Patient A, a 58-year-old woman, arrived in acute distress, febrile and tender in the right upper abdomen. A computed tomographic (CT) scan showed periduodenal inflammation and edema surrounding the second portion of the duodenum, associated with air/fluid collections posterior to its first and second portion. Edema was noted in the right retroperitoneum, extending from the posterior duodenal fluid collection (Fig. 1, overleaf). A perforated duodenal diverticulum was diagnosed, and a surgical repair was scheduled.

Patient B, a woman 61 years of age, was admitted with epigastric pain 24 hours after a colonoscopy with duodenal mucosal biopsies. She was in mild distress but afebrile; superficial palpation of the right upper abdomen disclosed tenderness. CT assessment of the abdomen revealed a collection of gas and fluid in the retroperitoneum. The collection was medial to the second part of the duodenum, which appeared thickened and inflamed (Fig. 2). The diagnosis was perforation of a duodenal diverticulum. The patient was treated successfully with a 4-day course of intravenous imipenen (500 mg every 6 h) followed by a 7-day course of oral cephalexin (500 mg every 6 h) and metronidazole (500 mg every 8 h).

The mortality rate of duodenal diverticula perforation is high, and its management controversial. The most common approach has been surgical,³ with a few reports of conservative management with antibiotics.⁴ Our approach was directed by the clinical and radiological findings. Patient A was in acute distress at presentation, and radiological signs suggested retroperitoneal involvement, prompting surgical management. In contrast, patient B was in mild distress, and described some symptom improvement with analgesia.