Diverticula of the fourth portion of the duodenum

DIVERTICULA OF THE FOURTH PORTION OF THE DUODENUM* JAMES A.

WHITING,

M.D., FURMAN

T. WALLACE,

Spartanburg,

M.D. AND RICHARD S. WILSON,

South Carolina

UODENAL diverticuIa are encountered fairIy frequently, occurring in about I per cent of al1 gastrointestinat x-ray series. There has been no uniform opinion in the past as to whether diverticma so encountered should be removed. Key9 in 191.5 First removed a duodenal diverticmum which had been demonstrated AuoroscopicaIIy. Mahorner6 by his presentations has done much to crystalize the opinion on the subject. It has been we11 established that asymptomatic duodenal diverticula should not be attacked surgically. The same holds true if minor symptoms are present. Etiology. It has been noted that a11 diverticula occur on the concave side of the duodenum and it has been postulated that this incidence is due to a pIace of Iower resistance where the vessels penetrate the duodena1 waI1. Another possibiIity is that some of the diverticula originated as a congenital out-pouching with later emargement. This seems more IikeIy in those in the region of the ampuIIa of Vater. 5+mptomatology. The incidence of symptoms in duodena1 diverticula is probabIy about I o per cent. One of the most frequent symptoms is a dull pain in the epigastrium, to the right of the midIine about mid-way between the umbiIicus and xyphoid. Nausea (possibly due to distention in the diverticulum) is the other most frequent symptom. Tenderness may be present if the diverticuIum is inflamed. Other symptoms that have been mentioned are diarrhea, possibly due to pancreatic disturbance, and weight 10s~. Location. The most frequent site for diverticuIa is in the second descending position of the duodenum near the ampuIIa of Vater. About two-thirds of the diverticuIa occur in this Iocation. The next most frequent sites, in order of incidence, are the third and fourth portions. IVhat appears to be diverticuIa sometimes

D

occur in the first portion of the duodenum, but practicaIIy a11 of these are pseudodiverticula. They are expansions of the duodenum or pouches developing proximal to an obstructive duodena1 uIcer. The diagnosis must always be established by IIuoroscopic and x-ray studies. Surgery is indicated in only a very small percentage of these cases. A11 other possibIe expIanations for the symptoms must be carefuhy excIuded. A trial of medica treatment is always indicated. Surgery should not be advised until after careful excIusion, a long trial of medica treatment and a demonstration of residual pooling in the diverticulum of barium for four to six hours. Even then, surgery is indicated onI!- if the symptoms are severe. Mahorne+ has suggested several advances in surgica1 technic, particuIarIy for diverticma of the second portion of the duodenum. Mine’ has reported the successful removal of a diverticulum of the third portion of the duodenum and has suggested an exposure technic for excision of diverticula of the third and fourth portions. One case of the successfui remova of a diverticulum of the fourth portion of the duodenum has been reported in the readily avaiIabIe American Iiterature.R UndoubtedIy, other diverticuIa of the fourth portion of the duodenum have been removed but were either not reported or the reports were overlooked. We wish to add a second and third case of removal of a diverticulum of the fourth portion of the duodenum and discuss certain of the clinical aspects. CASE REPORTS CASE I. R. H., a sixty-four year old white man, was admitted to the Spartanburg Genera1 HospitaI (No. 24,963) on July 29, 1941, complaining of epigastric distress, and nausea, for the past ten

* From the Department of Surgery, Spartanburg General HospitaI, and The burg, S. C. .-I

ugust,

1957

M.D.

233

Wallace

incIuding pain years. He had

Foundation,

Spatian-

Whiting

et aI.-DiverticuIa

of Duodenum

FIG.

FIG.

I.

received prolonged therapy, including antispasmodics and sedatives. The symptoms usualIy occurred foIIowing meals, although nausea was present just before meals. The patient had also noted dark blood in his stools in 1918, although, subsequentIy, no meIena had been noted. The systems review was essentiaIIy negative except for nocturia (times I) and intermittent prolapse of hemorrhoids. Physical examination reveaIed a we11 nourished, healthy white man in no particular discomfort. The pupiIs were reguIar and reacted to Iight and accommodation, and no diffIcuIties of the eyes, ears, nose and throat were noted. The thyroid was not paIpabIe, and no other masses were noted in the neck. The Iungs were cIear and the heart was reguIar in rhythm and rate at 80. The bIood pressure was 140,430. On examination of the abdomen a soft mass, apparentIy confined to the skin layers, was present in the midline. This mass was nontender. In addition, moderate tenderness in the right epigastric region was noted. No inguinal masses were present. Recta1 examination reveaIed a sIightIy enlarged prostate which was firm in consistency. Examination of the Iower extremities revealed moderate varicosities, biIateraI. No edema was present. The admission

2.

diagnosis was chronic cholecystitis, epigastric and scalp Iipomas and varicose veins. InitiaI laboratory examinations were essentiaIIy normal. A gastrointestinal series and gaIIbIadder series were obtained on August I, I 95 I, and the foIIowing reports were noted. The gaIIbIadder was essentially norma except for sIight impairment of the concentrating power. The gastrointestinal series (Fig. I) was reported to have a “very Iarge diverticuIum of the superior fIexure of the duodenum.” In consideration of persistent symptoms in this patient over a Iong’period of time, in spite of considerable medica therapy, surgica1 extirpation of the diverticulum was recommended. On August 4th surgery was performed under genera1 anesthesia. Examination of the superior portion of the duodenum reveaIed considerabIe distention, but no diverticuIum was found. Posterior to the first portion of the duodenum the fundus of a diverticuIum was seen. Subsequent mobilization from the gastrohepatic omentum and the duodenum reveaIed the origin of the mass to be in the fourth portion of the duodenum. The diverticuIum presented behind the stomach and anterior to the pancreas. It was heId in this abnormal position by passing under the pancreaticoduodena1 vesseIs. The estimated size at surgery was 6 by 354 cm. It was possible by constant traction and blunt and sharp dissection to expose the fourth portion of the duodenum through the gastrohepatic omenturn. The diverticuIum was excised, leaving a small cuff for suturing. The duodenal defect M-as cIosed transversely with interrupted intestina1 sutures, with an outer layer of cotton mattress sutures. (Fig. 2.) No other diverticula were present. The gaIlbladder was normal. American

Journal

of Surger).

Whiting

et aI.-DiverticuIa

Before cIosing the abdomen dissection of the epigastric mass revealed the presence of a smaII defect in the rectus fascia in the midIine and a smal1 amount of properitonea1 fat protruding through this opening. The hernia was repaired and the abdomen closed without drainage. The patient withstood surgery we11 and returned to his room in good condition. Postoperatively he was pIaced on continuous gastric suction, parentera fluids and proteins, antibiotics and vitamins for a period of six days. He was ambuIatecI on the third postoperative da!. At this time gastric intubation was discontinued. The patient was then pIaced on a progressive Sippy diet, supplemented by oral protein feedings. His postoperative course-was uneventful except for a smaI1 accumuIation of serosanguinous fluid in the incision. He was discharged asymptomatic on August 20, 19.5I, sixteen days following surgery. The patient was seen, subsequently, and had a good appetite without return of epigastric distress. The wound has healed without further compIication. CASE II. 0. M., a sixty-three year old widowed white woman, was admitted to the hospital (No. 33,053) on January 15, 1942, with a history of pain in the Iower chest, shouIders and upper arms, and soreness in the epigastric region of five years’ duration. Nausea and occasiona vomiting were also present. She had considerabIe intolerance to heavy foods, especially greasy foods. Just prior to admission episodes of pain were aIso noted in the right upper quadrant. For several years the patient had received antispasmodics, narcotics and other supportive measures to relieve her diffrcuIties. The admission diagnosis was possibIe chronic chotecystitis. A choIecystogram on January 16th revealed a norma gaIIbIadder. On January 18th an upper gastrointestinal series was obtained and the presence of a diverticuIum in the fourth portion of the duodenum was noted. (Fig. 3.) The remainder of the gastrointestina1 tract was found to be normal. On January 23rd excision of the diverticulum was performed. (Fig. 4.) A sac fiIIed with dark brown, thick material was noted. A pathoIogic report of “chronic inflammation in the mucosa of the diverticuIum” was returned. The patient was pIaced on continuous gastric suction for a period of one week during which time her postoperative course was uneventful. After a da\ August,

1953

of Duodenum

23s

FIG. 3.

of surgical liquids the patient was placed on a soft diet. She has not experienced abdominal discomfort since suction was discontinued. B! March I rth her appetite was better and she returned to work. COMMENTS

The approach to diverticula of the third and fourth portions of the duodenum varies according to the relation of the diverticulum to the superior mesenteric vesseIs. If the diverticuIum is to the right of the superior mesenteric vesseIs, the transverse coIon should be rrtracted downward and the leaves of the transverse mesocolon entered from above. If the diverticulum is to the Ieft of the superior mesenteric vessels, the transverse coIon shouId be retracted upward and the base of the transverse mesocolon entered from below after the division of the ligament of Treitz. The approach used in the second case is undoubtedly the best standard approach and would be the onIy one suitable in most cases. The diverticulum in the first case was in a bizarre position and was adjacent to the first portion of the duodenum and held in this position by vessels crossing its base. It is unlikeI>that the approach used in the first case would be suitable in any other case. The approach

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hours following ingestion. They emphasize the necessity of ruling out the presence of pseudodiverticulum due to duodena1 ulcer, congenital conditions distorting the duodenum and benign and malignant tumors. Surgery is indicated only when symptoms become pronounced in spite of adequate and prolonged medica therapy, and after carefu1 exclusion of other possibiIities. It is sometimes safer to enter the duodenum to visuaIize the opening of the sac, especiaIly where the biliar\ channels may be injured. Mahornels has recentIy reported intubation of the common duct to insure further against injury. FIG. 4. SUMMARY

used in the second case should be suitabIe for a11 diverticula of the third and fourth portions of the duodenum and we11 might be considered the standard approach. The incidence of diverticuIa of the fourth portion of the duodenum is not readily avaiIable, but it is certainIy a rare condition. The indication for surgery is persistence of severe symptoms after careful excIusion of other possible causes. The removal of diverticula of the fourth portion of the duodenum is technically Iess diffrcuIt than those of the second portion. Mahornerj has brought out that symptoms may be due to retarded emptying of the diverticulum because of fixation of the duodenum. It is probabIe that actual partiat obstruction of the duodenum occurs after fiIIing of the sac. The absence of a clearer cut relationship to eating is attributed to the filling of the sac with intestinal secretions. CIinicalIy, the patient presents symptoms simuIating duodena1 uIcer or cholecystitis, which may or may not be associated with eating. Moderate tenderness in the right epigastric region is usuaIIy the onIy physical finding. The diagnosis of duodenal diverticuIum is difficult without roentgenologic demonstration. Conti, Foltz et al.I” have demonstrated the presence of barium fIuoroscopicalIy as long as forty-

AND

CONCLUSIONS

I. Two cases of remova of the fourth portion of the duodenum are reported. One previous case was found in the literature. 2. A review of some of the clinica features of symptomatic diverticula is presented. REFERENCES

I. SLATER, F. and PARSONS, W. H. The surgica1 aspects of diverticula of the duodenum. South. Surgeon, 14: 240, 1948. 2. MCQUAY, R. V. Duodenal diverticuIa and their surgical treatment. Ann. Surg., 89: 36, 1929. 3. MORTON. J. J. The sureica1 treatment of Drimarv duodenal diverticula. Surgery, 8: 265, 1940. 4. PEARSE, H. E. The surgical management of duodenal diverticula. Surgery, 15: 705, 1944. 5. ILIAHORNER, H. Diverticula of the duodenum and jejunum. Surg., Gynec. 63’ Obst., 85: 607, 1947. [ 6. MAHORNER, H. Diverticula of the duodenum. Ann. Surg., I 33: 697-707, 195 I. 7. MINO, R. A. and LIVINGSTONE, R. G. A technic of exposure for diverticuIa of the third and fourth parts of the duodenum. Ann. Surg., 129: 235, 1

1949. 8. BARNES, F. L. Diverticulosis of the duodenum. Am. J. Surg., 20: 328, 1933. o. FORRSELL. G. and KEY. E. Divertike & nars deScendensduodenidiagnosticeradtmedeIsriintgenundeisBkning och operativt afflgsnadt. Nord. med. Ark., 48: I, 1915. IO. CON-H, J. G., JR., FOLTZ, T. P. ET AL. SurgicaI and roentgenoIogica1 aspects of duodena1 diverticula. J. A. M. A., 138: 403, 1948. I

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