Duodenal diverticula

Section: Small bowel Curriculum: Curriculum, page 59

Small bowel diverticula

Definition

• A out pouch of the duodenum
  • True
    • All layers
  • False
    • Mucosal protrusion through the muscular wall of the bowel

Incidence

• Incidence: 2nd most common site after colonic
• 2:1 M > F
• Classification
  • Congenital (True)
  • Acquired (False)
• 2/3 found in the peri-ampullary region
  • Project into the medial aspect of the duodenum

Presentation

• Majority asymptomatic
  • Can have vague epigastric pain
  • Rarely complicated
• Complications:
  • Obstruction of biliary/pancreatic ducts
  • Ampullary diverticulum
    • Ampulla usually enters at superior aspect of diverticulum
  • Haemorrhage
  • Perforation
  • Blind loop syndrome
    • Bacterial overgrowth in stasis of diverticulum

Diagnosis

• Incidental finding
  • On Imaging/endoscopy
  • 1-5% of all studies
• < 5% require intervention
• CT confirms diagnosis

Management

• Non-operative – majority left alone
• Operative
  • Complicated diverticulum (bleeding etc)
    • Diverticulectomy
      • Kocherise duodenum
      • Excise diverticulum, close with transverse or longitudinal closure
      • Need to be careful of ampulla and CBD/PD
    • Duodenotomy and invagination of the diverticulum
      • Then excised and the wall closed
  • Perforated diverticulum
    • Diverticulum excised and duodenum closed with patch of jejunum
    • May need to divert flow with gastrojejunostomy +/- pyloric closure with suture
  • If it is posterior into pancreatic bed
    • Surgery may be difficult and best treated with conservative management
    • Drainage +/- bypass with Gastrojejunostomy