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Case Reports in Surgery
Volume 2018, Article ID 6197828, 4 pages
https://doi.org/10.1155/2018/6197828
Case Report

Duodenal Diverticular Perforation after Small Bowel Obstruction: A Case Report

1Department of Surgery, Harlem Hospital Center, Columbia University, New York, NY, USA
2Department of Medicine, Richmond University Medical Center, Staten Island, New York, NY, USA

Correspondence should be addressed to Khuram Khan; moc.liamg@211marruhk

Received 22 April 2018; Accepted 13 June 2018; Published 7 August 2018

Academic Editor: Dimitrios Mantas

Copyright © 2018 Khuram Khan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Introduction. Duodenal diverticulum is a rare disease that can be easily missed. The incidence of duodenal diverticulum diagnosed by upper GI study is approximately 5%. Autopsy results show that 22% of the population have duodenum diverticulum. Most patients with duodenal diverticulum are asymptomatic. However, complications like inflammation, perforation with retroperitoneal abscess, sepsis, pancreatitis, bile duct obstruction, and bleeding can occur. Approximately 162 cases of perforated duodenal diverticulum have been reported in the literature. Case Presentation. We present a rare case of an 82-year-old female with perforation of a duodenal diverticulum caused by small bowel obstruction; in addition to this, there was a synchronous colonic tumor. Conclusion. Diagnosis and management of this rare disorder are controversial. Nonoperative management is advocated in some cases. Some of the cases require early aggressive surgical intervention. The mortality rate remains approximately 45% in all these patients.

1. Introduction

Perforation of the duodenum diverticulum (DD) is a rare disease that can be easily missed as it can be a clinical diagnosis. Management of the perforation requires urgent surgical intervention for favorable outcomes. Perforation can be caused by infections such as diverticulitis, ulceration, foreign body, trauma, and iatrogenic perforation after ERCP and would require CT scan of the abdomen for diagnosis and treatment in some cases, while diagnosis of duodenal diverticulum can be made with upper gastrointestinal series.

2. Case Presentation

An 82-year-old African American female with history of hypertension, chronic active smoker for 60 years along with prior surgical history significant for a laparotomy more than 20 years previously for unknown reason who was initially admitted to the medical service after a fall. She had a long history of nonspecific lower abdominal pain. As per her family, she had not seen a doctor for 10 years and never had a colonoscopy. She reported unintentional weight loss. Vital signs at the time of presentation were stable. On physical examination, she appeared cachectic and dehydrated. Her abdomen was soft, non-tender with audible bowel sounds. Mild right lower quadrant tenderness was noted. Labs were significant for microcytic hypochromic anemia and urine analysis positive for leukocyte esterase. Liver function test was normal. Chest X-ray showed cardiomegaly. Abdominal US revealed mild ascites and dilated common bile duct to 1 cm. The patient was admitted to medical service with a diagnosis of dehydration, failure to thrive, and for work-up of an occult gastrointestinal malignancy. She was scheduled for EGD and colonoscopy by gastroenterology team. In addition to all of this, her CEA was 12.2 ng/ml (normal less than 3 ng/ml). While the patient was on the medical service, her hemoglobin dropped to 6.2 gm/dL requiring blood transfusions. During the second unit of blood transfusion, the patient became hypoxemic and tachypneic. She was transferred to Medical Intensive Care Unit (MICU) and subsequently intubated for acute respiratory failure. Chest X-ray at this point showed bilateral infiltrates, and the patient was started on IV antibiotics for possible pneumonia. The scheduled GI procedures were cancelled due to critical health status. She had echocardiography in MICU which revealed mitral stenosis and severe pulmonary hypertension, with normal ejection fraction. Her respiratory status improved, and she was transferred back to medical floor after staying four days in MICU. She also had urine culture which grew klebsiella. Three days later after being transferred from MICU, she developed abdominal distension. A CT scan of the abdomen without contrast was obtained which revealed gastric, small bowel, and colonic distension. There was copious amount of stool in the colon. She was transferred to the surgical service for management of possible ileus/stool impaction pending colonoscopy to rule out colonic lesion. She was managed with nil per os, nasogastric tube suction, intravenous fluid hydration, and enemas. Nasogastric tube output was minimal but the patient’s abdomen remained distended while on surgical service. The patient became hypotensive and tachycardic and less responsive. After fluid resuscitation, another CT of the chest and abdomen with oral and intravenous contrast was performed one week from prior CT, which revealed persistent dilation of the stomach, small bowel, and large bowel, a left colonic mass, and large amount of retroperitoneal free fluid in the region of the duodenum and pancreas (Figures 1 and 2). She was taken to the operating room for exploratory laparotomy. A midline laparotomy was performed, and numerous adhesions from the previous laparotomy were seen. The patient had a high-grade small bowel obstruction with a transition point in the mid ileum caused by adhesions. Lysis of adhesions was performed. There was a large left descending colonic mass invading the lateral abdominal wall causing partial large bowel obstruction. The transverse colon was attached to the left colon mass with adhesions, creating a space through which there was herniation of dilated small bowel. However, this did not cause an obstruction. These dilated bowel loops were reduced. Because of the finding of free air in the retroperitoneum of the upper abdomen, we decided to explore that area. Generous kocherization of the duodenum was performed. The head of the pancreas and hepatic flexure were mobilized and found to be normal. With further mobilization of the duodenum, a perforated duodenal diverticulum was noticed in the third part of the duodenum. There was a leak of bile in the area. There was extensive retroperitoneal necrosis extending across the upper abdomen to the tail of the pancreas. The duodenal diverticulum was broad based, inflamed, and closely attached to the superior mesenteric artery. The diverticulum was dissected off, stapled, and sent for pathology (Figure 3). The third part of the duodenum became dusky, and we decided to resect it with a GIA. At this point, the patient was hypotensive and acidotic. A decision was made to perform damage control and a temporary abdominal closure and to transfer the patient to ICU for resuscitation. In the ICU, she was aggressively resuscitated with correction of her acidosis, coagulopathy, and hypothermia. She was brought back to the OR the following day. There were no signs of bowel ischemia, and the small bowel obstruction had resolved. An end to side duodenojejunostomy was performed using an EEA. The anastomosis was protected with a Stamm’s gastrostomy through which a feeding jejunostomy was passed distal to the anastomosis. A drain was left in the right upper quadrant. We then performed a transverse colon loop colostomy to divert the colonic tumor. Blood cultures later grew pseudomonas and yeast. The patient subsequently developed multiorgan failure, and the family requested DNI/DNR. Their after family requested terminal extubation 12 days after the last operation.
{"cc_re__cc_re__cc_by_4_0": ["ould be addressed to <a href=\"/84020824/\" class=\"author_name\" data-orcid=\"U84020824\"><span class=\"given_names\">Khuram</span> <span class=\"surname\">Khan</span></a>; <a href=\"mailto:null\" data-email=\"moc.liamg@211marruhk\" class=\"coemail\" >moc.liamg@211marruhk</a></p><p>Received 22 April 2018; Accepted 13 June 2018; Published 7 August 2018</p><p>Academic Editor: Dimitrios Mantas</p><div class=\"xml-content\"><p>Copyright \u00a9 2018 Khuram Khan et al. This is an open access article distributed under the <a xmlns:xsi=\"http://www.w3.org/2001/XMLSchema-instance\" rel=\"license\" href=\"http://creativecommons.org/licenses/by/4.0/\" target=\"_blank\">Creative Commons Attribution License</a>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</p></div><div class=\"xml-content\"><h4 class=\"header\">Abstract</h4><p><i>Introduction.</i> Duodenal diverticulum is a rare disease that can be easily missed. The incidence of duodenal diverticulum diagnosed by upper GI study is approximately 5%. Autopsy results show that 22% of the population have duodenum diverticulum. Most patients"], "copyright__copyright__copyright": ["rformed using an EEA. The anastomosis was protected with a Stamm\u2019s gastrostomy through which a feeding jejunostomy was passed distal to the anastomosis. A drain was left in the right upper quadrant. We then performed a transverse colon loop colostomy to divert the colonic tumor. Blood cultures later grew pseudomonas and yeast. The patient subsequently developed multiorgan failure, and the family requested DNI/DNR. Their after family requested terminal extubation 12 days after the last operation.", "rformed using an EEA. The anastomosis was protected with a Stamm\u2019s gastrostomy through which a feeding jejunostomy was passed distal to the anastomosis. A drain was left in the right upper quadrant. We then performed a transverse colon loop colostomy to divert the colonic tumor. Blood cultures later grew pseudomonas and yeast. The patient subsequently developed multiorgan failure, and the family requested DNI/DNR. Their after family requested terminal extubation 12 days after the last operation.", "rformed using an EEA. The anastomosis was protected with a Stamm\u2019s gastrostomy through which a feeding jejunostomy was passed distal to the anastomosis. A drain was left in the right upper quadrant. We then performed a transverse colon loop colostomy to divert the colonic tumor. Blood cultures later grew pseudomonas and yeast. The patient subsequently developed multiorgan failure, and the family requested DNI/DNR. Their after family requested terminal extubation 12 days after the last operation.", "rformed using an EEA. The anastomosis was protected with a Stamm\u2019s gastrostomy through which a feeding jejunostomy was passed distal to the anastomosis. A drain was left in the right upper quadrant. We then performed a transverse colon loop colostomy to divert the colonic tumor. Blood cultures later grew pseudomonas and yeast. The patient subsequently developed multiorgan failure, and the family requested DNI/DNR. Their after family requested terminal extubation 12 days after the last operation.", "rformed using an EEA. The anastomosis was protected with a Stamm\u2019s gastrostomy through which a feeding jejunostomy was passed distal to the anastomosis. A drain was left in the right upper quadrant. We then performed a transverse colon loop colostomy to divert the colonic tumor. Blood cultures later grew pseudomonas and yeast. The patient subsequently developed multiorgan failure, and the family requested DNI/DNR. Their after family requested terminal extubation 12 days after the last operation.", "rformed using an EEA. The anastomosis was protected with a Stamm\u2019s gastrostomy through which a feeding jejunostomy was passed distal to the anastomosis. A drain was left in the right upper quadrant. We then performed a transverse colon loop colostomy to divert the colonic tumor. Blood cultures later grew pseudomonas and yeast. The patient subsequently developed multiorgan failure, and the family requested DNI/DNR. Their after family requested terminal extubation 12 days after the last operation.", "rformed using an EEA. The anastomosis was protected with a Stamm\u2019s gastrostomy through which a feeding jejunostomy was passed distal to the anastomosis. A drain was left in the right upper quadrant. We then performed a transverse colon loop colostomy to divert the colonic tumor. Blood cultures later grew pseudomonas and yeast. The patient subsequently developed multiorgan failure, and the family requested DNI/DNR. Their after family requested terminal extubation 12 days after the last operation."]}