Gastrointestinal
Radiology
Gastrointest Radiol 3, 19--21 (1978)
Gallstone Duodenum: Unusual Complication of an Obstructing Intraluminal Duodenal Diverticulum Chandrakant
C. K a p d i 1 a n d M a u r i c e T a t e l m a n 2
1 Department of Radiology, Hutzel Hospital, Detroit, and a Department of Radiology, Sinai Hospital, Detroit, Michigan, USA
Abstract. A n u n u s u a l c a s e o f g a l l s t o n e s w i t h i n t h e duodenum, secondary to obstruction by an intralumin a l d i v e r t i c u l u m , is r e p o r t e d . T h e g a l l b l a d d e r a p p e a r e d n o r m a l a n o r a l c h o l e c y s t o g r a m , e x c l u d i n g internal biliary fistula as the source of duodenal gallstones. Key words: Duodenum, diverticulum, intraluminal Duodenum, congenital web - Gallstone, ileus Duodenal diverticulum, complication of - Megaduodenum.
Several cases of intraluminal diverticulum of the duodenum have been published since the early report b y K i n z e r [1], w h o p o p u l a r i z e d t h i s t e r m . N e l s o n [2] h a d d e s c r i b e d a s i m i l a r c o n d i t i o n as c o n g e n i t a l d i a phragm of the duodenum, probably the early manifestation ofintraluminal diverticulum. Sporadic cases have b e e n r e p o r t e d b y M e y e r a n d E d g r e n [3], Z a t z k i n [4], W i o t [5], L a u d a n [6], N a n c e [7, 8], T a n d o n [9], etc. Surgeons and pediatric radiologists seem to have des c r i b e d t h e i d e n t i c a l c o n d i t i o n i n its e a r l y s t a g e a s a c o n g e n i t a l d u o d e n a l w e b o r d i a p h r a g m . A s exp l a i n e d b y M e y e r a n d E d g r e n [3], t h e f o r m a t i o n o f the diverticulum in adults from the congenital web or diaphragm of children appears to be due to purely mechanical factors, such as forward pressure by food and strong peristaltic activity. This report deals with a patient who had gallstones within a dilated duodenum which was obstructed by a large intraluminal duodenal diverticulum.
meals ever since she was seven years old. The symptoms of abdominal pain, distention, and vomiting had increased in the past few years. She stated that the pain and distention were generally relieved following emesis. There was no other significant past history. Films of the abdomen demonstrated two round radiopaque densities in the right lower quadrant, which were tl~ought to be gallstones or radiopaque pills (Fig. 1). Oral cholecystography revealed no evidence of calculi within the normally functioning gallbladder. The radiopaque densities were seen outside the gallbladder within a collection of the oral cholecystography medium (Fig. 2). Upper Gastrointestinal (G.I.) Series demonstrated marked dilatation of the duodenum and very slow passage of the barium into the proximal small bowel loops. Two rounded filling defects were noted in the dilated duodenum, which corresponded in position and size with the previously noted radiopaque densities (Fig. 3A). A typical 'halo sign' near the third portion of the duodenal sweep was considered characteristic of an intraluminal duodenal diverticulum (Fig. 3 B). The patient was operated on approximately five weeks after the above studies. Exploratory laparotomy demonstrated a markedly dilated and thickened duodenum proximal to the ligament of Treitz. Duodenostomy demonstrated a large 'web' near the second portion of the duodenum. There was a small opening (6 mm in size) within the web, which was lined by mucous nmmbrane on both sides. A large amount of undigested food was present in the duodenum proximal to the site of obstruction, and also a single 9 mm gallstone. The diaphragm was excised and the duodenostomy was closed. Pathologic findings revealed that the duodenal diaphragm measured 3.8 x 3.3 cm in size and 0.6 cm thick. This was lined by mucosa on both surfaces. Also recovered was a spherical brownblack mixed gallstone measuring 0.9 cm in diamter. On close questioning, the patient stated that during the time between the Upper G.I. Series and surgery she vomited a black, marble-like object, apparently the second gallstone seen on the X-ray studies but not found in the duodenum at surgery. Follow-up studies demonstrated significant reduction in the size of the duodenum. The patient had significant relief of her symptoms after surgery.
Case Report A 31-year-old white female presented with classical symptoms of duodenal obstruction. She recalled having frequent vomiting after Address reprint requests to: Chandrakant C. Kapdi, M.D., Depart-
ment of Radiology, Hutzel Hospital, 432 E. Hancock, Detroit, MI 48201, USA
Discussion C o n c r e t i o n [10], f o o d d e b r i s , a n d f o r e i g n b o d i e s [3] have been described in the dilated duodenum of intraluminal diverticulum. Other associated conditions,
9
0 3 6 4 - 2 3 5 6 / 7 8 / 0 0 0 3 - 0 0 1 9 $01.00 1978 S p r i n g e r - V e r l a g N e w Y o r k I n c .
20
C.C. Kapdi and M. Tatelman: Gallstone Duodenum
Fig. 1. Flat plate film of the abdomen, showing two radiopaque densities in the right lower quadrant Fig. 2. Oral cholecystogram showing normal gallbladder. The two densities are seen outside the gallbladder Fig. 3. Upper GI series. A Note marked dilatation of the duodenum, showing two rounded filling defects (arrows), corresponding to the previously noted radiopaque densities seen in Figure 1. B Typical halo sign, characteristic of intraluminal duodenal diverticulum
such as annular pancreas [8], acute pancreatitis [ll, 4], bleeding ulcer [12] near the intraluminal diverticulum, etc. have been described in the excellent collective review by Nance [8]. The case reported here is apparently the first with gallstones present in the duodenum, partially obstructed by an intraluminal diverticulum. It seems probable that the marked dilatation of
the duodenum and stretching of the duodenal wall resulted in increased downward stretching and dilatation of the common bile duct, thus allowing the escape of gallstones from the gallbladder which resulted in the unique condition of 'gallstone duodenum'. The normal cholecystogram excludes the possibility of internal biliary fistula as the source of the gallstones in the duodenum.
C.C. Kapdi and M. Tatelman: Gallstone D u o d e n u m
References 1. Kinzer RE: Intraluminal diverticulum and other lesions producing intermittent duodenal obstruction or stasis. Am J Roentgenol Radium Ther Nucl Med 61:212 218, 1949 2. Nelson WI: Congenital diaphragm of the duodenum. Minn Med 30:745-752, 1947 3. Meyer AC, Edgren D C R : Duodenal obstruction by an intraluminal diverticulum. Arch Surg 73:1058:1059, 1956 4. Zatzkin H R , Macy JJ, Kveton F W : Intraluminal duodenal diverticulum: report of a case. Am J Roentgenol Radium Ther Nucl Med 82." 1036 1037, 1959 5. Wiot JF, Spiro E: Intraluminal diverticulum: A form of duplication. Radiology 80.'46 49, 1963 6. L a u d a n JCH, N o r t o n GI: Intraluminal duodenal diverticulum. Am J Roentgenol Radium Ther Nucl Med 90.'756 760, 1963
21 7. Nance FC, Cocchiara J, Kinder JL: Acute pancreatitis associated with an intraluminal duodenal diverticulum. Gastroenterology 52: 544-547, 1967 8, Nance FC: Collective review: Intraluminal duodenal diverticula. Surg Gynecol Obstetl25: 613-618, 1967 9. T a n d o n VM, Oesau HT, Rassa R R : Intraluminal diverticulum of the d u o d e n u m . Ann Surg 178:787-790, 1973 10. Kohler R: Intraluminal duodenal diverticulum. Acta Radiol (Diagn) (Stockh) 54.'439-442, 1960 11. Buisseret E, Van Den Eynde P: U n type particnlier de diverticule duodenum. Acta Gastroenterol Belg 25." 129-132, 1962 12..Pergola F, Willemin A, Levy U: Diverticule interne du duodenum. Arch Fr Mal App Dig 53.'844-846, 1964
Received: September 30, 1977; accepted: October 25, 1977
Radiology
Gastrointest Radiol 3, 19--21 (1978)
Gallstone Duodenum: Unusual Complication of an Obstructing Intraluminal Duodenal Diverticulum Chandrakant
C. K a p d i 1 a n d M a u r i c e T a t e l m a n 2
1 Department of Radiology, Hutzel Hospital, Detroit, and a Department of Radiology, Sinai Hospital, Detroit, Michigan, USA
Abstract. A n u n u s u a l c a s e o f g a l l s t o n e s w i t h i n t h e duodenum, secondary to obstruction by an intralumin a l d i v e r t i c u l u m , is r e p o r t e d . T h e g a l l b l a d d e r a p p e a r e d n o r m a l a n o r a l c h o l e c y s t o g r a m , e x c l u d i n g internal biliary fistula as the source of duodenal gallstones. Key words: Duodenum, diverticulum, intraluminal Duodenum, congenital web - Gallstone, ileus Duodenal diverticulum, complication of - Megaduodenum.
Several cases of intraluminal diverticulum of the duodenum have been published since the early report b y K i n z e r [1], w h o p o p u l a r i z e d t h i s t e r m . N e l s o n [2] h a d d e s c r i b e d a s i m i l a r c o n d i t i o n as c o n g e n i t a l d i a phragm of the duodenum, probably the early manifestation ofintraluminal diverticulum. Sporadic cases have b e e n r e p o r t e d b y M e y e r a n d E d g r e n [3], Z a t z k i n [4], W i o t [5], L a u d a n [6], N a n c e [7, 8], T a n d o n [9], etc. Surgeons and pediatric radiologists seem to have des c r i b e d t h e i d e n t i c a l c o n d i t i o n i n its e a r l y s t a g e a s a c o n g e n i t a l d u o d e n a l w e b o r d i a p h r a g m . A s exp l a i n e d b y M e y e r a n d E d g r e n [3], t h e f o r m a t i o n o f the diverticulum in adults from the congenital web or diaphragm of children appears to be due to purely mechanical factors, such as forward pressure by food and strong peristaltic activity. This report deals with a patient who had gallstones within a dilated duodenum which was obstructed by a large intraluminal duodenal diverticulum.
meals ever since she was seven years old. The symptoms of abdominal pain, distention, and vomiting had increased in the past few years. She stated that the pain and distention were generally relieved following emesis. There was no other significant past history. Films of the abdomen demonstrated two round radiopaque densities in the right lower quadrant, which were tl~ought to be gallstones or radiopaque pills (Fig. 1). Oral cholecystography revealed no evidence of calculi within the normally functioning gallbladder. The radiopaque densities were seen outside the gallbladder within a collection of the oral cholecystography medium (Fig. 2). Upper Gastrointestinal (G.I.) Series demonstrated marked dilatation of the duodenum and very slow passage of the barium into the proximal small bowel loops. Two rounded filling defects were noted in the dilated duodenum, which corresponded in position and size with the previously noted radiopaque densities (Fig. 3A). A typical 'halo sign' near the third portion of the duodenal sweep was considered characteristic of an intraluminal duodenal diverticulum (Fig. 3 B). The patient was operated on approximately five weeks after the above studies. Exploratory laparotomy demonstrated a markedly dilated and thickened duodenum proximal to the ligament of Treitz. Duodenostomy demonstrated a large 'web' near the second portion of the duodenum. There was a small opening (6 mm in size) within the web, which was lined by mucous nmmbrane on both sides. A large amount of undigested food was present in the duodenum proximal to the site of obstruction, and also a single 9 mm gallstone. The diaphragm was excised and the duodenostomy was closed. Pathologic findings revealed that the duodenal diaphragm measured 3.8 x 3.3 cm in size and 0.6 cm thick. This was lined by mucosa on both surfaces. Also recovered was a spherical brownblack mixed gallstone measuring 0.9 cm in diamter. On close questioning, the patient stated that during the time between the Upper G.I. Series and surgery she vomited a black, marble-like object, apparently the second gallstone seen on the X-ray studies but not found in the duodenum at surgery. Follow-up studies demonstrated significant reduction in the size of the duodenum. The patient had significant relief of her symptoms after surgery.
Case Report A 31-year-old white female presented with classical symptoms of duodenal obstruction. She recalled having frequent vomiting after Address reprint requests to: Chandrakant C. Kapdi, M.D., Depart-
ment of Radiology, Hutzel Hospital, 432 E. Hancock, Detroit, MI 48201, USA
Discussion C o n c r e t i o n [10], f o o d d e b r i s , a n d f o r e i g n b o d i e s [3] have been described in the dilated duodenum of intraluminal diverticulum. Other associated conditions,
9
0 3 6 4 - 2 3 5 6 / 7 8 / 0 0 0 3 - 0 0 1 9 $01.00 1978 S p r i n g e r - V e r l a g N e w Y o r k I n c .
20
C.C. Kapdi and M. Tatelman: Gallstone Duodenum
Fig. 1. Flat plate film of the abdomen, showing two radiopaque densities in the right lower quadrant Fig. 2. Oral cholecystogram showing normal gallbladder. The two densities are seen outside the gallbladder Fig. 3. Upper GI series. A Note marked dilatation of the duodenum, showing two rounded filling defects (arrows), corresponding to the previously noted radiopaque densities seen in Figure 1. B Typical halo sign, characteristic of intraluminal duodenal diverticulum
such as annular pancreas [8], acute pancreatitis [ll, 4], bleeding ulcer [12] near the intraluminal diverticulum, etc. have been described in the excellent collective review by Nance [8]. The case reported here is apparently the first with gallstones present in the duodenum, partially obstructed by an intraluminal diverticulum. It seems probable that the marked dilatation of
the duodenum and stretching of the duodenal wall resulted in increased downward stretching and dilatation of the common bile duct, thus allowing the escape of gallstones from the gallbladder which resulted in the unique condition of 'gallstone duodenum'. The normal cholecystogram excludes the possibility of internal biliary fistula as the source of the gallstones in the duodenum.
C.C. Kapdi and M. Tatelman: Gallstone D u o d e n u m
References 1. Kinzer RE: Intraluminal diverticulum and other lesions producing intermittent duodenal obstruction or stasis. Am J Roentgenol Radium Ther Nucl Med 61:212 218, 1949 2. Nelson WI: Congenital diaphragm of the duodenum. Minn Med 30:745-752, 1947 3. Meyer AC, Edgren D C R : Duodenal obstruction by an intraluminal diverticulum. Arch Surg 73:1058:1059, 1956 4. Zatzkin H R , Macy JJ, Kveton F W : Intraluminal duodenal diverticulum: report of a case. Am J Roentgenol Radium Ther Nucl Med 82." 1036 1037, 1959 5. Wiot JF, Spiro E: Intraluminal diverticulum: A form of duplication. Radiology 80.'46 49, 1963 6. L a u d a n JCH, N o r t o n GI: Intraluminal duodenal diverticulum. Am J Roentgenol Radium Ther Nucl Med 90.'756 760, 1963
21 7. Nance FC, Cocchiara J, Kinder JL: Acute pancreatitis associated with an intraluminal duodenal diverticulum. Gastroenterology 52: 544-547, 1967 8, Nance FC: Collective review: Intraluminal duodenal diverticula. Surg Gynecol Obstetl25: 613-618, 1967 9. T a n d o n VM, Oesau HT, Rassa R R : Intraluminal diverticulum of the d u o d e n u m . Ann Surg 178:787-790, 1973 10. Kohler R: Intraluminal duodenal diverticulum. Acta Radiol (Diagn) (Stockh) 54.'439-442, 1960 11. Buisseret E, Van Den Eynde P: U n type particnlier de diverticule duodenum. Acta Gastroenterol Belg 25." 129-132, 1962 12..Pergola F, Willemin A, Levy U: Diverticule interne du duodenum. Arch Fr Mal App Dig 53.'844-846, 1964
Received: September 30, 1977; accepted: October 25, 1977
