Iyad Al-bustami, MD, MPH(c)1, Abid Qureshi, MD2, Shamsa M. Qaadri, BSc3, Shafiq Qaadri, BA4, Amogh R. Kare, BS3, Saira Shah, MD2, Saigopal R. Gujjula, MD2, Anuj R. Sharma, MBBS2, Kenan Alrejjal, MBBS5, Nitish Mittal, MD6, Kazi T. Haque, MD7, Shahzaib Ahmed, MBBS8, Vikash Kumar, MD9, Camelia Ciobanu, MD2, Amr Dokmak, MD2, Ali Wakil, MD2, Denzil Etienne, MD2, Madhavi Reddy, MD, FACG2 1Brooklyn Hospital Center, Houston, TX; 2Brooklyn Hospital Center, Brooklyn, NY; 3St. George's University School of Medicine, Brooklyn, NY; 4Toronto Metropolitan University, Toronto, ON, Canada; 5MedStar Health-Georgetown/Washington Hospital Center, Washington, DC; 6University of Texas Health, McGovern Medical School, Houston, TX; 7University of Texas Health, McGovern Medical School, Pearland, TX; 8Fatima Memorial Hospital College of Medicine and Dentistry, Lahore, Punjab, Pakistan; 9Creighton University School of Medicine, Brooklyn, NY
Introduction: The duodenum is a common site for small bowel diverticula with only 1-5% being symptomatic. Diverticula rarely perforates causing a presentation of an acute abdomen. Here, we report a case of an immediate onset complication of a duodenal diverticulitis, with a contained perforation in the 4th part of the duodenum.
Case Description/Methods: A 71-year-old male with a past medical history of hypertension and diabetes mellitus presented to emergency with a one day history of vague abdominal pain and nausea. White blood count elevated to 18.6k with major left shift, normal amylase & lipase levels. CT abdominal and pelvis showed a complex large thick-walled collection measuring 7.1 x 6.6 x 8.0 cm, arising off the 4th portion of the duodenum with surrounding stranding/inflammation as well as peripancreatic stranding at the body and tail, concerning for complicated peripancreatic fluid collection sequelae of pancreatitis vs complicated diverticulitis vs contained perforation (fig.1). MRI abdomen and pelvis was performed to further characterization of the pancreatic parenchyma: redemonstrating duodenal diverticulitis with a small focal outpouching arising from the base of the diverticulum, while pancreatic parenchyma appeared as low to intermediate signal on T2-weighted images (fig.1). Due to difficult anatomy, there was no safe window for drainage, this patient successfully was managed conservatively with intravenous fluids & antibiotics; eventually managed to tolerate diet within 7 days.
Discussion: Symptomatic duodenal diverticulitis can be initially thought to be as a peripancreatic complicated fluid collection given anatomical proximity. In the setting of normal lipase & amylase levels, MRI can provide detailed characterization of the pancreas and organs’ structure. Different imaging modality can provide adequate accuracy to narrow differentials. Intra-abdominal source control of infection is the ideal modality of management; which can also include a conservative approach after adequate risk-benefit evaluation.
