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ACG Case Rep J
ACG Case Rep J
ACGCRJ
AC9
ACG Case Reports Journal
2326-3253
Wolters Kluwer Maryland, MD

ACGCR-24-0487
10.14309/crj.0000000000001516
00037
3
Case Report
Endoscopy
Successful Endoscopic Drainage of Acute Duodenal Diverticulitis Complicated by Abscess
Liane Billy-Joe MD 1
Quiles John MD 1jyq101@gmail.com

1 Department of Gastroenterology and Advanced Endoscopy, Brooke Army Medical Center, Fort Sam Houston, San Antonio, TX
Correspondence: Billy-Joe Liane, MD (billyjliane@gmail.com).
9 2024
19 9 2024
11 9 e0151625 5 2024
19 8 2024
© 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

ABSTRACT

Duodenal diverticulitis complicated by abscess formation is a rare clinical entity, albeit may, in some cases, be associated with significant morbidity and mortality. We present a unique case that elucidates the success of endoscopic management of duodenal diverticulitis complicated by an abscess in the third part of the duodenum, through forward-viewing endoscopic maneuvers. Although surgery has been the primary interventional strategy for complicated duodenal diverticulitis beyond medical management, endoscopy is shown to be a safe and effective alternative in the clinically stable patient and/or poor surgical candidate, for this uncommon sequela of duodenal diverticulosis.

KEYWORDS:

duodenal diverticulitis
duodenal abscess
endoscopic drainage
OPEN-ACCESSTRUE
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pmcINTRODUCTION

Duodenal diverticulitis can lead to complications with significant morbidity and mortality, including perforation.1 We describe a unique case where endoscopic drainage is a viable and effective management modality in the clinically stable patient with acute complicated duodenal diverticulitis. Previous endoscopic interventions described in the literature were localized to the second part of the duodenum, for which a duodenoscope was used.2,3 In this case, a unique approach was successful through the use of forward-viewing endoscopic techniques. This case highlights a multidisciplinary approach in the evaluation of duodenal diverticulitis and the effectiveness and safety of its endoscopic management.

CASE REPORT

A 64-year-old woman with history of peptic ulcer disease, hypertension, dyslipidemia, and chronic low back pain presented to the emergency department with a chief complaint of severe epigastric and left upper-quadrant abdominal pain for 2 days, along with persistent nausea and bouts of nonbloody emesis. Oral analgesics at home did not provide complete relief of pain. The patient had also been reporting subjective fevers and chills. Hydrochlorothiazide was her only scheduled medication. Tramadol was taken as needed for pain. She denied family history of gastrointestinal cancers.

The patient was febrile on presentation with a temperature of 100.8 F, up to 102.7 F later the night of admission. The rest of her vital signs were within normal limits. Her examination was notable for soft, nonrigid abdomen with tenderness to palpation in the epigastric area and left upper quadrant. No overt signs of gastrointestinal bleeding were noted. Laboratory test results were notable for leukocytosis with a white blood cell count of 24.8k. The hemoglobin level and platelet count were normal. Her renal panel, hepatic profile, and lipase were also within normal limits. Imaging with abdominal/pelvic computed tomography with intravenous contrast (oral contrast was not tolerated) was notable for showing evidence of duodenal diverticulitis complicated by an adjacent abscess measuring up to 4.3 cm, without intraperitoneal free air (Figure 1).

Figure 1. (A) Computed tomography (axial view) showing a 4.3-cm abscess from complicated duodenal diverticulitis (green arrow). (B) Endoscopic visualization of the diverticulum in the third part of the duodenum, impacted by debris. (C) View of the guidewire inserted into the duodenal diverticular cavity. (D) Final endoscopic image showing successful placement of 2 double pigtail stents (7 Fr × 5 cm). (E) Fluoroscopy showing lack of contrast extravasation toward the end of the procedure.

Initial evaluation and management consisted of drawing blood cultures, starting antibiotics, and admitting the patient to the hospital. The patient did not exhibit evidence of peritonitis or pneumoperitoneum and was not deemed to be a candidate for urgent surgical intervention by the surgical service. Nevertheless, she had persistent pain with fevers for which the in-patient gastroenterology service was consulted for evaluation for any possible endoscopic intervention, short of surgery, which carries a higher risk of adverse events.1

Extensive discussion with the patient regarding the benefits, risks, and alternatives to endoscopic evaluation with possible intervention was undertaken. The patient provided consent and agreed to endoscopic management.

In preparation for endoscopy, the patient underwent general anesthesia and endotracheal intubation for sedation and airway protection. A standard gastroscope was introduced through the mouth and was advanced to the third part of the duodenum, where the diverticulum was visualized, impacted by debris material (Figure 1). Biopsy forceps were introduced through the working channel and were used to remove debris alternating with water irrigation. Purulent drainage was also expressed from the cavity. The standard gastroscope was then switched to a therapeutic one for further endoscopic intervention given the latter's larger working channel diameter. Further debris removal was continued with water flush and the use of an 18-mm extraction balloon catheter through the therapeutic gastroscope.

On thorough debris removal and complete diverticular cavity evacuation, the 18-mm extraction balloon was inflated at the cavity opening, and contrast was injected above the balloon without extravasation noted under fluoroscopy to suggest any evidence of perforation. A 0.035-inch short guidewire was then introduced (Figure 1), over which two 7-Fr × 5-cm double pigtail plastic stents were placed (Figure 1). Contrast was reinjected into the diverticular cavity after stent placement to ensure its lack of extravasation (Figure 1). The contrast was then suctioned, and the cavity was irrigated with water before careful withdrawal. The procedure was successful without adverse events.

The patient tolerated the procedure well. Over the next day, her abdominal pain and fever subsided. Her white blood cell count downtrended, and her blood cultures were without growth. She was released later in the day after the procedure to complete a course of oral antimicrobials with outpatient gastroenterology follow-up. At an 8-week postprocedure clinic visit, she was without symptom recurrence, and the ensuing abdominal radiograph showed interval plastic stent passage. She has had no reported recurrence of symptoms or related hospitalizations since that procedure per recent chart review.

DISCUSSION

Previous endoscopic interventions were described in the literature for duodenal diverticulitis localized to the second part of the duodenum where it is most frequented, for which a duodenoscope was used given diverticulum location.2,3 In this case, given the more distal and en-face location in the third part of the duodenum, a different approach was planned through the use of forward-viewing endoscopes.

This case elucidates the success of endoscopic management of duodenal diverticulitis complicated by abscess formation in the third part of the duodenum, through forward-viewing endoscopic techniques.

Given the success of endoscopic drainage for this rare complication from a duodenal diverticulum, considering its low percentage of recurrence, coupled with the technique's lower periprocedural risks compared with diverticulectomy, endoscopic drainage should be at least entertained for the clinically stable patient with acute complicated diverticulitis, as part of a multidisciplinary approach.

DISCLOSURES

Author contributions: Both authors have made substantial/essential contributions to the case for its completeness, as noted in the ICMJE criteria for authorship. BJ Liane is the corresponding author of the case. J. Quiles is the staff supervisor. BJ Liane is the article guarantor.

Financial disclosure: None to report.

Previous presentation: ACG 10th Annual Endoscopy Video Forum, ACG Annual Scientific Meeting, Charlotte, NC, October 24, 2022.

Informed consent was obtained for this case report.
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REFERENCES

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2. Salah W Harrison ME Faigel DO Pannala R . Acute duodenal diverticulitis treated with endoscopic therapy. Gastrointest Endosc. 2014;80 (3 ):522–3.25127950
3. Fan HS Talbot ML . Successful management of perforated duodenal diverticulum by use of endoscopic drainage. VideoGIE. 2017;2 (2 ):29–31.29905220
