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An unusual case of acute pancreatitis secondary to an intraluminal duodenal diverticulum
At the Focal Point
An unusual case of acute pancreatitis secondary to an intraluminal duodenal diverticulum
A 23-year-old man with no history of medical problems developed acute abdominal pain associated with nausea and vomiting. Upon presentation, he was afebrile. His heart rate was 86 beats per minute and his blood pressure was 136/67 mm Hg. On physical examination, his abdomen was tender to palpation in the mid epigastrium without guarding. Laboratory testing revealed a white blood cell count of 21,000 cells/mcL (3.6-10.6 cells/mcL), amylase of 762 U/L (normal ⬍100 U/L), and lipase of 6970 U/L (normal ⬍50 U/L). Liver biochemical tests were normal. CT of the abdomen with oral contrast demonstrated pancreatic inflammation and a duodenal mass filled with debris (A). EGD confirmed the presence of a subepithelial mass on the posterior wall of the second portion of the duodenum with involvement of the ampulla (B). EUS of this lesion revealed a large intraluminal duodenal diverticwww.giejournal.org
ulum (IDD) with a characteristic “windsock” appearance (C). The patient was taken to the operating room where a transduodenal exposure of the lesion revealed an IDD that was resected (D). Sphincterotomy and sphincteroplasty also were performed because of ampullary involvement. The specimen measured 4.0 ⫻ 1.5 ⫻ 1.0 cm. Histology revealed benign duodenal mucosa. The patient had an uneventful recovery, and at his 6-month follow-up he remained symptom-free. DISCLOSURE The opinions are solely those of the authors and do not represent an endorsement by the Department of Defense. There are no restrictions on its use. The authors do not have any commercial or proprietary interest in any drug, Volume 72, No. 4 : 2010 GASTROINTESTINAL ENDOSCOPY
847
At the Focal Point
device, or equipment mentioned in the manuscript. There are no conflicts of interest, financial disclosures, grant support, or writing assistance. Fouad J. Moawad, MD, Walter Reed Army Medical Center, Gastroenterology Service, Department of Medicine, Washing-
ton, DC, USA, Andrew B. Gentry, MD, Ashley Humphries, MD, Patrick E. Young, MD, National Naval Medical Center, Division of Gastroenterology, Bethesda, Maryland, USA doi:10.1016/j.gie.2010.03.1055
Commentary In the eighth to tenth week of development, the solid duodenum recanalizes to result in the typically hollow cylinder that characterizes older intestine. On occasion, however, successful recanalization is thwarted and intestinal atresia, stenosis, or membranous web results. The former two most often manifest early in childhood with GI obstruction, whereas the last has a more variable time frame and manner of presentation. Because of the prograde movement of intestinal contents, the web may become stretched, forming an intraluminal diverticulum; the aperture of the original web usually remains near its initial position and allows variable amounts of intestinal secretions and ingested substances to pass through it into the intestinal lumen, now narrowed by the diverticulum. The appearance of the diverticulum has been likened in the medical literature to a windsock, which is used to judge the direction and magnitude of wind, usually in rural settings. To those of us who live in urban settings, this windsock diverticulum looks more like an unrolled condom, and, to some, also bears semblance to a bariatric sleeve. Of course, to those of us in urban settings, an actual ingested condom—still with rolled edges—tells us the person who harbors it is a mule, or drug trafficker. Duodenal membranes and windsock deformities are associated with other anomalies, such as intestinal malrotation and preduodenal portal vein; the latter is of importance to the operating surgeon. Pancreatitis may be caused by the associated anomaly such as pancreas divisum or by ampullary obstruction or distortion by a windsock that is filled or obstructed by accumulated intestinal material. Windsock deformity is diagnosed classically by barium meal, the barium being retained in the sock for longer than 6 hours; in this case, EUS was diagnostic. Khalil Gibran said, “If you reveal your secrets to the wind, you should not blame the wind for revealing them to the trees.” This patient went 23 years before the heretofore secret presence of his probably congenital lesion was revealed. Lawrence J. Brandt, MD Associate Editor for Focal Points
Recurrent acute pancreatitis caused by an annular pancreas in a child A 13-year-old girl visited our institute complaining of severe epigastric pain, which had begun after a heavy meal and lasted several hours. There was no relevant medical history and, specifically, no alcohol ingestion or history of trauma. Serology test results revealed elevated serum amylase (314 IU/L [normal 45-108 IU/L]) and lipase (592.2 IU/L, 13-60 IU/L) levels. A complete blood cell count, basic metabolic panel results, and immunologic data including serum immunoglobulin levels were normal, and antinuclear antibody levels were negative. An abdominal CT scan showed mild swelling of the pancreas, which formed a ring-like lesion that encircled the second portion of the duodenum (A, white arrow), along with a mildly dilated pancreatic duct. MRCP demonstrated dilatation of the main pancreatic duct, which curved around the duodenum—a picture compatible with annular pancreas (B, black arrow). EGD showed a circumferential mucosal fold that narrowed the lumen of the proximal second part of the duodenum (C). Hypotonic duodenography showed a mild mucosal thickening with extrinsic
848 GASTROINTESTINAL ENDOSCOPY
Volume 72, No. 4 : 2010
compression of the second portion of the duodenum (D, black arrow). Symptoms subsided with conservative treatment. Over the next two years, the patient was admitted twice for recurrent episodes of documented acute pancreatitis, and her condition improved with conservative treatment both times. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Seong Su Hwang, MD, Department of Radiology, Chang Nyol Paik, MD, Kang-Moon Lee, MD, Woo Chul Chung, MD, U-Im Jang, MD, Jin-Mo Yang, MD, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea doi:10.1016/j.gie.2010.03.1075
www.giejournal.org
An unusual case of acute pancreatitis secondary to an intraluminal duodenal diverticulum
A 23-year-old man with no history of medical problems developed acute abdominal pain associated with nausea and vomiting. Upon presentation, he was afebrile. His heart rate was 86 beats per minute and his blood pressure was 136/67 mm Hg. On physical examination, his abdomen was tender to palpation in the mid epigastrium without guarding. Laboratory testing revealed a white blood cell count of 21,000 cells/mcL (3.6-10.6 cells/mcL), amylase of 762 U/L (normal ⬍100 U/L), and lipase of 6970 U/L (normal ⬍50 U/L). Liver biochemical tests were normal. CT of the abdomen with oral contrast demonstrated pancreatic inflammation and a duodenal mass filled with debris (A). EGD confirmed the presence of a subepithelial mass on the posterior wall of the second portion of the duodenum with involvement of the ampulla (B). EUS of this lesion revealed a large intraluminal duodenal diverticwww.giejournal.org
ulum (IDD) with a characteristic “windsock” appearance (C). The patient was taken to the operating room where a transduodenal exposure of the lesion revealed an IDD that was resected (D). Sphincterotomy and sphincteroplasty also were performed because of ampullary involvement. The specimen measured 4.0 ⫻ 1.5 ⫻ 1.0 cm. Histology revealed benign duodenal mucosa. The patient had an uneventful recovery, and at his 6-month follow-up he remained symptom-free. DISCLOSURE The opinions are solely those of the authors and do not represent an endorsement by the Department of Defense. There are no restrictions on its use. The authors do not have any commercial or proprietary interest in any drug, Volume 72, No. 4 : 2010 GASTROINTESTINAL ENDOSCOPY
847
At the Focal Point
device, or equipment mentioned in the manuscript. There are no conflicts of interest, financial disclosures, grant support, or writing assistance. Fouad J. Moawad, MD, Walter Reed Army Medical Center, Gastroenterology Service, Department of Medicine, Washing-
ton, DC, USA, Andrew B. Gentry, MD, Ashley Humphries, MD, Patrick E. Young, MD, National Naval Medical Center, Division of Gastroenterology, Bethesda, Maryland, USA doi:10.1016/j.gie.2010.03.1055
Commentary In the eighth to tenth week of development, the solid duodenum recanalizes to result in the typically hollow cylinder that characterizes older intestine. On occasion, however, successful recanalization is thwarted and intestinal atresia, stenosis, or membranous web results. The former two most often manifest early in childhood with GI obstruction, whereas the last has a more variable time frame and manner of presentation. Because of the prograde movement of intestinal contents, the web may become stretched, forming an intraluminal diverticulum; the aperture of the original web usually remains near its initial position and allows variable amounts of intestinal secretions and ingested substances to pass through it into the intestinal lumen, now narrowed by the diverticulum. The appearance of the diverticulum has been likened in the medical literature to a windsock, which is used to judge the direction and magnitude of wind, usually in rural settings. To those of us who live in urban settings, this windsock diverticulum looks more like an unrolled condom, and, to some, also bears semblance to a bariatric sleeve. Of course, to those of us in urban settings, an actual ingested condom—still with rolled edges—tells us the person who harbors it is a mule, or drug trafficker. Duodenal membranes and windsock deformities are associated with other anomalies, such as intestinal malrotation and preduodenal portal vein; the latter is of importance to the operating surgeon. Pancreatitis may be caused by the associated anomaly such as pancreas divisum or by ampullary obstruction or distortion by a windsock that is filled or obstructed by accumulated intestinal material. Windsock deformity is diagnosed classically by barium meal, the barium being retained in the sock for longer than 6 hours; in this case, EUS was diagnostic. Khalil Gibran said, “If you reveal your secrets to the wind, you should not blame the wind for revealing them to the trees.” This patient went 23 years before the heretofore secret presence of his probably congenital lesion was revealed. Lawrence J. Brandt, MD Associate Editor for Focal Points
Recurrent acute pancreatitis caused by an annular pancreas in a child A 13-year-old girl visited our institute complaining of severe epigastric pain, which had begun after a heavy meal and lasted several hours. There was no relevant medical history and, specifically, no alcohol ingestion or history of trauma. Serology test results revealed elevated serum amylase (314 IU/L [normal 45-108 IU/L]) and lipase (592.2 IU/L, 13-60 IU/L) levels. A complete blood cell count, basic metabolic panel results, and immunologic data including serum immunoglobulin levels were normal, and antinuclear antibody levels were negative. An abdominal CT scan showed mild swelling of the pancreas, which formed a ring-like lesion that encircled the second portion of the duodenum (A, white arrow), along with a mildly dilated pancreatic duct. MRCP demonstrated dilatation of the main pancreatic duct, which curved around the duodenum—a picture compatible with annular pancreas (B, black arrow). EGD showed a circumferential mucosal fold that narrowed the lumen of the proximal second part of the duodenum (C). Hypotonic duodenography showed a mild mucosal thickening with extrinsic
848 GASTROINTESTINAL ENDOSCOPY
Volume 72, No. 4 : 2010
compression of the second portion of the duodenum (D, black arrow). Symptoms subsided with conservative treatment. Over the next two years, the patient was admitted twice for recurrent episodes of documented acute pancreatitis, and her condition improved with conservative treatment both times. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Seong Su Hwang, MD, Department of Radiology, Chang Nyol Paik, MD, Kang-Moon Lee, MD, Woo Chul Chung, MD, U-Im Jang, MD, Jin-Mo Yang, MD, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea doi:10.1016/j.gie.2010.03.1075
www.giejournal.org