CASE

mosis

of the

old

stump.

Further

normal relationship between num was the more medial pancreas

compared

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The

ultrasonic

findings.

folded

on

of a shift

pancreas superior

and the position

REFERENCES

in the diodeof the

1 . Anacker H, Weiss HD, endoscopic retrograde 1 22 :375-384. 1 974

to normal.

abnormal

operative

evidence

the and

The

each

other

scan

head

and

and

pulled

can

be explained

body

of the

by the

pancreas

superiorly

and

2.

This

3.

medially

demonstrates

ducts

Interpretation The of

of gastric

anatomical the

that

can

result

the

endoscopic

pancreas

in

without

altered

from

surgery

the

take

is caused

order

anatomy

Billroth

Silvis

MacCarty

to

the

iopancreatogram this

into

by rotation

achieve

of

the

account.

of the

head

gastroduodenal

tension.

Intraluminal

Duodenal

JOHN

Diverticulum

SAMPLINER,1

STEPHEN

A.

Kramann B, Rupp pancreatography.

SE,

Vennes

Radiology

RL, Stephens

DH,

in autopsy

JA 11

Brown

P : Experience Am

J

: Evaluation

of

3 : 297-304,

1974

AL,

Carlson

specimens.

Am

Associated

KOLLINS,1

AND

with

ROBERT

Trisomy

with

Roentgenol the

endo-

HC : Retrograde

J Roentgenol

359-366, 1975 4. Freeny PC, Bilbao MK, Katon RM : “Blind” evaluation scopic retrograde cholangiopancreatography (ERCP) diagnosis of pancreatic carcinoma : the.”double duct” signs. Radiology 119 :271-274, 1976 5. Clouse ME, Gregg JA, Sedgwick CE : Angiography creatography in diagnosis of carcinoma of the Radiology 114:605-610, 1975

I anastomosis.

cholang

should

distortion

anastomosis

CA,

pancreatogram.

pancreatography

case

following

Rohrmann

scopic

were

over the aorta. pancreatic

677

REPORTS

1 23:

of endoin the and other vs. panpancreas.

21

E. HERMANN2

An intraluminal duodenal diverticulum is an uncommon congenital abnormality that may produce intermittent obstruction. The true pathogenesis of this lesion is still disputed, but it probably results from ballooning of a congenital web or diaphragm with prolonged peristalsis. An intraluminal “wind sock”-Iike structure filled with barium and surrounded by a radiolucent halo is the classic and diagnostic radiologic appearance. An association with trisomy 21 is made.

Intraluminal duodenal diverticulum is an interesting but uncommon lesion that is often associated with symptoms of recurrent partial duodenal obstruction. Since the first radiologic demonstration by Nelson in 1 947, there have been only 36 cases reported [1 2] This paper describes a case of an intraluminal duodenal diverticulum associated with trisomy 21 Only one other similar association has been ,

.

.

reported

[3]. Case

Report

An 18-year-old mongoloid white male was admitted to hospital because of repeated episodes of abdominal pain. The tient’s mother described episodes of abdominal pain which he experienced several times each year since the age of 8. However, month prior to admission the patient developed more frequent severe

episodes

of

diffuse

crampy

abdominal

pain.

On

his clinical laboratory studies and physical examination remarkable except for his mongoloid features. An upper gastrointestinal examination demonstrated luminal

(wind

duodenum. resembled

Received 1 2

Am

sock)

Initially

diverticulum

the diverticulum

a pedunculated

March

Department Department

J Roentgenol

of

polyp,

the

second

was filled but

on

later

admission

were

films

barium and its small orifice and narrow neck were clearly identified (figs. 1 and 2). The remainder of the small intestine was normal. The diagnosis was confirmed surgically, and the diverticulum was excised

un-

through

a longitudinal

had an uncomplicated

an intra-

portion

with

our pahad 1 and

secretions it filled

of

and

During ment,

the

the seventh

week

intestinal

lumen

22, 1 976 ; accepted after revision May 1 9, 1 976. of Radiology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44106. of Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44106.

1 27 : 677-679,

1976

incision.

The

patient

Discussion

the with

duodenotomy

recovery.

of normal is

embryologic

occluded

by

developproliferating

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678

with

CASE

REPORTS

barium.

epithelial

cells.

Shortly

plete recanalization diaphragm. There

are

two

genesis

of

implies

that

to

theories

concerning

produces

forms

a

the

diverticula

diverticulum

or

a

patho-

[4].

when

commu

Incom-

stenosis,

The

first

incomplete

nicating

incomplete

[5]. The second suggests that the diverticulum a distal outpouching of a congenital diaphragm

prolonged

surprising

peristaltic

action

to find an intraluminal

mongoloid

patient,

abnormalities been

in atresia,

duodenal

the

recanalization

it is recanalized.

result

proposed

intraluminal

duplication forms from due

thereafter

may

since

(e.g.,

clearly

a higher

duodenal

associated

[6].

this

not

be

diverticulum

incidence

atresia

with

It should

duodenal

in a

of congenital

and

stenosis)

chromosomal

have

abnormal-

ity [7]. Another intraluminal duodenal diverticulum in a mongoloid was reported by Curtis et al. [3] and, as in the present case, supports the second of the above theories. Most

patients

present

with

obstruction. These

described lesions

of

and

When

filled

the the

duodenal

intermittent

complicating

diverticula

partial this

lesion

intestinal has

been

[8].

are

because

barium late

intraluminal

Pancreatitis

previously tion

with

symptoms

often

missed

diverticulum

collapsed

sac

with

secretions,

a pedunculated

polyp,

on

does may

not

radiologic

not

examina-

always

fill

be appreciated

with [4].

the radiolucent

sac may simu-

as in this

[5].

case

When

the

sac fills with barium, it appears as an intraluminal diverticulum surrounded by a lucent halo which is its wall (fig. 2).

One may see duodenal lum

that

may

obstruct

dilatation the

lumen

proximal at the

to the diverticutime

of the

exami-

tion. Fig.

elevated Arrows

3.-Photograph

with indicate

clamp size

during

positioned of diverticulum.

surgery

adjacent

showing

to it in true

internal

diverticulum

lumen

of duodenum.

The internal diverticulum both sides of a membranous

has duodenal septum with

mucosa lining a thin layer of

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CASE

2. Nelson

muscularis mucosa and submucosa between (fig. 3). This lesion typically arises near or at the papilla of Vater and balloons distally into the duodenum. The papilla with its duct may extend directly into the diverticulum or may open proximally or distally to it. The surgical treatment for the obstructing symptomatic lesion is either excision or a bypass procedure. It is very important to make this diagnosis preoperatively, since the diverticulum

may

surgeon.

The

not

be palpable

difficulty

in

or visible

making

externally

a correct

diagnosis

be performed, the

opening

septum.

divided

into

In most

patients

or excised

tum

or those

into

the septum,

preferable.

patients

bile

[11,

12].

1.

Fleming

the

; in a few

must

above

diverticular

patients

in which

a bypass

Care

common

the duodenum

the

papilla

can

be taken

to

prevent

ducts

due

5.

7.

duodenal

AD, Stephens

diverticulum

of the literature.

Mayo

Displaced

Clin

: report

8.

9.

the

10.

Proc

50 : 244-248,

Lateral

HC : Intra-

cases

and

1 2.

Liver

M,

ELIAS

KAZAM,

[1

]

described edge

visualization

on abdominal

of a medially radiographs

displaced

in patients

with

ascites. He explained this phenomenon by reasoning that the intraperitoneal fluid was slightly less dense than the adjacent hepatic parenchyma and that this small density Received This 1 All Street.

Am

January

1 9. 1 976

; accepted

after

work was supported in part by grant authors : Division of Cardiovascular New York, New York 1 0021 . Address

J Roentgenol

1 27

:

679-682,

1976

revision

May

diverticulum.

: a form

of duplica-

White

LLR,

Carter

CO,

Louw

JH

duodenal : Congenital

Y,

Greenspan

A,

Farber

M,

duodenal

Richter

RM,

Bryk

Arch

diverticulum.

D,

Surg

Sign)

Secondary

to an

Collection AND

difference

JOSEPH

P.

could

be seen

radiographs

displaced

Hellmer’s denied

quality

radiolucent and

lateral

description,

possibility

of

well

positioned

zone

between

abdominal

wall.

other

the After

investigators

radiographically

either

differentiating

soft tissues of close but different density [2] or alternative explanations of Hellmer’s observa-

tions [3]. However,

revealed

the

that

advent

subtle

soft

Three

confirmed density

fluid tion

and hepatic of a medially

computerized

density

independent

differences

radiographs a zone between

of

tissue

Hellmer’s

5%)

dominal

on good

liver

original the

between offered

against fluid)

WHALEN

as a relatively

medially

cently

Introduction

liver

diverticulum

BS : Intraluminal

discriminated.

Hellmer

duodenal

1963

E : Intraluminal

(Heilmer’s

Fluid

In 1942, Hellmer [1] first described visualization of a medially displaced lateral liver edge on abdominal radiographs in patients with ascites. In Hellmer’s original article and all cases subsequently reported, this appearance was described as being pathognomonic of intraperitoneal fluid. This paper reports the occurrence of Hellmer’s sign in a patient with a large extraperitoneal fluid collection extending into the flank. Thus the differential diagnosis associated with a medially displaced lateral liver edge includes pathologic processes in both the intraand extraperitoneal spaces.

lateral

GI : Intraluminal

90 : 756-760,

1 09 : 1 1 3-1 1 5, 1974

of the

WIXSON,1

Spiro

Levowitz

Extraperitoneal DAVID

JF,

Tzu-Shong

review

1975

Surface

Norton

duodenal obstruction and mongolism. Br MedJ 1 : 77-78, 1 952 Nance FC, Cocchiara J, Kinder JL : Acute pancreatitis associated with an intraluminal duodenal diverticulum. Gastroenterology52 :544-547, 1967 Rowe MI, Buckner D, Clatworthy HW Jr : Wind sock web of the duodenum. AmJ Surg 1 1 6 : 444-449, 1968 Bill AH Jr. Pope WM : Congenital duodenal diaphragm : report of two cases. Surgery 35 : 482-486, 1954 Cooperman AM, Adachi M, Rankin GB, Sivak M : Congenital duodenal diaphragms in adults : a delayed cause of intestinal obstruction. Ann Surg 182 : 739, 1975

proximity

DH, Carlson of two

JCH,

Bodian

REFERENCES

luminal

duodenum : case 30 : 745-752,

Med

W, Lowdon AGR : Intraluminal diverticuin a mongol. Clin Radiol 16:289-291,

duodenum

J Roentgenol

Wiot

11.

CR, Newcomer

Minn

Radiology 80 : 46-49, 1963 6. Pratt AD Jr : Current concepts of the obstructing diaphragm. Radiology 100:637-643, 1971

be

to

of the

studies.

tion.

opens

damage

GT, Simpson of the

Landan Am

may be

to their

x-ray

1965 4.

sep-

of Vater

duodenoduodenostomy

or pancreatic

lum

at

a thickened

diaphragm

preoperative

1947

below

septum

with

with

3. Curtis

duoshould

and

WI : Congenital

report

to the

surgery has been emphasized [9, 10]. A longitudinal denotomy along the lateral border of the duodenum

679

REPORTS

investigators

observation may

parenchyma displaced [4-6].

of relative it and the

scanning

differences

exist

which lateral The

have

that

between

has

can

subtle

be re-

(2%-

intraperitoneal

can allow visualizahepatic edge on ab-

liver

edge

radiolucency (the lateral abdominal

is silhouetted intraperitoneal wall.

25, 1 976.

no. 1 TO 1 HL0596603 CAR from Radiology, Department of Radiology, reprint requests to D. Wixson.

the

National Institutes of Health. New York Hospital-Cornell

University

Medical

Center,

525

East

68th