Emerg Radiol DOI 10.

1007/s10140-012-1019-2

CASE REPORT

Duodenal diverticulitis followed by enterolith-associated small bowel obstruction

Avinash Medsinge & Erick M. Remer & Charles G. Winans

Received: 4 November 2011 / Accepted: 5 January 2012 # Am Soc Emergency Radiol 2012

Case report A 77-year-old woman presented to the emergency department with right upper quadrant pain, nausea and vomiting of approximately 2-week duration. The gallbladder was reported to be normal on ultrasound at another hospital. With a lipase of 287 units/l and total leukocyte count of 16,300/ml, there was clinical concern for pancreatic pathology. Computed tomography (CT) scan showed three duodenal diverticulatwo in second portion and one in the fourth portion of duodenum. There was an enterolith within a large diverticulum arising from second portion with extension into pancreaticoduodenal groove and displacement of pancreatic head (Fig. 1). The enterolith had internal gas foci. The wall of the diverticulum and postbulbar duodenum were thickened (Fig. 2). The distal pancreatic and common bile ducts were dilated to 6 and 10 mm, respectively (Fig. 3). Infiltration in the retroperitoneum surrounded the diverticula and extended along the medial portion of the second and third portions of duodenum (Fig. 3). There were a few punctate extraluminal gas foci lateral to the descending duodenum. Other scattered diverticula were present in the rest of the small bowel. The appendix was normal.
A. Medsinge : E. M. Remer (*) Section of Abdominal Imaging, Imaging Institute A21, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA e-mail: remere1@ccf.org C. G. Winans Department of Hepato-pancreato-biliary and Transplant Surgery, Digestive Diseases Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA

With the imaging diagnosis of duodenal diverticulitis, the patient was resuscitated and treated with ciprofloxacin, metronidazole, and analgesics. Her symptoms improved and lipase and total leukocyte counts normalized. Upper gastrointestinal endoscopy found a complex diverticulum containing food and debris that originated from the anteromedial wall of second portion of duodenum. The diverticulum was cleared of all debris. For better delineation of biliary ductal anatomy in anticipation of future surgical resection, magnetic resonance imaging was performed that included magnetic resonance cholangiopancreatography (MRCP) images [T2-weighted half-Fourier acquisition single-shot turbo spin-echo (HASTE)] and unenhanced and enhanced T1-weighted 3D gradient echo (volumetric interpolated breath-hold examination) images. Figure 4 shows 3.7 and 5 cm air containing diverticula in the descending and transverse portions of the duodenum. There was minimal adjacent free fluid with air pockets along the second and third portions of the duodenum. The pancreas was normal. The patient was discharged on oral antibiotics and was scheduled for follow-up. However,the patient presented with abdominal pain, nausea, and vomiting 10 days after discharge. CT scan with oral and intravenous contrast showed an interval decrease in the peridiverticular inflammatory changes. There was no enterolith within the duodenal diverticulum, but a mid small bowel obstruction by a 3.8 cm enterolith was seen (Figs. 5 and 6). The enterolith had similar appearance to that seen in duodenum on the prior CT scan. The gallbladder was normal and there was no pneumobilia to suggest gallstone ileus. The CT interpretation was that the enterolith causing the small bowel obstruction had originated from the duodenum. At laparotomy, the enterolith was found to be impacted in distal jejunum with associated proximal dilatation.

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Fig. 1 Contrast-enhanced CT coronal multiplanar reformation shows a complex mass containing gas in the pancreaticoduodenal groove between the duodenum (arrow) and pancreatic head (thick arrow)

Fig. 4 Coronal HASTE MRCP images after the endoscopic clearing and irrigation of the diverticulum shows low signal intensity gas within the diverticulum (arrow)

Enterolithotomy was performed after milking the enterolith to the distal nonedematous jejunum. There were innumerable diverticula along mesenteric border in jejunum and ileum. Due to patients cardiac status, a complicated resection was avoided. After surgery, the patients condition improved and she was discharged.

Fig. 2 Contrast-enhanced axial CT shows enterolith containing central gas within the diverticulum (arrow)

Fig. 3 Contrast-enhanced coronal CT MPR shows normal gallbladder with absence of pneumobilia. There is another diverticulum in distal duodenum (arrow). The common bile duct and pancreatic duct are dilated

Fig. 5 Coronal MPR from CT with oral and IV contrast shows enterolith (arrow) within the ileal loop and associated jejunal dilatation in the left upper quadrant

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Fig. 6 Contrast-enhanced axial CT shows the enterolith (arrow) within the small bowel loop with proximal fluid-filled dilated loop

Discussion Duodenal diverticulosis is a common entity; the duodenum is the second most common bowel site for diverticulosis after the colon. The reported prevalence of duodenal diverticula is 22% on autopsies and endoscopic retrograde cholangiopancreatography procedures and 510% on imaging studies of abdomen [1]. But complications are rare; only 1% of these patients require treatment for either perforation, hemorrhage, or diverticulitis [2, 3]. Duodenal diverticula can be seen in the second through fourth portions of duodenum, but the periampullary region is the most common site. These juxtapapillary or paravaterian diverticula arise within 2.5 cm of the papilla on the medial wall [4]. Only 5% of diverticula arise from the lateral wall [5]. True diverticula, containing all three layers of duodenal wall,

are congenital and are rare. Most duodenal diverticula are acquired from herniation of mucosa and submucosa through a focal mural weakness. This typically occurs at the entry or exit site of a blood vessel, the pancreatic or common bile duct, or at the site of an ectopic pancreatic rest. On CT, an uncomplicated diverticulum is seen as a saccular outpouching with a thin wall or a complex mass-like lesion in pancreaticoduodenal groove. The diverticulum may contain air, an airfluid level, debris, or ingested contrast material. Air within a diverticulum may help the radiologist confirm its diagnosis. At times, a diverticulum may be fluid-filled and can be mistaken for a cystic pancreatic neoplasm or pseudocyst. These diverticula can enlarge on follow-up, and, on occasions, pancreaticoduodenectomy has been performed in such cases due to inability to diagnose the diverticulum preoperatively [6]. Inflammation within a duodenal diverticulum is rare compared to other bowel diverticula. This can be attributed to the typically large size of duodenal diverticula with easy efflux of relatively sterile, liquid duodenal contents. Duodenal diverticulitis or perforation has nonspecific clinical signs and symptoms and is rarely diagnosed clinically. It is often confused with acute cholecystitis, a perforated peptic ulcer, or pancreatitis (Table 1). On occasion, diverticulitis or perforation has characteristic diagnostic imaging findings [3]. Diverticulitis shows wall thickening with diffuse adjacent fat and soft tissue stranding, as was seen in our case (Fig. 1). A complex mass with air, an airfluid level, debris, or contrast material can be seen. On occasion, there can be extraluminal air with minimal fluid adjacent to inflammatory changes. A perforation can cause a small amount of gas in the surrounding area, typically without pneumoperitoneum, or a periduodenal abscess [7].

Table 1 Differential diagnosis of upper abdominal pain Diagnosis Duodenal diverticulitis Clinical Right upper quadrant (RUQ) pain Imaging Diverticular wall thickening with adjacent fat and soft tissue stranding. Complex mass with air, an airfluid level, debris, or contrast material can be seen. Extraluminal gas and minimal fluid adjacent to inflammatory changes or abscess are possible Pancreas enlargement, peripancreatic inflammation, or fluid, intrapancreatic collections Pneumoperitoneum near stomach or liver. Concentration of extraluminal air bubbles, a focal defect of the bowel wall, and segmental bowel wall thickening [12] Gallbladder dilation, wall thickening, pericholecystic infiltration, and/or fluid

Steady abdominal pain (epigastrium, RUQ, or diffuse), nausea, vomiting and distention. Restlessness, agitation, relief when bending forward Perforated ulcer History of peptic ulcer symptoms and sudden onset of severe, diffuse abdominal pain Cholecystitis Murphy sign; mass, pain, and/or tenderness in right upper quadrant or epigastrium with possible radiation to right shoulder or back. Pain is characteristically steady and severe. May have nausea, vomiting, and anorexia. Often a history of fatty food ingestion and usually of biliary colic. Systemic signs of inflammation (fever, elevated C reactive protein level, elevated white blood cell count) present

Pancreatitis

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Review of the literature indicates an increased preoperative diagnosis of duodenal diverticulitis with the advent of CT [7]. However, there is a significant misdiagnosis rate as it is often not considered as a differential diagnosis due to its rarity [7]. Other more common entities that mimic duodenal diverticulitis on CT include pancreatitis and its complications, pancreatic head neoplasms, perforated peptic ulcer, or peripancreatic lymphadenopathy. Duodenal diverticulitis should be considered in the differential of peripancreatic inflammatory pathologies containing a complex mass with air, an airfluid level, debris, or contrast material, particularly if serum lipase and amylase levels are normal [7]. Enterolith formation within duodenal diverticulum is the most uncommon complication of duodenal diverticula, and its description is limited to case reports [8]. The small bowel obstruction due to passage of enterolith from the duodenal diverticulum is likewise rare [9]. Enterolith ileus cannot be distinguished clinically from gallstone ileus. The presence of a normal gallbladder and small bowel diverticula on imaging are essential for making the diagnosis [10]. If conservative treatment fails, fragmentation and milking of the enterolith distally into the colon is the least invasive treatment solution. Alternatively, an enterolithotomy can be carried out, preferably after milking it into a nonedematous area [11]. In conclusion, though inflammation of duodenal diverticulum is uncommon, duodenal diverticulitis should be considered as one of the differential diagnosis in appropriate given clinical setting and supporting imaging findings. An

enterolith in a duodenal diverticulum is a rare finding, especially one leading to small bowel obstruction.

References
1. Yin WY, Chen HT, Huang SM, Lin HH, Chang TM (2001) Clinical analysis and literature review of massive duodenal diverticular bleeding. World J Surg 25:848855 2. Macari M, Lazarus D, Israel G, Megibow A (2003) Duodenal diverticula mimicking cystic neoplasms of the pancreas: CT and MR imaging findings in seven patients. AJR 180:195199 3. Rao PM (1999) Perforated duodenal diverticulitis. Radiology 211:711713 4. Vandenbroucke F, Op de Beeck B, de Mey J (2006) Duodenal diverticulitis. CT and MRI findings. Emerg Radiol 13:9597 5. Gore RM, Ghahremani GG, Kirsh MD, Nemcek AA, Karoll MP (1991) Diverticultis of the duodenum: clinical and radiological manifestations of seven cases. Am J Gastroenterol 86:981985 6. Hariri A, Siegelman SS, Hruban RH (2005) Duodenal diverticulum mimicking a cystic neoplasm. Br J Radiol 78:562564 7. Pearl MS, Hill MC, Zeman RK (2006) CT findings in duodenal diverticulitis. AJR 187:W392W395 8. Franzen D, Gurtler T, Metzger U (2002) Solitary duodenal diverticulum with enterolith as a rare cause of acute abdomen. Swiss Surg 8:277279 9. Yang HK, Fondacaro PF (1992) Enterolith ileus: a rare complication of duodenal diverticula. Am J Gastroenterol 87:18461848 10. Skocket E, Simon SA (1982) Small bowel obstruction due to enterolith (bezoar) formed in a duodenal diverticulum: a case report and review of literature. Am J Gastroenterol 77:621624 11. Hugo WN, Jasper B, Abraham R (2009) Small bowel obstruction due to enterolith expelled from duodenal diverticulum. ANZ J Surg 79:7778 12. Stoker J, van Randen A, Lamris W, Boermeester MA (2009) Imaging patients with acute abdominal pain. Radiology 253:3146