A new endoscopic therapy for an intraluminal diverticulum of the duodenum

We report the case of a 33-year-old woman with dyspeptic symptoms and 5 kg weight loss in 5 months.

During upper gastrointestinal endoscopy at another institution, access to the second part of the duodenum had not been possible for reasons that were unclear. At our hospital, a barium follow through revealed a sac-like contrast-containing structure within the duodenal lumen, suggestive of an intraluminal diverticulum of the duodenum (IDD) (Figure [1] and [2]). Repeat endoscopy confirmed that the second portion of the duodenum could only be reached through a tiny passage at the level of the genu superius, laterally to the diverticular orifice.

Figure 1 Conventional radiograph showing intraluminal diverticulum of the duodenum projecting within the lumen of the second duodenum.

Figure 2 Barium retention in both the bulbus and intraluminal diverticulum of the duodenum.

After obtaining consent and with the aid of a therapeutic endoscope, we punctured the bottom of the diverticulum with a needle knife papillotome. A 0.035-inch guide wire was introduced in the hole, and hydrosoluble contrast material was injected above and below the puncture site to confirm the exact localization of the IDD (Figure [3]). Consequently the puncture site was enlarged using a 7-Fr cystogastrotome, allowing the introduction of an insulated-tip needle knife to incise the diverticular wall longitudinally, up to the diverticular mouth at the genu superius (Figure [4] and video sequences[*]). Endoscopic control with side-viewing scope identified both the papilla and the presumed location of the intramural part of the common bile duct laterally to the section. No immediate or delayed complication occurred. A control endoscopy was performed 1 month later showing complete healing and easy passage to the second duodenum (Figure [5]). Clinical evaluation, 8 months postprocedure revealed continued absence of the dyspeptic symptoms, and no additional weight loss.

Figure 3 Hydrosoluble contrast injection in the diverticulum and in the duodenal lumen through the perforation of the diverticulum.

Figure 4 Endoscopic view from within the diverticulum, showing progression of the diverticulotomy using the insulated-tip knife; note the presence of the guide wire in the incision orifice.

Videos 1 - 3Sequence 1 Inspection of the intraluminal diverticulum of the duodenum. Sequence 2 Perforation of the diverticular sac using a needle-knife papillotome. Sequence 3 Progressive incision of the diverticular septum with the insulated-tip knife.

Figure 5 Endoscopic view of the genu superius from the bulbus showing complete healing of the mucosa and patency of the duodenum.

IDD is a rare developmental anomaly found in adulthood [1] [2] [3]. The main symptoms are related to partial or intermittent obstruction. The most common complications include bleeding, acute or recurrent pancreatitis, cholangitis, and intussusception [3] [4]. Several techniques of endoscopic management of IDD have been described [4] [5]. The present procedure allows avoidance of trauma to the papilla, the common bile duct, or the opposite duodenal wall.

Endoscopy_UCTN_Code_TTT_1AO_2AN

References

• 1 De Castro M L, Hermo J A, Pineda J R. et al . Acute bleeding and anemia associated with intraluminal duodenal diverticulum: case report and review.  Gastrointest Endosc. 2003;  57 976-979
• 2 Ravi J, Joson P M, Ashok P S. Endoscopic incision of intraluminal duodenal diverticulum. Case report of a new technique.  Dig Dis Sci. 1993;  38 762-766
• 3 Finnie I A, Ghosh P, Garvey C. et al . Intraluminal duodenal diverticulum causing recurrent pancreatitis: treatment by endoscopic incision.  Gut. 1994;  35 557-559
• 4 Lee S H, Park S H, Lee J H. et al . Endoscopic diverticulotomy with an isolated-tip papillotome (Iso-Tome) in a patient with intraluminal duodenal diverticulum.  Gastrointest Endosc. 2005;  62 817-819
• 5 Hiraoka T, Nakamura M, Ohno K. et al . Endoscopic excision of intraluminal duodenal diverticulum.  Dig Dis Sci. 1985;  30 274-281