2026, Number 2
Perforated duodenal diverticulum treated conservatively
Full text
10.35366/122617
Language: English/Spanish [Versión en español]
References: 6
Page: 135-138
PDF size: 1132.63 Kb.
ABSTRACT
Introduction: duodenal diverticula are common conditions; however, perforation is a rare occurrence. Accuracy is required for its diagnosis because it is not the first suspicion in the face of abdominal pain and is often confused with other differential entities. Although there are few reported cases of conservative treatment, as some patients can use it, several reports have shown satisfactory results. However, it is necessary to maintain close monitoring, and surgical procedures should always be considered. We describe the case of a patient diagnosed with a perforated duodenal diverticulum who received conservative treatment, which evolved satisfactorily. Case presentation: a 50-year-old patient with a history of systemic arterial hypertension, transient ischemic attack, and gastroesophageal reflux disease was admitted to the emergency department secondary to severe abdominal pain, postural discomfort, abdominal distension, and a CT scan diagnosis of duodenal perforation. He was hemodynamically stable. A new imaging study with oral contrast was performed due to the lack of a previous study, reporting perforation of the duodenal diverticulum with no contrast medium leak. Conservative treatment was decided upon, with an adequate outcome four months after the event described. Conclusion: conservative treatment is effective for initially treating patients without complications.ABBREVIATIONS:
- DD = duodenal diverticula
- EVA = visual analog scale (VAS)
- NP = parenteral nutrition
- TC = computed tomography (CT)
INTRODUCTION
Duodenal diverticula (DD) are entities that represent the herniation of mucosal and submucosal layers of the duodenal wall through a muscular defect. They have an estimated prevalence of 0.46–22%,1,2 can be congenital or acquired, and are usually asymptomatic. In most cases, the diagnosis is incidental, made during an imaging study for another cause or as a result of an autopsy. When symptoms do present, the most frequent are abdominal pain, dyspepsia, and gastrointestinal bleeding. A rare complication of this pathology is duodenal perforation, with 209 cases published up to 2022 and an associated mortality between 8 and 34%.3,4
There is no consensus on the management of a perforated DD. The initial recommendation is surgical treatment, although conservative management has gained greater relevance given the complications reported in surgery.5
We describe the conservative management of a perforated diverticulum in the third portion of the duodenum.
CASE PRESENTATION
A 50-year-old female patient, with a history of hypertension, transient ischemic attack, and gastroesophageal reflux disease, and with two previous upper endoscopies. She was admitted to the emergency department reporting abdominal pain of four days' evolution, postural discomfort, and abdominal distension. On physical examination: weight 63.5 kg, height 166.3 cm; body mass index (BMI) 23 kg/m2. Heart rate (HR) 85 bpm, respiratory rate (RR) 21 rpm, temperature 35.7 °C, oxygen saturation 92%, blood pressure (BP) 113/66 mmHg. Neurologically intact; Glasgow Coma Scale 15 points. Cardiopulmonary system without compromise. Abdomen soft, depressible, with tenderness to superficial and deep palpation of the right hypochondrium (visual analog scale [VAS] 8/10), positive rebound, without signs of peritoneal irritation; with decreased peristalsis. Laboratory and imaging studies were requested, as well as an evaluation by general surgery. Laboratory results indicated leukocytosis, elevated acute phase reactants (C-Reactive Protein [CRP], Procalcitonin [PROCA]), and protein-calorie malnutrition/hypoalbuminemia (Table 1), while the abdominal tomography showed a duodenal diverticulum with a contained perforation (Figure 1).
Due to the absence of contrast medium leakage into the extraluminal space, the duration of evolution, and the fact that the patient was hemodynamically stable, it was decided to initiate conservative management. This consisted of the administration of parenteral nutrition (PN), with a distribution of 50% carbohydrates, 30% amino acids, and 20% lipids, broad-spectrum antibiotic therapy with ertapenem and fluconazole, thromboprophylaxis with enoxaparin, and analgesic management with paracetamol and nonsteroidal anti-inflammatory drugs.
After six days of surveillance maintaining mean arterial pressure (MAP) between 65–70 mmHg, HR 60–75 bpm, RR 14–16 rpm, oxygen saturation > 94%, temperature 36–36.8 °C, with PN and clinically asymptomatic, a follow-up CT scan was performed. It showed the diverticulum with a smaller amount of extraluminal air (Figure 2)(Table 1), and the absence of symptoms. Therefore, a liquid diet to tolerance was initiated, with progression to a specific diet and a progressive reduction of PN. The diet was advanced to a soft diet, free of fats and irritants; once seven days of antibiotic treatment were completed, ertapenem and fluconazole were discontinued. At ten days, the patient showed improvement in abdominal symptoms, adequate clinical progression, and 100% tolerance of her nutritional requirements, and was therefore discharged.
Currently, four months after the initial event, the patient has remained stable; her laboratory values are within normal limits (Figure 1), and the main symptoms she presents are secondary to gastroesophageal reflux disease, for which she is undergoing treatment with proton pump inhibitors (PPIs), a prokinetic, and a mucosal protector.
DISCUSSION
Perforation of a duodenal diverticulum is rare and potentially life-threatening. It is considered to occur due to the presence of a thin wall, described in most diverticula located in the second or third portion of the duodenum. Its main cause is diverticulitis; the clinical presentation is variable and nonspecific due to its location. Some symptoms include abdominal pain, vomiting, and fever, often being confused with more common intra-abdominal conditions such as cholecystitis, pancreatitis, peptic ulcer disease, colitis, and retrocecal appendicitis.4
Timely diagnosis of a diverticular perforation is crucial to determine conservative management. Identifying a duodenal diverticulum and a perforation of this type of diverticulum requires a thorough clinical examination, laboratory tests, as well as fine-cut imaging tests (computed tomography [CT]). CT is the reference test for the diagnosis of a perforated duodenal diverticulum.3 The radiological findings to take into account are: duodenal wall thickening ≥ 4 mm, stranding of mesenteric fat, and extraluminal or retroperitoneal air/fluid.3 In accordance with what has been presented, our patient did not show signs of peritoneal irritation because the growth was at the retroperitoneal level, causing vague symptoms; the diagnosis was made through the CT protocol.6 The absence of oral contrast leakage demonstrated that the diverticulum was contained; the risk of subjecting the patient to emergency surgery was greater than the benefits it could offer.3
Several reports describe conservative management based on antibiotics and percutaneous drainage,3,6 however, this management can only be performed in hemodynamically stable patients without signs of an infectious process; in case of failure to improve, a surgical procedure must be considered.6
If a surgical procedure is chosen, it is necessary to determine the appropriate surgical technique based on the evaluation of several elements, such as the degree of tissue friability, the location of the diverticulum, and the size of the diverticular neck. Diverticulatectomy is the appropriate technique for cases with limited tissue friability and a small diverticular neck; however, the risk of leakage is higher in the second and third duodenal portions. On the other hand, partial duodenectomy with end-to-end or end-to-side duodenojejunostomy is used for friable tissues, a wide diverticular neck, and a location in the D3/D4 portions, where diverticulatectomy is suspected to carry a high risk of leakage. For diverticula located in D2, the surgical approach can range from duodenal exclusion, duodenostomy, to pancreaticoduodenectomy (Whipple).3
Regardless of the choice, all procedures represent a high surgical risk, morbidity and mortality, and intraoperative complications, as well as complications in the early postoperative period, which can affect the patients' quality of life.
CONCLUSIONS
The clinical, laboratory, and tomographic features presented in this patient were the basis for the decision to opt for conservative treatment. The success of conservative management consists in properly and timely identifying patients who could benefit from this type of treatment. Despite being an uncommon pathology with a complex approach, timely detection and adequate follow-up prevent the use of invasive treatments that can be risky and have short-, medium-, and long-term consequences on the patient's quality of life.
REFERENCES
AFFILIATIONS
1 Hospital Angeles Lindavista. Ciudad de México, México.
2 Cirugía General, Robótica y Cirugía de Trasplantes. orcid: 0009-0001-7338-6878
3 Ginecología y Obstetricia, Hospital Angeles Pedregal. Ciudad de México, México. orcid: 0000-0003-3827-8836
4 Medicina interna, Gastroenterología y Endoscopia. orcid: 0000-0002-4917-762X
5 Médico interno de pregrado. orcid: 0009-0000-4048-639X
Conflict of interest: the authors declare that they have no conflict of interest.
For study with human subjects: informed consent was obtained from the patient for inclusion in this case report.
Funding: none.
If you wish to consult the supplementary data for this article, please contact editorial.actamedica@saludangeles.mx
CORRESPONDENCE
Ricardo Daniel Romero-Morelos. Correo electrónico: doc.romero.morelos@gmail.comReceived: 2024-11-08. Accepted: 2025-03-13.