DOI:10.2214/AJR.06.0215
AJR 2006; 187:W392-W395
© American Roentgen Ray Society
CT Findings in Duodenal Diverticulitis
Monica S. Pearl1,
Michael C. Hill1 and
Robert K. Zeman1
1 All authors: Department of Radiology, George Washington University Medical
Center, 900 23rd St., NW, 1st Floor Radiology, Washington, DC 20037.
Received February 8, 2006;
accepted after revision March 30, 2006.
Address correspondence to M. S. Pearl.
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Abstract
OBJECTIVE. Duodenal diverticulitis is a rare complication of
duodenal diverticulosis. It is often clinically misdiagnosed because it has no
pathognomonic signs or symptoms and its CT findings may mimic other
intraabdominal processes. We describe two patients with duodenal
diverticulitis who presented with abdominal pain, nausea, and leukocytosis. At
the time of initial presentation, only one of the two patients was diagnosed
correctly. In the first case, which was initially misdiagnosed as acute
pancreatitis, the correct diagnosis was evident only after the disease process
had become more quiescent and a follow-up CT scan using orally and
IV-administered contrast agents was performed. In the second case, the coronal
reformatted images confirmed the diagnosis suggested by the axial images.
CONCLUSION. Duodenal diverticulitis can be a difficult CT diagnosis
to make; however, maintaining it in the differential diagnosis of duodenal and
pancreatic inflammatory processes and masses as well as defining the anatomy
with nonaxial imaging including coronal images may be helpful in confirming
the diagnosis.
Keywords: CT • duodenal diverticulitis • diverticulosis • duodenum • gastrointestinal radiology • small bowel
Introduction
Duodenal diverticulosis is a common entity with a prevalence of up to 23%,
depending on the mode of diagnosis. The duodenum ranks second to the colon as
the most common site of diverticula in the gastrointestinal tract
[1,
2]. They are usually
asymptomatic, with less than 10% causing symptoms
[3], and only 1% or less
require treatment for perforation, hemorrhage, obstruction, and acute
diverticulitis [2,
3]. Unlike diverticulosis,
duodenal diverticulitis is rare, and before the advent of CT it was seldom
diagnosed before surgery [1,
4]. Making the correct
diagnosis can be challenging because its clinical presentation is not
distinctive and its radiographic features sometimes mimic other acute
intraabdominal processes. We report two cases of duodenal diverticulitis, only
one of which was diagnosed correctly at the time of initial presentation.
Materials and Methods
Two female patients with duodenal diverticulitis were diagnosed at our
institution in 2002 and 2005. Institutional review board approval was obtained
before review of their medical records.
Patient 1
A 61-year-old woman presented to the emergency department complaining of
nausea, acute abdominal pain radiating from her right upper quadrant to her
groin, and dysuria. She was afebrile, and her vital signs were stable. On
physical examination, she was tender in the right upper quadrant but did not
have peritoneal signs. Her only laboratory abnormality was a WBC of 16.5
x 109/L. The initial clinical diagnosis was ureteric colic,
and an unenhanced CT scan of the abdomen and pelvis was performed. This showed
stranding around the pancreatic head and duodenum, with a 2.5-cm soft-tissue
density posterior to the lower pancreatic head and second portion of the
duodenum (Fig. 1A). The
pancreatic body and tail were normal. The radiologic diagnosis of acute
pancreatitis was made; however, pancreatic neoplasm and duodenal pathology
including neoplasm, hematoma, and ulcer with contained perforation were other
possible considerations. Given her normal lipase and clinical picture, she was
treated for urinary tract stone disease despite the absence of urolithiasis
radiographically. The patient returned 1 week later for a follow-up CT scan of
the abdomen and pelvis, which was performed with orally and IV-administered
contrast agents using a pancreatitis protocol. This revealed a 2-cm duodenal
diverticulum with mild surrounding inflammatory stranding, which had improved
when compared with the prior examination
(Fig. 1B). The patient declined
further treatment and left the emergency department against medical
advice.
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Fig. 1A —61-year-old woman with duodenal diverticulitis. Axial
unenhanced CT scan at level of head of pancreas (P). Ill-defined 2.5-cm mass
(arrow) is present posterior to pancreas and second portion of
duodenum. Associated soft-tissue stranding is present.
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Fig. 1B —61-year-old woman with duodenal diverticulitis. Axial
contrast-enhanced CT scan performed 1 week later shows mass is smaller and
more well-defined (arrow), contains air, and has appearance of
duodenal diverticulum. Amount of soft-tissue stranding has decreased.
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Fig. 2A —53-year-old woman with duodenal diverticulitis. Axial
contrast-enhanced CT scan shows air-containing 2.5-cm mass (large
arrow) posterior to mesenteric vessels (small arrow) and
uncinate process of pancreas with adjacent soft-tissue stranding.
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Fig. 2C —53-year-old woman with duodenal diverticulitis. Coronally
reformatted image reveals second diverticulum (arrow) that is
partially air filled and thick walled with surrounding soft-tissue stranding
caused by acute duodenal diverticulitis.
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Patient 2
A 53-year-old woman presented to the emergency department with nausea,
vomiting, and a 3-day history of diffuse abdominal pain, which began in the
epigastric area and radiated to her back. On physical examination she was
diffusely tender without peritoneal signs. She was afebrile, and her vital
signs were stable. Her laboratory results were unremarkable, except for a WBC
of 18.3 x 109/L. A CT scan of the abdomen and pelvis
performed with orally and IV-administered contrast agents showed a 2.5-cm
air-containing soft-tissue mass adjacent to the third portion of the duodenum
and posterior to the superior mesenteric artery/vein and uncinate process of
the pancreas (Fig. 2A). The
exact cause of this process was not fully realized until coronal reformatted
images were reviewed (Figs. 2B,
2C, and
2D). These showed three
duodenal diverticula with acute diverticulitis involving the middle
diverticulum (Fig. 2C). She was
admitted and managed nonoperatively with antibiotics and bowel rest. On her
fifth hospital day, her WBC normalized and she was discharged home with 10
days of oral antibiotics.
Discussion
Duodenal diverticulosis is a common entity first described by Chomel in
1710 [5]. Its prevalence varies
depending on the mode of diagnosis. Diverticula are found in 6% of upper
gastrointestinal series, 9-23% of ERCP procedures, and in 22% of autopsies
[1,
5]. Its occurrence has no sex
predilection, and the age range for detection varies from 26 to 69 years
[5]. Duodenal diverticula may
be congenital or acquired, with the latter being more common
[5]. Congenital or true
diverticula are rare, contain all layers of the duodenal wall, and may be
subdivided into intraluminal and extraluminal forms
[6]. Intraluminal duodenal
diverticula, first observed by Silcock in an autopsy specimen in 1885, are
postulated to be secondary to congenital webs or membranes formed during the
recanalization stage of the duodenal anlage after the seventh week of
gestation. The diagnosis in the literature has been almost exclusively based
on upper gastrointestinal series
[6], with the pathognomonic
"wind sock sign," a barium-filled sac surrounded by a narrow
radiolucent line entirely within the duodenum. The acquired or false type is
more common and, like pulsion diverticula elsewhere in the gastrointestinal
tract, is formed by protrusion of the mucosa, muscularis mucosa, or submucosa
through a focal weakness in the duodenal wall. This is usually near blood
vessels, the pancreatic duct, the common bile duct, or areas of aberrant
growth of pancreatic tissue in the duodenal wall
[5].
Primary acquired diverticula occur in the second through fourth portions of
the duodenum, usually along its medial aspect
[2], although 5% arise from the
lateral wall of the descending duodenum
[1]. Their distribution along
the duodenum is not uniform, as 62% arise from the second portion, 30% from
the third, and 8% from the fourth. Secondary acquired diverticula are caused
by an outpouching of the bowel wall secondary to a healed or healing peptic
ulcer [5]. Unlike colonic and
jejunoileal diverticula, duodenal diverticula are unlikely to become infected.
This is probably because of their larger size and improved intraluminal flow
of relatively sterile, liquid duodenal contents
[1].
In a study of 208 patients with small-bowel diverticula, Akhrass et al.
showed that jejunoileal diverticula were four times more likely to develop
complications and nearly 18 times more likely to perforate and develop
abscesses than duodenal diverticula
[7]. Duodenal diverticulitis
can be caused by stasis, particularly when the diverticular neck is small,
which limits efflux of intraluminal contents from the diverticulum. Other
reported predisposing factors include the presence of foreign bodies such as
gallstones or enteroliths, ulceration within the diverticulum, and blunt
trauma [4]. Approximately 5% of
patients with duodenal diverticula develop clinical symptoms. This is most
commonly caused by perforation and hemorrhage, with acute diverticulitis being
less common [2,
3]. Other less common reported
complications include malabsorption secondary to duodenocolic fistulas
[1], superior mesenteric vein
thrombosis [7], and common bile
duct obstruction with or without associated cholangitis
[8]. The most common clinical
presentation includes abdominal pain, fever, and leukocytosis. These signs and
symptoms are nonspecific, and the clinical presentation can mimic acute
cholecystitis, acute pancreatitis, peptic ulcer disease, retrocecal
appendicitis, or colitis [1,
3,
9].
The CT appearance of a duodenal diverticulum includes a saccular
outpouching, which may resemble a masslike structure interposed between the
duodenum and the pancreas that contains air, an air-fluid level, fluid,
contrast material, or debris
[1,
3]. A periampullary
diverticulum may simulate a pseudocyst or tumor
[1]. The CT features of
duodenal diverticulitis appear similar to diverticulitis at other locations
and may include wall thickening and stranding of the surrounding soft tissues
and adjacent mesenteric or retroperitoneal fat
[1,
3,
9]. Surrounding extraperitoneal
free air is not rare; however, pneumoperitoneum is rare
[1].
Early reports suggest that radiographic studies do not routinely add to the
accuracy of preoperative diagnosis. Of the approximately 60 cases of duodenal
diverticulitis reported in the literature up to 1978, Glasser et al. found
that only seven were diagnosed radiographically
[9]. In addition, in a 1992
review of the world literature, Duarte et al. found that only 13 of 101
patients were correctly diagnosed preoperatively with radiographic imaging
[4]. Furthermore, in a series
of seven patients with duodenal diverticulitis, although five were known to
have duodenal diverticula on prior upper gastrointestinal series, a correct
diagnosis was not made in a single patient
[1].
Although duodenal diverticulitis has been increasingly recognized before
surgery with the advent of CT
[1], misdiagnosis remains
problematic because duodenal diverticulitis is not commonly considered in the
differential diagnosis and a number of processes may simulate it on CT. These
include acute pancreatitis and its complications (phlegmon, pseudocyst,
abscess), cystic pancreatic head neoplasms, and peripancreatic
lymphadenopathy. Duodenal processes such as perforation or penetrating peptic
ulcer disease, Crohn's duodenitis, primary duodenal neoplasm, infected
duodenal duplication cyst, and intramural duodenal hematoma caused by trauma
have been cited as potential mimickers
[1]. Since 2000, however, eight
of nine reported cases were correctly diagnosed with CT, indicating that we
are getting better at diagnosing duodenal diverticulitis with more refined
technology [4,
7,
8,
10-12].
The ninth case of duodenal diverticulitis was diagnosed by ERCP
[8]; however, an upper
gastrointestinal study could have alternatively been performed for
diagnosis.
In our first case of duodenal diverticulitis, the unenhanced CT showed
findings suspicious for pancreatitis and a mass lesion adjacent to the
pancreatic head. Although the pancreatic body and tail were normal, focal
pancreatitis of the head, although unusual, was considered the top
differential diagnosis. Duodenal diverticulitis is not common, and its
misdiagnosis stems from erroneously attributing the inflammatory changes to
the pancreas and not accurately identifying the duodenum as the primary source
of the pathology. The anatomy in this region can be indistinct, and the use of
orally administered contrast material, particularly neutral or negative, and
IV-administered contrast material may have been helpful in defining the
anatomy and demonstrating an inflamed duodenal diverticulum. It was not until
the repeat study with orally and IV-administered contrast agents 1 week later,
when the inflammation had significantly subsided, that the accurate diagnosis
was obtained. This illustrates the diagnostic dilemma described previously,
where extensive inflammatory stranding caused by duodenal diverticulitis was
attributed to acute pancreatitis.
In the second patient, the coronal reformatted images increased confidence
in suggesting the diagnosis. In retrospect, the axial images did show the
characteristic features of duodenal diverticulitis. In addition, the second
case showed multiple diverticula, any of which may potentially be complicated
by diverticulitis. This is important to note because duodenal diverticulitis
is not always confined to the segment adjacent to the pancreatic head.
The clinical condition and stability of the patient guide the therapeutic
management. Nonoperative management is particularly attractive in an elderly
patient or in a patient with a high preoperative risk secondary to multiple
medical comorbidities. In patients with mild abdominal symptoms and no
evidence of impending sepsis, conservative management is a legitimate option
with bowel rest, IV hydration, and broad-spectrum antibiotics
[4] alone or in combination
with percutaneous CT-guided drainage of peridiverticular abscesses
[1]. In cases of nonoperative
management, close clinical monitoring for signs of deterioration and
subsequent CT scans are necessary to confirm resolution of the inflammation or
abscess. Surgical intervention is indicated in septic patients with an acute
abdomen, in patients with radiologic evidence of a large retroperitoneal
paraduodenal fluid collection, and in cases of diagnostic uncertainty
[4]. Evaluation of the location
and extent of the inflammatory process determines whether the surgical
approach should involve straightforward diverticulectomy or segmental duodenal
resection with a diverting gastrojejunostomy. More complex surgery may be
needed if pancreaticobiliary complications are present
[1].
In summary, duodenal diverticulitis can be a difficult CT diagnosis to
make. It should be considered when peripancreatic inflammatory changes are
present and there is an adjacent masslike structure that may contain air, an
air-fluid level, contrast material, or debris. In addition, duodenal
diverticulitis should be maintained in the differential diagnosis when these
peripancreatic inflammatory changes are seen in the presence of normal serum
amylase and lipase levels. Furthermore, defining the anatomy with nonaxial
imaging including coronal, sagittal, or 3D slab images may help confirm the
diagnosis, particularly in cases in which it is not clearly evident on axial
images alone.
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Abstract
Introduction
