact that the windsock diaphragm of the duodenum in children and the intraluminal duodenal diverticulum in adults are probably the same entity, Most authorities now feel that the diverticulum occurs as the result of pulsion forces on a duodenal diaphragm. The most commonly observed symptoms are epigastric pain, postprandial fullness and vomiting. One-fourth of the patients exhibit evidence of gastrointestinal blood loss.
REFERENCES 1. Richardson WR, Martin LW: Pitfalls in the surgical management of the incomplete duodenal diaphragm. J Pediat Surg 4:303312, Jun 1969 2. Nance FC, Cocchiara J, Kinder JL: Acute pancreatitis associated with an intraluminal duodenal diverticulum. Gastroenterology 52:544-547, Mar 1967
1 From the Department of Radiology (J. LN.,. Chief Resident: W. B. S., Professor and Chairman), Columbia-Presbyterian Medical Center, New York, N. Y. Accepted for publication in November 1974. dk
21
22
JOHN
L. NOSHER AND WILLIAM B. SEAMAN
3. Buisseret E, Van Den Eynde P: Un type particular de diverticule duodenal. Acta Gastroent Belg 25:129-132, Feb 1962 4. Pergola F, Willemin A, Levy C: Diverticule interne de duodenum. Arch Mal Appar Dig 53:844-846, Jul-Aug 1964 5. Martinotti A, Di Carlo V, Bevilacqua G: Su un raro caso di diverticolo intraluminale del duodeno complicato da pancreatite acuta. Minerva Chir 24:1267-1271,15 Nov 1969 6. Lawson TL: Intraluminal duodenal diverticulum. A rare cause
April 1975
of acute pancreatitis. Am J Dig Dis 19:673-677, Jul1974 7. Pfeffer RB, Stasior 0, Hinton JW: The clinical picture of the sequential development of acute hemorrhagic pancreatitis in the dog. Surg Forum 8:248-251,1957 Department of Radiology Columbia-Presbyterian Medical Center New York, N. Y. 10032
