Perforated duodenal diverticulum case report.
BACKGROUND
The duodenum is the second most common location of intestinal diverticula following the colon (Juler et al., 1969) [1]. Only 1-5% of patients with duodenal diverticula become symptomatic (Oukachbi, 2013) [2]. The least common but most serious complication of duodenal diverticula is perforation, which has a mortality rate of 20% (Oukachbi, 2013; Yin et al., 2001; Song, 2015; Schnueriger et al., 2008) [2-5].


METHODS
A 65year old female presented with sudden onset periumbilical and epigastric pain. Her abdomino-pelvic CT without contrast revealed a duodenal perforation of the anterior wall of the duodenum. After attempting a laparoscopic approach, the operation was converted to an open procedure to enhance visualization. A wide Cattell-Braasch maneuver was performed, mobilizing the duodenum, which revealed an inflamed diverticulum. Following a pyloric exclusion, a gastrojejunostomy and a Braun enteroenterostomy were completed in addition to a jejunostomy tube on the efferent limb.


CONCLUSIONS
Clinical presentation of duodenal diverticula is vague and often varies. Although difficult to elucidate on imaging, the most sensitive exam to detect a duodenal diverticulum perforation is an abdominal CT scan, which can reveal thickened bowel wall, mesenteric fat stranding, and an extraluminal, retroperitoneal collection of air or fluid (Song, 2015) [4]. Due to the rareness of perforated duodenal diverticulum, surgical treatment guidelines are lacking.


CONCLUSIONS
Ultimately, it is necessary to have a high index of suspicion to detect a duodenal diverticulum perforation. The perforation usually necessitates operative treatment that consists of a diverticulectomy and two-layer closer of the duodenum, Kocher maneuver, and drainage of the retroperitoneum.
University of Central Florida College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, USA. Electronic address: jglener@knights.ucf.edu.
Julie
J
Glener
Florida Hospital, 601 E Rollins St., Orlando, FL 32803, USA. Electronic address: Stephenie.poris.md@flhosp.org.
Stephenie
S
Poris
Florida Hospital, 601 E Rollins St., Orlando, FL 32803, USA. Electronic address: Brandon.Foles.MD@flhosp.org.
Brandon
B
Foles
Florida Hospital, 601 E Rollins St., Orlando, FL 32803, USA. Electronic address: Rhonda.harmon.md@flhosp.org.
Rhonda
R
Harmon
Case report; Duodenal diverticulum; Perforation