Acute duodenal diverticulitis treated with endoscopic therapy

Dr. PannalaDr. Wajeeh SalahAuthors Wajeeh Salah, MD and Rahul Pannala, MD from the Mayo Clinic Arizona in Phoenix, Arizona, USA discuss this video case “Acute duodenal diverticulitis treated with endoscopic therapy.”

Our video highlights a case of acute periampullary diverticulitis caused by impaction of bowel contents within the diverticular lumen. We demonstrate the technique for treating this type of diverticulitis with endoscopic therapy. The diverticulum is first carefully disimpacted using a balloon catheter resulting in the drainage of a large quantity of pus. The diverticulum cavity is then irrigated using a sterile solution. The cavity is further debrided and two plastic double pigtail stents placed to facilitate continued drainage. The stents are then removed 3 weeks later with complete resolution of the diverticulitis.

Periampullary diverticulitis is a rare adverse event of periampullary diverticulum and can present with severe sepsis and abdominal pain. Due to the diverticulum’s proximity to the pancreas and biliary system, the presentation can mimic cholangitis, cholecystitis, pancreatitis, or an intra-abdominal abscess. We present this case of duodenal diverticulitis in order to showcase its classic presentation and aid in the more rapid recognition and treatment of similar cases.

The treatment of duodenal diverticulitis is similar to the process used in endoscopic necrosectomy. A multimodal treatment approach is required. Antibiotics, fluids, and supportive care are needed in patients presenting with sepsis or signs of systemic infection. When inflamed, the thin wall of the diverticulum becomes even more susceptible to perforation. Thus, care must be taken when debriding the diverticular cavity. If the diverticular cavity cannot be completely cleared using gentle debridement and irrigation, stenting can be used to facilitate continued drainage. It is also important to involve surgical colleagues early on in the course of these cases to provide support and surgical therapy if needed.

Familiarity with the presentation of periampullary diverticulitis is the key to recognizing it and establishing a rapid diagnosis. Surgical therapy can be challenging when the infected diverticulum is near the ampulla. Endoscopic treatment of the infected diverticular cavity can be accomplished using disimpaction, debridement, irrigation and stenting. Our video demonstrates that endoscopic therapy can be successful in treating cases of periampullary diverticuluitis when conservative management fails and that this can be a viable alternative to surgery.

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The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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