Duodenal diverticula are found in up to 22% of the population.1
Of these, only 1%–2% of patients are symptomatic and require surgery. The rarest, most severe complication is perforation, which carries a death rate of up to 30%. Although the signs and symptoms of perforated duodenal diverticulitis are often nonspecific, and the radiologic findings subtle, a correct preoperative diagnosis is essential and may significantly lower this rate.2
CT is the modality of choice. Findings consist of a thickened bowel wall, mesenteric fat stranding and an extraluminal collection of air or fluid, often retroperitoneal.3
In 60% of cases, a duodenal diverticulum is identified in the juxtapapillary position.
Because of the intimate relationship of the duodenum to adjacent structures, the most appropriate procedure may be a tube duodenostomy and feeding jejunostomy.4
Despite reports such as this, and those advocating combined percutaneous and endoscopic management, or a laparoscopic approach, the treatment of choice for perforated duodenal diverticula remains transduodenal diverticulectomy and 2-layer closure.2
Injury to the common bile duct and pancreatic duct is prevented by inserting a feeding tube into the ampulla of Vater before beginning dissection of the diverticulum. Other potential complications of this procedure are duodenal fistula, sepsis, intra-abdominal abcess and pancreatitis.
This case highlights the importance of early, correct radiologic diagnosis and the safety of diverticulectomy and 2-layer closure because of the high morbidity and mortality still associated with this condition.