ENDOSCOPIC TREATMENT OF INTRALUMINAL DUODENAL ("WINDSOCK") DIVERTICULUM WITH DIVERTICULOTOMY

Aims:

Intraluminal duodenal diverticulum (IDD), also known as windsock's diverticulum is a rare congenital anomaly, which results from an incomplete recanalization of the foregut in the embryonic formation. Although most patients are asymptomatic, the most frequent symptoms are nausea, vomit, early satiety and epigastric discomfort. Complications are rare and include gastrointestinal bleeding, obstruction, pancreatitis and cholangitis. Endoscopic therapeutic can be used as an alternative treatment in symptomatic cases.

Methods:

Case report of endoscopic treatment of IDD in a Brazilian tertiary reference center.

Results:

A 19-year-old female with uncontrollable nausea, vomit and weight loss with twenty-days evolution. Laboratory tests and abdominal ultrasonography showed no alterations. Symptoms worsened during hospitalization with refractoriness to the clinical treatment. Introduction of total parenteral nutrition was necessary. Upper gastrointestinal endoscopy revealed a large IDD in the second duodenal portion partially occupying the lumen and with a small orifice in distal portion. The duodenal papilla was identified proximal to the diverticulum. Endoscopic diverticulotomy was recommended after multidisciplinary discussion. The septotomy was performed with needle-knife from the proximal to the distal portion, pulling the catheter in a contralateral direction to the wall of the diverticulum and thermal hemostasis was done with a coagrasper, with complete diverticulotomy and allowing easy passage of the endoscope. A laceration area was observed in the second duodenal portion, contralateral to the diverticulotomy, and metal clips were placed. Patient presented massive hematemesis, one day after the procedure, which was resolved with placement of metal clips and injection of adrenaline solution. Oral diet was started without new intercurrences.

Conclusions:

IDD are rare and generally asymptomatic. New minimally invasive techniques have been described for the treatment of symptomatic cases. The endoscopic approach by diverticulotomy may be the treatment of choice, with good success rates as described in the literature.