The challenging diagnosis and treatment of duodenal diverticulum perforation: a report of two cases

Case 1

A 51-years old female patient was admitted through the emergency department with abdominal pain of acute onset, mainly epigastric with a right lumbar reflection. The patient had already visited a private medical facility, where she underwent a CT-scan of the abdomen with oral and IV contrast. The findings were consistent with a duodenal perforation and the clinicians referred the patient to the emergency department for further diagnosis and treatment. The patient did not complain of fever, vomit or nausea. Also, she denied any history of NSAIDs and steroid use or a history of ulcer disease, nor did she describe related symptoms.

On clinical examination, the patient had a soft abdomen, mild epigastric tenderness with no signs of peritoneal irritation. The patient’s vital signs were normal. She mentioned a medical history of Hashimoto disease under treatment. We proceeded on laboratory testing with the following findings: WBC: 12.93 K/μL, Neut: 76.1%, Hb: 131 g/L, Hct: 36.1%, C-reactive protein on a level of 212.8 mg/l and d-dimmers: 855 ng/ml. Consequently, a new CT scan of the abdomen revealed free air located in the hepatic hilum, the retroperitoneal follicle and the upper liver surface (Fig. 1a, b).

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We decided to perform an immediate exploratory laparotomy during which we noted the presence of a perforated duodenal diverticulum on the second part of the duodenum (Fig. 2a-b). A diverticulectomy was performed with the use of a linear stapler along with the placement of a drain tube in the anatomical area of the second part of the duodenum. The diverticulum was sent for pathology. A Naso-Gastric tube was used and the patient returned to the ward. She stayed at nil per os until hospital day (HD) 8 and started treatment with intravenous antibiotics and PPIs. On post-operative laboratory tests, we noted an immediate drop of WBC (8.37 K/μL). The highest drainage measurement per day was 200 ml on hospital day 2 and the NG tube measurement ranged from 100 to 600 ml per day.

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The pathology report confirmed the presence of a small intestine diverticulum with a partial perforation of its wall, with no signs of malignancy. On Hospital Day 8 the patient underwent a radiological small intestine transit with gastrographine, as a part of our department’s protocol for upper GI perforation, before initiating oral feed. In this study, the absence of a duodenal diverticulum in the second part of the duodenum was proved and no signs of leakage could be identified. After that, the NG tube was removed and the patient gradually started oral feeding. The next day the drainage was removed too.

The patient was discharged on hospital day 10, stable with no symptoms of pain with advice for alimentation and post-operative reassessment.

Case 2

A 58-year old female patient was referred to the emergency department from a District General Hospital with the diagnosis of a perforated duodenal diverticulum in the second part of the duodenum. The patient was admitted through the emergency department of the above hospital with sudden epigastric pain and was hospitalized for 5 days. She underwent an abdominal CT-scan that showed a lesion in the anatomical area of the pancreatic head with air locules and inflammation, findings that were non-specific for a certain clinical entity. In order to discern the exact pathology, an MRI scan was then requested, which showed a diverticulum close to the ampulla of Vater. She was referred for further treatment. The patient’s medical history included Hypertension, Hypothyroidism and Hyperlipidemia, all under treatment. On clinical examination, she had epigastric tenderness and no signs of peritoneal irritation.

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On admission, her vital signs were normal, with no fever and her laboratory tests showed: Potassium: 3.4 mmol/l, WBC: 14.33 K/μL with 77.9% neut and 11.1% lymph, Hb: 10.3 g/dL and Hct: 31.3%. We decided to order a new CT scan that revealed free fluid at the sub-hepatic space, spleen and the right paracolic gutter and an abscess of 5 cm diameter near the head of the pancreas (Fig. 3). We decided to proceed with a conservative approach and she was immediately set under treatment which consisted of metronidazole, tigecycline, tinzaparin, paracetamol. The patient stayed at nil per os until hospital day 9 and she received daily 1 L of parenteral nutrition until HD 22.

On patient’s laboratory tests on hospital day 2 we noticed high inflammatory markers (C-reactive protein at 73.10 mg/l and WBC count at 11.36 K/μL) with a Procalcitonin level of 0.2 ng/ml. The WBC count went back to normal on HD 8. On HD 7 the patient was complicated with cough and fever up to 38.4 °C so she was treated for a viral upper respiratory tract infection with oseltamivir 75 mg 12hourly along with ipratropium-salbutamol as required, until HD 12. The patient started oral feeding gradually from HD 10 following an upper GI transit with oral contrast, negative for extra-luminal spillage.

Prior to her discharge, on hospital day 18, we repeated the abdominal CT scan on which we noted the presence of the duodenal diverticulum now being clearly shaped with fluid traces on the second part of the duodenum. The above findings are suggestive of significant improvement. On HD 19 the patient underwent an abdominal MRI that also confirmed the presence of a duodenal diverticulum on the second part of the duodenum with a mild inflammation (Fig. 4). The patient continued on conservative treatment with no signs of recurrence. Her hospital stay was complicated by an upper respiratory tract infection by the influenza virus and treated with oseltamivir. She was finally discharged home on hospital day 26 free of symptoms.

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