Clinical analysis and literature review of massive duodenal diverticular bleeding

A duodenal diverticulum (DD) appears in 2.5% of upper gastrointestinal (UGI ) examinations and up to 22% of endoscopic retrograde cholangiopancreaticog raphies (ERCP) and autopsies. Most of these patients are asymptomatic, but the lesion is occasionally associated with bleeding, inflammation, perforat ion, obstruction of the duodenum or biliary-pancreatic duct (or both), fist ula formation in the bile duct, and bezoar formation inside the diverticulu m. A total of 816 patients have undergone ERCP examination at our instituti on since January 1987, and 100 (12.25%) of them have DD. Seven (7%) patient s presented with bloody or tarry stools from massive UGI bleeding followed by shuck. Only two could be diagnosed by UGI endoscopy preoperatively. The lesions were demonstrated in angiographic studies in another four cases. Ho wever, only one was correctly interpreted and one required reoperation afte r a correct repeat endoscopic finding. The lesions in the other two patient s were identified by thorough exploration during laparotomy. The remaining case was diagnosed by intraoperative endoscopy via pyloroduodenotomy, Six u nderwent surgical intervention, and one was successfully treated by expecta nt treatment. Three (50%) had leakage from the duodenotomy but recovered un eventfully with conservative treatment. In conclusion, we believe that DD b leeding is more frequent than usually thought. A high index of suspicion sh ould be raised in cases of UGI bleeding when more obvious and common causes have been excluded by routine endoscopy. Aggressive but careful endoscopic examination combined with accurate angiography can help us diagnose most o f the cases preoperatively. Diverticulectomy is an effective surgical proce dure, though it is associated with a considerable leakage rate. The morbidi ty is minimal if we can identify the lesion earlier and evacuate the lesion without delay.