Video Endoscopic Sequence 1 of 2.

Duodenal Diverticula.

A large duodenal diverticular cavity can be seen in the lower right aspect of the image.

Most duodenal diverticula are asymptomatic structures. About 75% of duodenal diverticula are located in the second portion of the duodenum. They can be periampullary, when they originate within a range of 2 to 3 cm from Vater’s ampulla, or ampullary when the papilla ends at the bottom of the diverticulum.

Duodenal diverticula are not unusual in the general population and it is well-documented that their incidence increases with age. Nevertheless, their clinical diagnosis is difficult for the surgeon since, when symptomatic, their symptoms are non-specific. The clinical importance of duodenal diverticula is mostly based on the complications relating to the periampullary region; recurrent pancreatitis or cholangitis added to the commonly observed duodenal obstruction, bleeding and perforation, which may prove life-threatening because of delay in diagnosis due to the unsuspected underlying condition.

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All endoscopic images shown in this Atlas contain
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Video Endoscopic Sequence 2 of 2.

Endoscopic Image of Duodenal Diverticula.

Duodenal diverticula (DD) are more often observed in patients older than 50 years and are considered to be of the acquired pulsion type. They may be single or multiple and may occur anywhere in the duodenum; however th site of predilection is the medial aspect of the second part. They measure from few mm to giant diverticula.

The symptoms of duodenal diverticula are usually nonspecific and their complications may be related to their location. Periampullary diverticula are complicated with cholangitis, pancreatitis and stone disease.

Although duodenal diverticula constitute a rare cause of acute abdomen, careful analysis of imaging studies can aid to the identification of this uncommon factor of abdominal symptomatology.

Duodenal Diverticulum was first reported by Chomell in 1710 and was regarded an anatomic curiosity until 1913 when first radiological demonstration was done by JT Case. With modern radiological techniques and widespread use of endoscope it has been found that these diverticula occur more frequently than was formely supposed. Most of these are asymptomatic, situated in second part of duodenam and are rarely associated with complication which are usually cause of presentation.

With lengthening of life span, diverticulosis has come to occupy a more important position in the sphere of clinical gastroenterology. Duodenum is second most common site of diverticula in alimentary tract after colon followed by jejunum, ileum and stomach. Rarely cause symptoms when complications occur, early diagnosis is essential if treatment is to be successful.

Video Endoscopic Sequence 1 of 2.

Periampullary Diverticula

Periampullary duodenal diverticula increase the risk of failure for cannulation of the papilla.

An important percentage of patients have a peri-diverticular papilla of Vater (PD). It could hinder the biliary and/or pancreatic cannulation at endoscopic retrograde cholangiopancreatography (ERCP) and might change the outcomes in this procedure.

The presence of a peri-papillary duodenal diverticulum does not involve a difficult biliary cannulation or lower cannulation rate. In these patients, complication rate is higher, although mainly represented by mild post-papillotomy bleeding easily solvable.

Although periampullary diverticulum is usually asymptomatic and discovered incidentally in patients during endoscopic retrograde cholangiopancreatography (ERCP), it may lead to post-ERCP morbidity.

Periampullary diverticulum is commonly situated on the second part of the duodenum and usually occurred in the elderly, with a slight female preponderance. It is usually caused by the progression of duodenal motility disorders. Furthermore, progressive weakening of intestinal smooth muscles and increased intraduodenal pressure have been known as main underlying etiologies for this defect.

The duodenal diverticula rarely produce
signs of inflammation, obstruction, hemorrhage
or perforation. In some cases secondary
biliary-pancreatic complications are found
when a diverticulum originates from the region
of Vater’s papilla.

Video Endoscopic Sequence 2 of 2.

Periampullary Diverticula

Several studies have demonstrated that periampullary
diverticula in patients undergoing endoscopic
retrograde cholangiopancreatography (ERCP) procedures
have an impact on procedural success, success
of cannulation, and inter- and post-procedure complications.
However, these results are considered to be controversial
due to the small number of patients and the differences in study designs.

Periampullary diverticula are usually acquired lesions.
They are quite uncommon under the age of forty,
and their prevalence increases with age. Advanced age
contributes to the development of PD due to weakening
of regional connective tissue.

Periampullary diverticula have a major impact on
the formation of choledocholithiasis, and in the increase
in size or impaction of existing stones. However,
the presence of periampullary diverticula in patients
with biliary stones does not affect the success of ERCP,
the prevalence of procedure-related complications, or
the rate of endoscopic treatment success in the hands
of experienced physicians. The negative impact of periampullary diverticula on the therapeutic procedure
might be related to the increased incidence, and comorbidities, with age.

Video Endoscopic Sequence 1 of 2.

Juxtapapillary Diverticula

Endoscopic View of Duodenal Diverticula.

Duodenal diverticula may cause difficulties with
cannulation as the papilla may be located on the edge or
rarely inside a diverticulum. Note relationship of papilla to
duodenal diverticula.

Periampullary diverticula and sphincterotomy Diverticula
do not increase the risk of sphincterotomy unless the
papilla is located on the edge or inside a large diverticulum.
Cannulation may be technically more difficult and the risk
of perforation is increased as a result of a deviated cut.

Video Endoscopic Sequence 2 of 2.

Juxtapapillary Diverticula

Endoscopic image and video clip of Duodenal Diverticula.

When diverticula are located near the major duodenal papilla they are called juxtapapillary diverticula (JD). JD are important because they may obstruct the biliary and pancreatic ducts. Furthermore, the biliary and pancreatic ductal systems may terminate into JD. The prevalence of JD in the general population is around20%, they are often associated with biliary lithiasis.JD appears to be a risk factor for complications of endoscopic sphincterotomy for bile duct stones and their recurrence.

Congenital diverticula are commonly found on the medial wall of the duodenum adjacent to or involving the papilla of Vater and as a result are of particular relevance to ERCP. As the neck of the diverticulum is often narrow, the opening is usually small.

Periampullary diverticula occur more commonly in older patients and are associated with an increased incidence of multiple bile ductstones. * Largersize (> 1 cm) of the diverticula was also found to correlate directly with the presence of bile ductstones. * These findings may be beneficial to endoscopistsin planning their treatment of choledocholithiasis.

Duodenal Diverticula.

Endoscopic image and video clip of Duodenal Diverticula.

Congenital diverticula are commonly found on the medial
wall of the duodenum adjacent to or involving the papilla of
Vater, and as a result are of particular relevance to ERCP.
As the neck of the diverticulum is often narrow, the
opening is usually small.

Diverticula of the duodenum are incidental findings in
1%-5% of barium examinations of the upper
gastrointestinal tract. They are acquired lesions consisting
of a sac of mucosal and submucosal layers herniated
through a muscular defect in the bowel wall. They arefound
most commonly along the medial border of the descending
duodenum where penetrating vessels cause potential weak
spots in the bowel wall. Thirty to forty percent of diverticula
arise in the third and fourth portions of the duodenum.

Over 95% of duodenal diverticula project from inner or pancreatic border of duodenal curve in second, third and fourth parts. Second part is most common site with 85 to 90% of total DD.

Video Endoscopic Sequence 1 of 2.

Duodenal Diverticula with retained content

Duodenal diverticula are acquired outpouchings of the
mucosa and submucosa, 90 percent of which are on the
medial aspect of the duodenum. They are rare before age
40. There is a high incidence of gallstone disease of the
gallbladder in patients with juxtapapillary diverticula.
Diverticula are not seen in the first portion of the
duodenum, where diverticular configurations are due to
scarring by peptic ulceration or cholecystitis (inflammation
of the gall bladder).

Video Endoscopic Sequence 2 of 2.

Endoscopic image and video clip of Duodenal Diverticula.

Large septated diverticulum

Great majority of duodenal diverticula are asymptomatic.

Clinical presentation may be characterized by non-specific
abdominal symptoms and less than 5% of patients have
abdominal symptoms. Abdominal discomfort is usually
locatedin epigastrium, right upper abdomen or umbilical
area which is made worse or brought on by eating and
relieved by vomiting, belching or assuming certain posture.
There are no characteristic symptom complex from which
one may make a positive diagnosis of Duodenal
Diverticulum.

Duodenal Diverticula.

Pathophysiology: The cause of this condition is not known.
It is believed to develop as the result of abnormalities in
peristalsis, intestinal dyskinesis, and high segmental
intraluminal pressures.

Video Endoscopic Sequence 1 of 3.

Multiple diverticula of the duodenum

A peripapillary diverticulum is observed

This is the case of a of 75-year-old male, who due to clogged bulb, was scheduled for abdominal surgery. Comes to our endoscopic unit for a second opinion, upper endoscopy was performed finding the duodenal bulb with an ulcer of the anterior wall with edema and a pseudo-obstruction. The endoscope was advanced to the fourth portion of the duodenum, finding multiple diverticula and one juxtapapillary.

Video Endoscopic Sequence 2 of 3.

Multiple diverticula of the duodenum

Video Endoscopic Sequence 3 of 3.

Multiple diverticula of the duodenum

Video Endoscopic Sequence 1 of 3.

Duodenal Ulcera and Multiple diverticula of the duodenum

This is the case of an 80 year-old female, because of anorexia an upper endoscopy is practiced, finding the ulcer shown here and three duodenal diverticula are also seen.

Video Endoscopic Sequence 2 of 3.

Papilla juxtapapillary in two diverticula

In the image as well as the the video clip, shows the two diverticula divided by a septum in which displays the papilla of Vater.

CLINICAL FEATURES Great majority of duodenal diverticula are asymptomatic. Clinical presentation may be characterized by non-specific abdominal symptoms and less than 5% of patients have abdominal symptoms.

Abdominal discomfort is usually located in epigastrium, right upper abdomen or umbilical area which is made worse or brought on by eating and relieved by vomiting, belching or assuming certain posture. There are no characteristic symptom complex from which one may make a positive diagnosis of DD.

Video Endoscopic Sequence 3 of 3.

It is observed the third diverticulum

Many believe that there are three main
factors in production of symptoms.
A. Mechanical causes producing
1. Delayed empting of diverticula
2. Pressure on the common bile or pancreatic duct
3. Obstruction of the duodenum

B. Inflammatory causes producing
1. Symptoms simulating peptic ulcer, gall bladder
or pancreatic disease
2. Pyloro-spasm
3. Perforation
C. Neoplasia

The peptic ulcer like syndrome has been noted in several patients, however in the absence of ulcers, the symptoms may be due to inflammation and stasis in the sac. The simulation of peptic ulcer disease by DD may be close. Intermittent diarrhea and constipation, weight loss because of the fear of eating and steatorrhea may also occur in some patients.