Preoperative diagnosis of perforated duodenal diverticulum with ultrasonography
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Case Report Preoperative Diagnosis of Perforated Duodenal Diverticulum with Ultrasonography Kouki Ido, MD, Hiroatsu Agata, MD, Kyotaro Toshimitsu, MD, Keiichi Kimura, MD, Takashi Suzuki, MD Department of Surgery, Nagoya Tokushukai Hospital, 2-1 Kozojicho, Kasugai city, Aichi Prefecture, Japan Received 5 March 1996; accepted 2 July 1996 The duodenum is the second most common site of enteric diverticula. The incidence of duodenal di- verticula is reported to be 11%–22% in autopsy studies. 1 However, duodenal diverticula seldom require surgical treatment unless symptoms oc- cur. Although perforation is the most serious but rarest complication of duodenal diverticula, 2 the diagnosis of perforated duodenal diverticula is very difficult, and preoperative diagnosis is sel- dom correct. This is one of the reasons for its high mortality rate. 3 We report a case of perforated duodenal diverticulum diagnosed preoperatively with ultrasonography. CASE REPORT A 41-year-old woman was admitted to Nagoya Tokushukai Hospital on July 23, 1993, with a 6-hour history of acute onset of right upper and lower quadrant abdominal pain. There were nau- sea and vomiting but no jaundice. She had under- gone an appendectomy 21 years previously. Physical examination revealed the following findings: blood pressure 90/60 mmHg, pulse rate 84 beats per minute, temperature 36.8°C. The heart and lung examinations were normal. The abdomen was soft and diffusely tender; however, tenderness was especially strong in the right up- per quadrant. Mild guarding and rebound tender- ness were noted in this area. Bowel sounds were hypoactive. Laboratory findings revealed the fol- lowing values: white blood cell count (WBC) 10,800/mm 3 , hematocrit 39.5%, serum amylase 77 IU/L, total bilirubin 1.3 mg/dL, alkaline phos- phatase 86 IU/L. Glucose, liver enzymes, and uri- nalysis were normal. The chest and abdominal x-rays at admission were normal. No free air was seen under the dia- phragm or in the retroperitoneal space (Figure 1). Ultrasonography revealed a small amount of as- cites in Morrison and Douglas pouches. The sec- ond portion of the duodenum was dilated and pro- truded to the anterior abdominal wall, and at the posterior area adjacent to it, there was a cavity containing fluid and gas in the retroperitoneal space. No local thickening of the duodenal wall suggestive of an ulcerative lesion was seen with ultrasound (Figure 2). Computed tomography (CT) gave the same findings as ultrasonography. The dilated second portion of the duodenum was attached to the anterior abdominal wall, and there was a cavity containing fluid and gas adja- cent to the back of it (Figure 3). These findings suggested retroperitoneal perforation of a diver- ticulum in the second portion of the duodenum. However, it showed neither a duodenal diverticu- lum nor extravasation with upper gastrointesti- nal (UGI) study nor upper gastrointestinal CT en- hanced with gastrografin (Figures 4 and 5). On this basis, we diagnosed perforated duode- nal diverticulum, and the patient underwent an emergency exploratory laparotomy. At laparotomy, a bulge in the paraduodenal area and a yellowish exudate in the retroperito- neum were found. After the duodenum was mobi- lized by the Kocher maneuver, an abscess cavity 4 cm in diameter was found adjacent to the back of the second portion of the duodenum. The cavity Correspondence to: K. Ido J Clin Ultrasound 25:149–153, March/April 1997 © 1997 John Wiley & Sons, Inc. CCC 0091-2751/97/030149-05 149 VOL. 25, NO. 3, MARCH/APRIL 1997
Transcript of Preoperative diagnosis of perforated duodenal diverticulum with ultrasonography
Case Report
Preoperative Diagnosis of PerforatedDuodenal Diverticulumwith Ultrasonography
Kouki Ido, MD, Hiroatsu Agata, MD, Kyotaro Toshimitsu, MD,Keiichi Kimura, MD, Takashi Suzuki, MD
Department of Surgery, Nagoya Tokushukai Hospital, 2-1 Kozojicho, Kasugai city,Aichi Prefecture, Japan
Received 5 March 1996; accepted 2 July 1996
The duodenum is the second most common site ofenteric diverticula. The incidence of duodenal di-verticula is reported to be 11%–22% in autopsystudies.1 However, duodenal diverticula seldomrequire surgical treatment unless symptoms oc-cur. Although perforation is the most serious butrarest complication of duodenal diverticula,2 thediagnosis of perforated duodenal diverticula isvery difficult, and preoperative diagnosis is sel-dom correct. This is one of the reasons for its highmortality rate.3 We report a case of perforatedduodenal diverticulum diagnosed preoperativelywith ultrasonography.
CASE REPORT
A 41-year-old woman was admitted to NagoyaTokushukai Hospital on July 23, 1993, with a6-hour history of acute onset of right upper andlower quadrant abdominal pain. There were nau-sea and vomiting but no jaundice. She had under-gone an appendectomy 21 years previously.Physical examination revealed the following
findings: blood pressure 90/60 mmHg, pulse rate84 beats per minute, temperature 36.8°C. Theheart and lung examinations were normal. Theabdomen was soft and diffusely tender; however,tenderness was especially strong in the right up-per quadrant. Mild guarding and rebound tender-ness were noted in this area. Bowel sounds werehypoactive. Laboratory findings revealed the fol-lowing values: white blood cell count (WBC)
10,800/mm3, hematocrit 39.5%, serum amylase77 IU/L, total bilirubin 1.3 mg/dL, alkaline phos-phatase 86 IU/L. Glucose, liver enzymes, and uri-nalysis were normal.The chest and abdominal x-rays at admission
were normal. No free air was seen under the dia-phragm or in the retroperitoneal space (Figure 1).Ultrasonography revealed a small amount of as-cites in Morrison and Douglas pouches. The sec-ond portion of the duodenum was dilated and pro-truded to the anterior abdominal wall, and at theposterior area adjacent to it, there was a cavitycontaining fluid and gas in the retroperitonealspace. No local thickening of the duodenal wallsuggestive of an ulcerative lesion was seen withultrasound (Figure 2). Computed tomography(CT) gave the same findings as ultrasonography.The dilated second portion of the duodenum wasattached to the anterior abdominal wall, andthere was a cavity containing fluid and gas adja-cent to the back of it (Figure 3). These findingssuggested retroperitoneal perforation of a diver-ticulum in the second portion of the duodenum.However, it showed neither a duodenal diverticu-lum nor extravasation with upper gastrointesti-nal (UGI) study nor upper gastrointestinal CT en-hanced with gastrografin (Figures 4 and 5).On this basis, we diagnosed perforated duode-
nal diverticulum, and the patient underwent anemergency exploratory laparotomy.At laparotomy, a bulge in the paraduodenal
area and a yellowish exudate in the retroperito-neum were found. After the duodenum was mobi-lized by the Kocher maneuver, an abscess cavity 4cm in diameter was found adjacent to the back ofthe second portion of the duodenum. The cavity
Correspondence to: K. IdoJ Clin Ultrasound 25:149–153, March/April 1997© 1997 John Wiley & Sons, Inc. CCC 0091-2751/97/030149-05
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contained a duodenal diverticulum 1.5 cm in di-ameter with necrotic tissue. The diverticulumwas resected at the base (0.5 cm) with primarydouble-layer closure. The retroperitoneal areawas drained by a Penrose drain, and the stomachwas decompressed by means of a naso-gastrictube. Pathological findings showed that the duo-denal diverticulum was necrotic and there wereno muscle layers.The postoperative course was uncomplicated.
DISCUSSION
The incidence of duodenal diverticula has beenfound in 1%–2% of patients having upper gastro-intestinal series, and in 11%–22% of those pa-tients at autopsy.1 They were rarely symptom-
atic, and only 1%–5% of those patients requiredan operation.4,5 Perforation is considered to bethe most serious complication but also the rarest.Only about 100 patients have been reported in theworld literature.2 The diagnosis of perforatedduodenal diverticula is very difficult because thesigns and symptoms are nonspecific and may besimilar to other acute abdominal conditions: per-forated duodenal ulcer, acute cholecystitis, acuteappendicitis, acute pancreatitis and nephrolithia-sis.2,6 According to Duarte et al,2 a correct preop-erative diagnosis was made in only 13 of 101 pa-tients (13%). Further, in some cases, a correct di-agnosis was not obtained even during theoperation.1,3 The difficulty in diagnosis is due, inpart, to the fact that the duodenal diverticulumusually develops in retroperitoneal space. This di-
FIGURE 1. Abdominal roentgenogram demonstrating no abnormal findings.
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FIGURE 3. Abdominal CT study showing second portion of the duodenum (D) protruding to the anterior
abdominal wall. An abnormal cavity (arrowhead) containing fluid and gas is also found (G: gallbladder).
FIGURE 2. Longitudinal (left) and transverse (right) scan of the second portion of the duodenum. The duodenum (D) protrudes to the anterior
abdominal wall and is extremely dilated without wall thickening. An abnormal cavity (arrows) containing fluid and gas (white arrows) is found
posterior to it (G: gallbladder).
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minishes the severity of clinical findings andleads to misdiagnosis in plain abdominal x-raysbecause of the low incidence of free air.4,5,7 Duarteet al found that 50% of plain abdominal radio-graphs were normal and only 27% demonstratedretroperitoneal and paraduodenal free air.2
UGI series may show a diverticulum and ex-travasation of contrast medium; however, Vanek
et al reported that 17% of patients having UGIseries were normal, and the percentage of duode-nal diverticula without perforation, with perfora-tion, and with colonic fistula were 21%, 25%, and25%, respectively, in such patients.1 This lowincidence of abnormal findings is due to thepresence of an enterolith or a narrow neck thatmight stop flow of the contrast medium.1,4,5,8
FIGURE 4. Upper gastrointestinal CT study enhanced with gastrografin showing the enhanced second portion
of the duodenum (D) and the abnormal cavity (arrows) without enhancement (G: gallbladder).
FIGURE 5. Upper gastrointestinal series demonstrating neither duodenal diverticulum nor extravasation.
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Therefore, UGI series are not so useful for diag-nosing of this entity.To date, CT has confirmed the diagnosis in
three cases.2 Goodman et al6 mentioned the util-ity of CT in perforated duodenal diverticulum be-cause CT allows demonstration of small amountsof retroperitoneal gas and fluid, regardless of theextent of abnormality and its relationship to ad-jacent vital structures. On the other hand, ab-dominal ultrasonography has never been used inthe diagnosis of this condition because it wasthought to be difficult to examine the gastroin-testinal tract due to its contained gas. But insome gastrointestinal diseases, investigatorshave suggested that the intestinal tract can beobserved easily because of ascites, fluid-filled in-testine, and intestinal wall thickening in such pa-tients.8–10
We recognize that ultrasonography could dem-onstrate small amounts of gas as a strong echowith comet-tail artifacts, the extent of the abnor-mal lesion, and its relationship to close vitalstructures by various direction scanning as wellas CT scan. In our case, although the UGI serieswas normal, we found retroperitoneal free air andfluid collection adjacent to the second portion ofduodenum with both ultrasonography and CT,and these findings led to a correct preoperativediagnosis. Therefore, it is suggested that a com-bination of ultrasonography and CT can be veryuseful in diagnosing this condition. Ultrasonogra-phy may be inferior to CT in detecting free air,but ultrasonography can examine patients at thebedside who cannot hold their breath or lie with-out moving. Moreover, ultrasonography is less ex-pensive and less invasive than CT.Ultrasonography would be useful for diagnos-
ing duodenal rupture as well. Therefore, when pa-tients with acute abdominal pain are examined
with ultrasonography, attention should be paid tofindings in the retroperitoneal space. Ultrasonog-raphy may provide early diagnosis and thus per-mit earlier surgical intervention in perforatedduodenal diverticula, improving the prognosis ofthis potentially life-threatening condition.
REFERENCES
1. Vanek VW, McNamara K, Lyras LS: Perforatedduodenal diverticulum: Case report and literaturereview. Contemp Surg 34:36–47, 1989.
2. Duarte B, Nagy KK, Cintron J: Perforated duode-nal diverticulum. Br J Surg 79:877–881, 1992.
3. Peutz WH, Sannen LJMJ, Sing LH: The perforateddiverticulum of the duodenum. Arch Chir Neer-landicum 25:313–318, 1973.
4. Juler GL, List JW, Stemmer EA, Connolly JE: Per-forating duodenal diverticulitis. Arch Surg 99:572–578, 1969.
5. Haugh DC, McBee MH: Perforation of duodenaldiverticula. Contemp Surg 25:72–75, 1984.
6. Goodman P, Raval B, Zimmerman G: CT diagnosisof perforated duodenal diverticulum. Clin Imaging13:321–322, 1989.
7. Wolfe RD, Perl MJ: Acute perforation of duodenaldiverticulum with roentgenographic demonstra-tion of localized retroperitoneal emphysema. Radi-ology 104:301–302, 1972.
8. Gooding GAW, Filly RA, Laing FC: Ultrasonogra-phy of the alimentary tube. In Margulis AR,Burhenne HJ, eds. Alimentary Tract Radiology.4th ed. vol 1. St Louis, C.V. Mosby Co Inc, 1989, pp197–213.
9. Limberg B: Diagnosis of acute ulcerative colitisand colonic Crohn’s disease by colonic sonography.J Clin Ultrasound 17:25–31, 1989.
10. Fleischer AC, Parulekar S, Seibert JJ: Sonographyof the small bowel. In Herlinger H, Maglinte D,eds. Clinical Radiology of Small Intestine. Phila-delphia, WB Saunders, 1989, pp 153–159.
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