Intraluminal duodenal diverticula are rare congenital malformations that may present with vague abdominal symptoms such as pain or bloating; however, patients may also present with pancreatitis, biliary obstruction, duodenal obstruction, or GI bleeding. We report a case of intraluminal duodenal diverticulum causing recurrent overt GI bleeding and exhibiting a unique endoscopic appearance of a double lumen (Video 1, available online at www.VideoGIE.org). A 67-year-old woman was admitted with melena and an acute drop in hemoglobin. The patient had had iron deficiency anemia since childhood and intermittent melena of unknown cause despite numerous upper and lower endoscopic examinations. Upper endoscopy demonstrated 2 lumens in the second part of the duodenum. A culprit lesion was found, with an adherent clot that was treated with epinephrine and hemostatic clips. In consideration of the abnormal anatomy, a CT scan was performed that demonstrated a tubular structure containing oral contrast material and an air-fluid level communicating with the duodenum (Fig. 1A). A repeated endoscopy with a transparent hood demonstrated the true lumen and the lumen of the duodenal diverticulum (Figs. 1B-D). The duodenal diverticulum was resected, and the defect was closed with hemostatic clips (Fig. 1E). Pathologic examination demonstrated duodenal-lined mucosa on both sides of the structure with dilated submucosal vessels (Figs. 1F and G). The patient was subsequently discharged home without any adverse events and without recurrence of melena during a follow-up period of 1.5 years.
Figure 1.
A, CT axial image of the abdomen demonstrating cystic structure containing oral contrast material. B, Endoscopic view of septum between lumens. C, Endoscopic view of native lumen with diverticulum located superiorly. D, Endoscopic view within the distal end of the diverticular lumen. E, Endoscopic view after resection. F, Gross specimen taken for pathologic examination. G, Microscopic low-power view demonstrating duodenal mucosa lining both surfaces and dilated submucosal vessels (hematoxylin phloxine saffron, orig. mag. × 20).
Disclosure
Dr Bechara is a consultant for Olympus. All other authors disclosed no financial relationships relevant to this publication.
Footnotes
Written transcript of the video audio is available online at www.VideoGIE.org.
Supplementary data
A 67-year-old woman was admitted with melena and an acute hemoglobin drop. The patient had a history of iron-deficiency anemia since childhood with intermittent melena of unknown etiology despite numerous upper and lower endoscopic examinations. An upper endoscopy revealed 2 lumens in the second part of the duodenum. A culprit lesion was found with an adherent clot which was treated with epinephrine and hemostatic clips. In light of the abnormal anatomy, a CT scan was performed. The CT scan demonstrated a large cystic structure containing oral contrast and an air-fluid level, communicating with the duodenum, that measured 5.4×2.4×4.6 centimeters in size. An upper endoscopy was performed with a transparent distal attachment. Here we can see 2 lumens; in the upper half of the screen is the native lumen and in the lower half is the diverticular lumen. Slowly advancing into the diverticular lumen with the endoscope and distal attachment, the end of the diverticular lumen can be reached. At the distal end of the diverticulum an opening is noted. Through the opening the native lumen can be appreciated. At the base of the septum the ampulla can be seen. Extending from the septum the long intraluminal diverticulum can be seen. This extends well into the to the 3rd part of the duodenum. Here the previously placed hemostatic clips on the distal end of the diverticulum. Considering the recurrent bleeds, we opted to resect the diverticulum using a snare. This was removed in 2 pieces, a small stump due to its proximity to the ampulla. After resection, additional hemostatic clips were placed to prevent delayed bleeding. Pathology demonstrated duodenal mucosa lining both surfaces and dilated submucosal vessels. This was consistent with an intraluminal duodenal diverticulum, also known as a “windsock” diverticulum. The patient was subsequently discharged home without any complications and there were no recurrences of melena over a 1.5 year follow up. This case demonstrated a rare congenital malformation of an intraluminal duodenal diverticulum presenting as a recurrent upper GI hemorrhage. In addition, the unique endoscopic appearance of a double lumen and the successful excision of the intraluminal diverticulum was observed.
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Supplementary Materials
A 67-year-old woman was admitted with melena and an acute hemoglobin drop. The patient had a history of iron-deficiency anemia since childhood with intermittent melena of unknown etiology despite numerous upper and lower endoscopic examinations. An upper endoscopy revealed 2 lumens in the second part of the duodenum. A culprit lesion was found with an adherent clot which was treated with epinephrine and hemostatic clips. In light of the abnormal anatomy, a CT scan was performed. The CT scan demonstrated a large cystic structure containing oral contrast and an air-fluid level, communicating with the duodenum, that measured 5.4×2.4×4.6 centimeters in size. An upper endoscopy was performed with a transparent distal attachment. Here we can see 2 lumens; in the upper half of the screen is the native lumen and in the lower half is the diverticular lumen. Slowly advancing into the diverticular lumen with the endoscope and distal attachment, the end of the diverticular lumen can be reached. At the distal end of the diverticulum an opening is noted. Through the opening the native lumen can be appreciated. At the base of the septum the ampulla can be seen. Extending from the septum the long intraluminal diverticulum can be seen. This extends well into the to the 3rd part of the duodenum. Here the previously placed hemostatic clips on the distal end of the diverticulum. Considering the recurrent bleeds, we opted to resect the diverticulum using a snare. This was removed in 2 pieces, a small stump due to its proximity to the ampulla. After resection, additional hemostatic clips were placed to prevent delayed bleeding. Pathology demonstrated duodenal mucosa lining both surfaces and dilated submucosal vessels. This was consistent with an intraluminal duodenal diverticulum, also known as a “windsock” diverticulum. The patient was subsequently discharged home without any complications and there were no recurrences of melena over a 1.5 year follow up. This case demonstrated a rare congenital malformation of an intraluminal duodenal diverticulum presenting as a recurrent upper GI hemorrhage. In addition, the unique endoscopic appearance of a double lumen and the successful excision of the intraluminal diverticulum was observed.