Preoperative

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CARY

M. GLASSER,’

Duodenal

Diagnosis

STANFORD

diverticulum

is a frequent

upper gastroi ntestinal exami tion of a duodenal diverticulum

seventh the

recorded

first

abdominal mortality tant

case

in which

the

M. GOLDMAN,2

incidental

CLARO

finding

diagnosed

diagnosis

preoperatively,

was

and

recognized

on

recognize

it radiologically

to

alert

L. PlO

serious

Report

earlier,

and ulcer

disease

Physical

examination

tenderness

abdomen

and with

active

films

revealed

Chest

bowel

sounds.

no free

films demonstrated and small pockets

emergency

upper

history

patients

on the right side of the

diagnosed

only

Stool

pattern was surrounding

guiac

air under

series

upper was

the

air within a it (fig. 1). An

confirmed

the

sus-

pected diagnosis: a perforated, laterally placed diverticulum (fig. 2). At surgery, a perforated duodenal diverticulum was found with localized peritonitis and abscess formation on the

anterior sion

aspect

was

of the second

performed.

inflammation, No peptic considered

The

focal necrosis ulcer was the probable

portion

of the duodenum.

pathologic .

.

.

specimen

and fibropurulent

,

Exci-

showed

demonstrated. lschemic cause. The patient made

‘acute

present

peritonitis.”

diverticulum,

of

enteric

of 1%-2%

[1].

Beachley

10% of duodenal vague chronic et al. found

second has

and

diverticula complaints

few

diverticula

In

Duodenal

Lankau

it may

[2]

August

Department M. Glasser. ,

8, 1977;

of Surgery,

2

Department

of Radiology,

3

Department

of Medicine,

Am J Ro.ntgenol © 1978 American

13O.563-564,

Roentgen

believe

that

serious

is diagnosed numerous

1%-

When should

Of

peptic partial

accepted

after

revision

of

diseases

November

of Baltimore,

Hospital

of Baltimore,

Sinai Hospital

of Baltimore

March Ray Society

1978

ap-

recognized

at

[2,

7,

plain

8].

We

identified

abdominal

retroperitoneal the duodenum

air and

films The

three who

most

were

common

other

case

[11],

localized the upper

but

its

significance

was

with

early

of intramural the two

emphysematous

as well conditions.

level

should

diverticulum plain be

the

present

tion

was

used.

are We

case, not

diagnostic,

found

in which

be

the fluid would

not

suspected)

invariably

gas will advanced present

on

with emphysematous cholewould not be present in a

since

films

cholecystitis,

as intraluminal In more

six

cases

either or

leak out.

contrast [2,

material

4-7],

including

barium

(when

Gastrografmn

was

perforaused.

A

Lucinian

[6]

made

diverticulum was pointed down and

the ‘ ‘

diagnosis

not round appeared

on

the

basis

that

as seen normally to dip into the head

.

.

the

but of the .

22, 1977.

Belvedere Johns

not

perforation was the most common finding and was present in two patients [5, 7] as well as in our own.

ulcer disease, pancreatitis, duodenal obstruction, and

Sinai Hospital Sinai

by a process

case with

an air-fluid

ruptured

complications,

abdominal

may

is

or autopsy.

patients

cases,

either Juler

diverticulitis, acute pain.

probable

and

perforation

the upright film in patients cystitis. Theoretically this

[4], as in our patient.

mimic

such as cholecystitis, appendicitis, colitis,

Received

cause

diverticulitis

exclusion;

common incidence

are symptomatic with or acute pain. However,

that

are laterally placed

most

a reported

[3], in reviewing perforated duodenal a 71.4% incidence of sudden or

those 5%

the

diverticulum,

the

30%-40%

at surgery

in one

the pattern differentiate

Discussion Duodenal

considered is

not recognized.

necrosis was an uneventful

recovery.

form

most

to the area pole of the right kidney [7-10]. The gas collection apparently displaces the transverse colon downward [9] or dissects into the mediastinum [7]. Our case is of importance because the plain films suggested the diagnosis; an oval collection of air was visualized (the diverticulum) with smaller collections of air surrounding it (the peridiverticular abscesses). A similar x-ray pattern may have been

nega-

diaphragm.

of

was

the

our

additional

diffuse,

the presence of air surrounding

gastrointestinal

including

ab-

moderate,

with some guarding

Abdominal large space

medical

the

preopera-

surgery [3]. Of the approximately 60 cases of duodenal diverticulitis described in the literature, Beachley and Lankau [2] found only six cases preoperatively diagnosed radiographically [4-8]. Plain film findings in perforated duodenal diverticulitis have been reported in four cases diagnosed preopera-

was suspected

Other

if

is

recognized

perforation include diverticulitis, located gastric mucosa, enterand ischemic necrosis. In our

mortality

100%

tively,

showed

dominal tive.

laterally.

D. BRONSTEIN3

is rarely

necrosis

Operative

proach

clinically. At that time, the source of bleeding was not demonstrated by an upper gastrointestinal series or endoscopy. A large duodenal diverticulum was noted originating in the sec-

ond portion of the duodenum, was noncontributory.

but

ischemic

cause.

A 49-year-old white female had epigastric abdominal pain for several weeks. The pain became worse the day before admission and was associated with nausea. The patient had a bleed-

7 years

HOWARD

and perforation. a duodenal diverticulum

of

complication

case,

ing episode

AND

tively [3]. Causes of ulceration of ectopically oliths, foreign bodies,

for

management. Case

Diverticulum

RODA,’

fistula formation, Perforation

plain

clinicians

Duodenal

internal fistulae [2]. Complications include biliary obstruction with cholangitis, partial duodenal obstruction, pancreatitis, ulceration with or without hemorrhage,

at

nation . However, perforais rare. We describe the

films. Because of the high morbidity and rate associated with this condition, it is impor-

to

proper

of a Perforated

at Greenspring Hopkins

School

and Johns Hopkins 563

Avenues, of Medicine

School

Baltimore,

Maryland

and University

of Medicine,

Baltimore,

21215. Address

of Maryland,

reprint

Baltimore,

requests

to C.

Maryland.

Maryland.

0361 -803X/78/0300

-

0563

$02.00

CASE

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564

REPORTS

D

,

B 4

S ,

,

ft.

r’

Til

‘#{149}

,*-! ‘

‘._:

Fig. 1.-Abdominal surrounded by small

pancreas.’ diverticulum [4].

In

and

by

Beachley

situations,

[2] did

patient,

and

duodenal

ulcer

This

would

not be definitive

If the excision

diagnosis and

Juler

et

the treatment

can

also

diagnosis

can However,

failed

reported

that

be

to

of

by Juler

et

studies

preoperatively, of the

neck

surgical of the

sac is

of choice. ACKNOWLEDGMENT

We preparing

thank this

Dr.

Julian

0.

Salik

for

his

advice

and

aid

in

manuscript.

duodenum

of the 1968

Lankau radiographic

CA: Inflamed diagnosis.

duodenal diverticulum, Am J Dig Dis 22 : 149-

GL,

List

JW,

diverticulitis.

5. Christiaens J: Diverticule duodenale complique d’abscess retroperitoneal. Acta Gastroenterol Belg 9:533-535, 1946 6. Lucinian JH: Diverticulum of the duodenum perforated into the pancreas: report of a case. Am J Roentgenol 24 : 684685, 1930 7. Shackleton ME: Perforation of a duodenal diverticulum with massive retroperitoneal emphysema. NZ Med J 62 : 9394, 1963 8. Wolfe AD, Pearl MJ: Acute perforation of duodenal diverticulum with roentgenographic demonstration of localized retroperitoneal emphysema. Radiology 104 : 310-312, 1972 9. Munnel ER, Preston WJ: Complications of duodenal diverticula.Arch Surg 92 : 152-156, 1966

Sampsel JW, Zaugg A: Perforation denal diverticulum: a case report.

10.

AM, Heald RJ: Perforated diverticulum and its treatment. Br J Surg 55 : 396-397,

material in perfodiverticulum.

Stemmer EA, Connally JE: Perforating Arch Surg 99 : 572-578, 1969 4. Castlemann B (ed): Case records of the Massachusetts General Hospital, case 46091 . N EngI J Med 262 : 462-466,

REFERENCES 1 . Desmond

=

1960

a

and Greaney without excontrast

sweep showing contrast bulb, S = stomach, D

1977

duodenal

even

instances.

made

closure

[3]

154,

3. Juler

a perfora-

misdiagnosis

MC,

preoperative

the

patient

Wilkinson diverticulum

indicate be

al. A

was

in some

two-layer

between

series.

of duodenal = duodenal

B

(d)

in another

not demonstrate

in another case. Similarly, reported only seeing the

travasation.

present

diverticulum.

duodenal

diverticulum

2. Beachley

correct

gastrointestinal

perforated

may

the

upper

the

duodenal

colon

Lankau

in their

[11]

was

an

find [3]

tract

the ascending

and

tion

al.

film showing air-filled pockets of air (arrows).

A fistulous

‘

these

made

Fig. 2.-View ration (arrows).

.

11

.

1960 Wilkinson denal

G, Greaney

diverticulitis.Am

and abscess Arch

Surg

of a duo-

81 : 542-544,

EM Jr: Perforated perivaterian J Surg 111 : 351-355, 1966

duo-