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Duodenal diverticula are relatively common pseudodiverticula of the small intestine.1 Frequently asymptomatic, they may become clinically evident only upon perforation or inflammation. With only about 110 reports of perforations of duodenal diverticula over the past 2 decades,2 the optimal management of duodenal diverticula perforations remains uncertain. We describe 2 approaches to the management of this condition.
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.
After entering her peritoneal cavity we mobilized the hepatic flexure, exposing the second portion of the duodenum. The duodenum was kocherized, and the second and third portions mobilized over to the midline. We found the decompressed diverticulum plastered to the posterior wall of the duodenum and the head of the pancreas. Her diverticulum was dissected back to its origin, and reduced. The remaining 7-mm defect in the duodenal wall was closed in a transverse fashion with interrupted 3.0 Vicryl sutures. To complete the repair, we mobilized a tongue of greater omentum off the right colon and patched it over the repair.
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.
In summary, the clinical presentation can be used as a guide to management. Nonoperative treatment should be considered for patients who present with mild symptoms and whose leak is shown by CT to be contained. But if these patients deteriorate clinically, they must undergo surgical intervention.
Competing interests: None declared.
Correspondence to: Dr. Wilson W. Marhin, Department of Surgery, Royal Jubilee Hospital, 2334 Trent St., Rm. 186, Victoria BC V8R 4Z3; fax 250 384-7571; wilson.marhin/at/utoronto.ca
Accepted for publication Mar. 22, 2004