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Perforated duodenal diverticulum
Perforated Duodenal Diverticulum K.ALPHA. NATVIG.M.D.ANDJ. PAUL WAMPLER,M.D., Rlcbmon$, Virginiu
From the Del)urlmenf qf Surgery, Medical College of
I/irEiniu, und Xicbmond,
D
t/~e
Veferun.s
Admini.strution
fiospital,
Virginia.
UODENALDIVERTICULA are usuaIIy innocuous lesions detected in I to z per cent of
roentgenographic upper gastrointestinal series [I]. They rarely require surgery unIess comPI&ted hy perforation, obstruction or hemorrhage. A case of perforated duodena1 diverticulum with successfu1 surgica1 management is present&. Clues to the recognition of this
lesion at Iaparotomy
are described.
CASE REPORT The patient (A. J.), a sixty-eight year old Negro woman, entered the Medical CoIIege of Virginia HospitaI on March 17, 1961, because of moderate cpigastric pain, nausea and vomiting for five days, The symptoms became worse twenty-four hours prior to admission and the pain Iocalized in the right upper quadrant. A miId, similar episode had occurred ten months before. On physica examination, bIood pressure was 140/70 mm. Hg, pulse 104 per minute, temperature IOI’F. and respirations 18 per minute. The abdomen was flat with generaIized tenderness. Spasm of the right upper quadrant and referred rebound tenderness were present. No masses were noted. Peristalsis was hypoactive. PeIvic examination reveaIed minima1 diffuse tenderness. Laboratory studies were as foIIows: hemogIobin was I 1.4 gm. per cent and white blood ceI1 count 7,100 per cu. mm. with 8g per cent poIymorphonuclear leukocytes. Urine showed no abnormalities except for 1 plus proteinuria. Serum amyIase was Iess than 50 Somogyi units. Chest and abdomina1 roentgenograms were noncontributory. Intravenous choIangiogram showed a faint outIine of the common duct. A presumptive diagnosis of acute cholecystitis was made and the patient treated conservatively for tweIve hours. Because of increased abdomina1 findings the patient was explored on March 18. At Iaparotomy, thin, cIoudy ffuid was encountered. Exploration rcveaIed edema, exudate and white flecks of fat necrosis retroperitoneaIIy, IateraI to
the descending duodenum. After medial reflection of the duodenum, a perforated diverticulum was found. (Fig. I.) The diverticuIum arose from the posteromedia1 aspect ot the second portion of the duodenum, dista1 to the ampulla of Vater. The diverticuIum was excised Ieaving a short stump to facilitate the cIosure. The defect was cIoscd in three Iayers (Fig. 2) and the right subhepatic space
drained. The patient recovered uneventfully and was discharged on March 30, 1961. The gross description was as follows: the diverticuIum measured 7 by 2.5 cm. The distal portion was necrotic with a Iarge perforation measuring 4 by 1.5 cm. at the apex. hGcroscopitally, sections of the duodena1 diverticulum showed areas of necrosis in a11 layers. PoIymorphonucIcar Ieukocyte infiltration was present subserosaIIy, with edema, vascuIar congestion and hemorrhage. No muscularis propria was seen. The pathoIogic diagnosis was gangrene of perforated diverticulum of duodenum.
COMMENTS DuodenaI diverticuIa are cIas&ed as primary or secondary diverticuIa. Primary diverticuIa Iack a muscuIar coat and occur mainIy in the second and third portions of the duodenum. Secondary diverticuIa are usuaIIy found in the first portion of the duodenum. They resuIt from IocaI scarring and retraction, usuaIIy secondary to duodena1 uIcer, and their waIIs contain al1 the norma layers of the boweI. CompIications of primary duodena1 diverticuIa are uncommon 121.Inflammatory compIications range from diverticuIitis to perforation with peritonitis, abscess or fistuIa formation. DiverticuIum may cause obstruction of the duodenum, common biIe duct or the pancreatic duct. Hemorrhage occurs, and tumors arising in these diverticuIa have been described. Two recent reviews of the American and European Iiterature incIude thirty-one reported cases of perforated duodena1 diverticuIa [3,4].
@T
American Journal of Surgery,
Volume 107. June
1964
Natvig
and WampIer
I
FIG. I. Operative of diverticuIum.
2
picture showing (I) duodenum,
(2) duodena1 diverticuhrm
FIG. 2. Operative picture showing (I) branch of gastroduodena1 after div&ticuIectomy and (3) g&Iadder.
Thirteen of these patients died, for a mortaIity of 42 per cent. AI1 five patients not operated upon died. Five patients whose Iesions were unrecognized at Iaparotomy aIso died. OnIy three patients in whom the perforation was demonstrated at surgery died. Recognition of this condition at Iaparotomy is therefore essentia1 to its successfu1 treatment. CIues to the diagnosis may be minimaI; carefu1 expIoration is necessary to revea1 edema, exudate, biIe staining or fat necrosis in the retroperitonea1 tissues IateraI to the duodenum. An adequate Kocher maneuver wiI1 expose the pathoIogic defect and Iead to proper management. DiverticuIectomy has been aImost uniformIy successfu1 and is the treatment of choice 141. To prevent injury to the nearby common biIe duct and ampuIIa of Vater, excision and cIosure require the utmost care. Gastrojejunostomy may be indicated if the integrity of the duodena1 cIosure is in doubt.
886
and (3) perforation
artery, (2) cIosure of duodenum
SUMMARY I. A case of a successfuIIy treated perforated duodena1 diverticuIum is reported. 2. A brief review of thirty-one previousIy reported cases is presented. 3. Recognition of this Iesion at Iaparotomy is essentia1 to its proper management. 4. DiverticuIectomy is the treatment of choice. REFERENCES I. CATTELL, R.
B. and MUDGE, T. J. The surgica1 signihcance of duodena1 diverticuIa. New England J. Med., 246: 317, 1952. 2. WAUCH, J. M. and JOHNSON, E. V. Primary diverticuIa of the duodenum. Ann. Surg., 141: 193, 1955. 3. PAPPALARDO, C. and SHERWIN, C. S. DuodenaI diverticulitis with perforation: report of three cases. Ann. Surg., 154: 107, 1961. 4. ZEIFER, H. D. and GOERSCH, H. DuodenaI diverticulitis with perforation. Arch. Surg., 82: 746, 1961.
From the Del)urlmenf qf Surgery, Medical College of
I/irEiniu, und Xicbmond,
D
t/~e
Veferun.s
Admini.strution
fiospital,
Virginia.
UODENALDIVERTICULA are usuaIIy innocuous lesions detected in I to z per cent of
roentgenographic upper gastrointestinal series [I]. They rarely require surgery unIess comPI&ted hy perforation, obstruction or hemorrhage. A case of perforated duodena1 diverticulum with successfu1 surgica1 management is present&. Clues to the recognition of this
lesion at Iaparotomy
are described.
CASE REPORT The patient (A. J.), a sixty-eight year old Negro woman, entered the Medical CoIIege of Virginia HospitaI on March 17, 1961, because of moderate cpigastric pain, nausea and vomiting for five days, The symptoms became worse twenty-four hours prior to admission and the pain Iocalized in the right upper quadrant. A miId, similar episode had occurred ten months before. On physica examination, bIood pressure was 140/70 mm. Hg, pulse 104 per minute, temperature IOI’F. and respirations 18 per minute. The abdomen was flat with generaIized tenderness. Spasm of the right upper quadrant and referred rebound tenderness were present. No masses were noted. Peristalsis was hypoactive. PeIvic examination reveaIed minima1 diffuse tenderness. Laboratory studies were as foIIows: hemogIobin was I 1.4 gm. per cent and white blood ceI1 count 7,100 per cu. mm. with 8g per cent poIymorphonuclear leukocytes. Urine showed no abnormalities except for 1 plus proteinuria. Serum amyIase was Iess than 50 Somogyi units. Chest and abdomina1 roentgenograms were noncontributory. Intravenous choIangiogram showed a faint outIine of the common duct. A presumptive diagnosis of acute cholecystitis was made and the patient treated conservatively for tweIve hours. Because of increased abdomina1 findings the patient was explored on March 18. At Iaparotomy, thin, cIoudy ffuid was encountered. Exploration rcveaIed edema, exudate and white flecks of fat necrosis retroperitoneaIIy, IateraI to
the descending duodenum. After medial reflection of the duodenum, a perforated diverticulum was found. (Fig. I.) The diverticuIum arose from the posteromedia1 aspect ot the second portion of the duodenum, dista1 to the ampulla of Vater. The diverticuIum was excised Ieaving a short stump to facilitate the cIosure. The defect was cIoscd in three Iayers (Fig. 2) and the right subhepatic space
drained. The patient recovered uneventfully and was discharged on March 30, 1961. The gross description was as follows: the diverticuIum measured 7 by 2.5 cm. The distal portion was necrotic with a Iarge perforation measuring 4 by 1.5 cm. at the apex. hGcroscopitally, sections of the duodena1 diverticulum showed areas of necrosis in a11 layers. PoIymorphonucIcar Ieukocyte infiltration was present subserosaIIy, with edema, vascuIar congestion and hemorrhage. No muscularis propria was seen. The pathoIogic diagnosis was gangrene of perforated diverticulum of duodenum.
COMMENTS DuodenaI diverticuIa are cIas&ed as primary or secondary diverticuIa. Primary diverticuIa Iack a muscuIar coat and occur mainIy in the second and third portions of the duodenum. Secondary diverticuIa are usuaIIy found in the first portion of the duodenum. They resuIt from IocaI scarring and retraction, usuaIIy secondary to duodena1 uIcer, and their waIIs contain al1 the norma layers of the boweI. CompIications of primary duodena1 diverticuIa are uncommon 121.Inflammatory compIications range from diverticuIitis to perforation with peritonitis, abscess or fistuIa formation. DiverticuIum may cause obstruction of the duodenum, common biIe duct or the pancreatic duct. Hemorrhage occurs, and tumors arising in these diverticuIa have been described. Two recent reviews of the American and European Iiterature incIude thirty-one reported cases of perforated duodena1 diverticuIa [3,4].
@T
American Journal of Surgery,
Volume 107. June
1964
Natvig
and WampIer
I
FIG. I. Operative of diverticuIum.
2
picture showing (I) duodenum,
(2) duodena1 diverticuhrm
FIG. 2. Operative picture showing (I) branch of gastroduodena1 after div&ticuIectomy and (3) g&Iadder.
Thirteen of these patients died, for a mortaIity of 42 per cent. AI1 five patients not operated upon died. Five patients whose Iesions were unrecognized at Iaparotomy aIso died. OnIy three patients in whom the perforation was demonstrated at surgery died. Recognition of this condition at Iaparotomy is therefore essentia1 to its successfu1 treatment. CIues to the diagnosis may be minimaI; carefu1 expIoration is necessary to revea1 edema, exudate, biIe staining or fat necrosis in the retroperitonea1 tissues IateraI to the duodenum. An adequate Kocher maneuver wiI1 expose the pathoIogic defect and Iead to proper management. DiverticuIectomy has been aImost uniformIy successfu1 and is the treatment of choice 141. To prevent injury to the nearby common biIe duct and ampuIIa of Vater, excision and cIosure require the utmost care. Gastrojejunostomy may be indicated if the integrity of the duodena1 cIosure is in doubt.
886
and (3) perforation
artery, (2) cIosure of duodenum
SUMMARY I. A case of a successfuIIy treated perforated duodena1 diverticuIum is reported. 2. A brief review of thirty-one previousIy reported cases is presented. 3. Recognition of this Iesion at Iaparotomy is essentia1 to its proper management. 4. DiverticuIectomy is the treatment of choice. REFERENCES I. CATTELL, R.
B. and MUDGE, T. J. The surgica1 signihcance of duodena1 diverticuIa. New England J. Med., 246: 317, 1952. 2. WAUCH, J. M. and JOHNSON, E. V. Primary diverticuIa of the duodenum. Ann. Surg., 141: 193, 1955. 3. PAPPALARDO, C. and SHERWIN, C. S. DuodenaI diverticulitis with perforation: report of three cases. Ann. Surg., 154: 107, 1961. 4. ZEIFER, H. D. and GOERSCH, H. DuodenaI diverticulitis with perforation. Arch. Surg., 82: 746, 1961.