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doi:10.1111/jgh.12258
E D U C AT I O N A N D I M A G I N G
Gastrointesintal: Rare congenital abnormality of the duodenum: Intraluminal duodenal diverticulum a
a
b b
Figure 2
Figure 1
A 35-year-old man presented with tarry stool and was referred to our hospital. His medical history included congenital intestinal occlusion for which he underwent bypass surgery. Laboratory data revealed anemia (Hb 9.2 g/dL). We suspected upper gastrointestinal bleeding. Esophagogastroduodenoscopy revealed a markedly dilated bulb and a mass-like submucosal tumor in the second portion of the duodenum (Figure 1a). The mass was very soft and movable and appeared to derive from the normal mucosa of the duodenum. There was no active bleeding in the stomach. The duodenum was stenotic due to the soft mass; however, we could manage to insert the endoscope into the distal duodenum. An upper gastrointestinal series (UGI) revealed a barium-filled sac with windsock sign in the second portion of the duodenum (Figure 1b, arrows). These findings were consistent with a diagnosis of intraluminal duodenal diverticulum (IDD). We performed endoscopic diverticulectomy by using a twochannel endoscope to remove the obstruction caused by the IDD. We grasped the diverticular mucosa with the forceps in one channel and resected it with an electrocautery snare passed through the other channel (Figure 2a). The IDD was successfully excised, and the endoscope could be advanced easily to the distal duodenum through the orifice made by endoscopic resection (Figure 2b). We could not identify the source of bleeding; however, UGI after resection revealed no barium-filled sac in the duodenum, and the patient’s anemia was improved by correcting his iron deficiency.
IDD is a rare congenital anomaly found in adulthood. Previous reports showed that IDD is often complicated by other congenital malformations such as annular pancreas. Bypass surgery for congenital intestinal occlusion was previously performed on this patient. IDD is usually diagnosed by UGI. The typical appearance is called a windsock sign (Figure 1b, arrows), which consists of a barium-filled sac that lies entirely within the duodenum and that is surrounded by a narrow radiolucent line. IDD with certain symptoms, such as epigastralgia, nausea or vomiting requires treatment. Surgical duodenostomy and direct excision of the diverticulum have been suggested as treatments for IDD. Recently, two endoscopic treatments for IDD have been introduced, endoscopic diverticulectomy and endoscopic diverticulotomy. Successful endoscopic treatment of IDD is dependent on two major factors, creation of an adequate orifice size and avoidance of injury to the ampulla of Vater. In this case, we successfully opened the diverticulum without complications. In conclusion, we suggest that endoscopic diverticulectomy using a two-channel endoscope is a useful method for treating IDD. Contributed by M Nakamura*, J Nishikawa*, S Hashimoto*, S Takeo†, O Miura* & I Sakaida* *Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube and † Department of Surgery, Hofu Institute of Gastroenterology, Hofu, Yamaguchi, Japan
Journal of Gastroenterology and Hepatology 29 (2014) 893 © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
893
doi:10.1111/jgh.12258
E D U C AT I O N A N D I M A G I N G
Gastrointesintal: Rare congenital abnormality of the duodenum: Intraluminal duodenal diverticulum a
a
b b
Figure 2
Figure 1
A 35-year-old man presented with tarry stool and was referred to our hospital. His medical history included congenital intestinal occlusion for which he underwent bypass surgery. Laboratory data revealed anemia (Hb 9.2 g/dL). We suspected upper gastrointestinal bleeding. Esophagogastroduodenoscopy revealed a markedly dilated bulb and a mass-like submucosal tumor in the second portion of the duodenum (Figure 1a). The mass was very soft and movable and appeared to derive from the normal mucosa of the duodenum. There was no active bleeding in the stomach. The duodenum was stenotic due to the soft mass; however, we could manage to insert the endoscope into the distal duodenum. An upper gastrointestinal series (UGI) revealed a barium-filled sac with windsock sign in the second portion of the duodenum (Figure 1b, arrows). These findings were consistent with a diagnosis of intraluminal duodenal diverticulum (IDD). We performed endoscopic diverticulectomy by using a twochannel endoscope to remove the obstruction caused by the IDD. We grasped the diverticular mucosa with the forceps in one channel and resected it with an electrocautery snare passed through the other channel (Figure 2a). The IDD was successfully excised, and the endoscope could be advanced easily to the distal duodenum through the orifice made by endoscopic resection (Figure 2b). We could not identify the source of bleeding; however, UGI after resection revealed no barium-filled sac in the duodenum, and the patient’s anemia was improved by correcting his iron deficiency.
IDD is a rare congenital anomaly found in adulthood. Previous reports showed that IDD is often complicated by other congenital malformations such as annular pancreas. Bypass surgery for congenital intestinal occlusion was previously performed on this patient. IDD is usually diagnosed by UGI. The typical appearance is called a windsock sign (Figure 1b, arrows), which consists of a barium-filled sac that lies entirely within the duodenum and that is surrounded by a narrow radiolucent line. IDD with certain symptoms, such as epigastralgia, nausea or vomiting requires treatment. Surgical duodenostomy and direct excision of the diverticulum have been suggested as treatments for IDD. Recently, two endoscopic treatments for IDD have been introduced, endoscopic diverticulectomy and endoscopic diverticulotomy. Successful endoscopic treatment of IDD is dependent on two major factors, creation of an adequate orifice size and avoidance of injury to the ampulla of Vater. In this case, we successfully opened the diverticulum without complications. In conclusion, we suggest that endoscopic diverticulectomy using a two-channel endoscope is a useful method for treating IDD. Contributed by M Nakamura*, J Nishikawa*, S Hashimoto*, S Takeo†, O Miura* & I Sakaida* *Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube and † Department of Surgery, Hofu Institute of Gastroenterology, Hofu, Yamaguchi, Japan
Journal of Gastroenterology and Hepatology 29 (2014) 893 © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd
893
