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
