Intraluminal Duodenal Diverticula

Abstract

A developmental anomaly of the duodenum described as an intraluminal diverticulum was first reported in the radiologic literature by Kinzer in 1949 (4). Two years earlier, however, Nelson (7) had published an account of a case of congenital diaphragm of the duodenum in which the radiographs revealed a similar entity, and the accompanying semidiagrammatic sketch showed an orifice on the upper medial side of the diaphragm from which a sac (intraluminal diverticulum) extended downward into the duodenum. The first gross pathological report of this anomaly was published by Silcock in 1885 (10). It is interesting to note the hiatus of sixty-two years between the pathological report of this condition and the first account in the radiological literature. Even though the gastrointestinal radiologic examination had not been widely employed before the second decade of this century, it is difficult to understand why this anomaly was not discovered radiologically before 1949. Up to the present time 8 cases have been reported with the radiographic findings (3–7, 13, 14). This report adds 6 examples of which 1 is from the senior author's experience and 5 have been collected from his radiologic colleagues. The clinical, radiologic, and surgical findings in all 14 cases will be summarized, and an attempt will be made to evaluate the embryological background. Clinical Manifestations All intraluminal diverticula previously reported, as well as the present group, were discovered in adults ranging from twenty-two to fifty-seven years of age. The 4 patients not treated surgically had no symptoms or very indefinite intermittent symptoms related to the upper abdomen. Eight of those operated upon experienced abdominal pain and discomfort, and, of these, 3 had associated nausea and vomiting. Intermittent nausea and vomiting of many years duration had been the chief complaint in only 1 instance. In 3 cases severe gastrointestinal bleeding had occurred, associated in 1 with nausea and vomiting. The physical and laboratory examinations were negative except for the evidence of blood loss disclosed by the lowered hemoglobin and hematocrit values in the patients who had suffered bleeding. Table I summarizes the clinical and operative findings of all the cases. Roentgen Findings The correct diagnosis is dependent upon the roentgen examination. All previously reported cases as well as the 6 added cases have demonstrated similar roentgen findings in the uncomplicated state. The intraluminal diverticulum or sac usually begins in the ampullary region of the second portion of the duodenum and extends caudally. When outlined by barium, the wall of the diverticulum is identified as a uniformly thin radiolucent line lying within the duodenum. The sharpness of this line will depend upon the amount of barium contained within the sac and the amount in the surrounding duodenal lumen.