Perforated duodenal diverticulum

Case contributed by Dr Craig Hacking

Presentation

RUQ pain one day after fall onto epigastrium

Patient Data

Age: 76
Gender: Female
Modality: CT

In the right side of the abdomen there is high density material pooling within a lumen. This likely represents a duodenal diverticulum. Medial to this this is a gas filled structure containing solid material measuring 3.7cm. This is not continuous with bowel and is suspicious for a contained perforation. The site of the perforation is not evident. There is a further small gas locule medial to this which is also extraluminal. Marked surrounding fat stranding. No lymphadenopathy. No free intra-abdominal or pelvic fluid.

Hepatomegaly. The liver, spleen, pancreas and kidneys opacify normally, with no evidence of contusion or laceration. Low density lesion in segment VII of the liver likely represents a cyst. The gallbladder, adrenals and bladder are unremarkable.

There is a long segment of colon from the hepatic flexure to the mid transverse colon, which has a thickened and enhancing wall with marked pericolic fat stranding. Luminal narrowing throughout this segment. No overlying subcutaneous stranding. Although this is a portal venous phase study, the SMA opacifies normally. No SMV thrombosis.

Bibasal scarring and bronchiectasis.Haemangioma in L3 body. No lumbar vertebral fracture or malalignment. No paravertebral haematoma. No fracture of the imaged lower ribs. No fracture of the pelvis, sacrum or proximal femora. The sacroiliac joints and pubic symphysis are not widened.

Conclusion

Contained perforation in the central abdomen, with marked associated inflammatory change within the gastrocolic ligament. The site of perforation appears to be an inflamed D3 duodenal diverticulum.

Thickened and enhancing colon from the hepatic flexure to the mid transverse colon with marked pericolic fat stranding and luminal narrowing. These changes are likely reactive to the contained perforation located superiorly however there is quite a distance between the two processes.

CT with oral contrast

Modality: CT

Oral contrast study.

Administration of oral contrast confirms the presence of two duodenal diverticuli. Both diverticuli arise from the medial D2 segment of the duodenum. The more superior diverticulum extends to the level of the porta hepatis.The more inferior diverticulum is associated with a contained perforation at its medial aspect, with contrast entering the contained perforation. Surrounding stranding is unchanged. There are now small locules of intraperitoneal free gas.

Conclusion

Perforation from the inferior duodenal diverticulum confirmed. New intraperitoneal free gas.

Case Discussion

Laparoscopy confirmed perforated a duodenal diverticulum, which was excised.

The diverticulum likely ruptured from the rapid change in intra-abdominal pressure when the patient fell on her epigastrium.

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Case Information

rID: 42002
Case created: 31st Dec 2015
Last edited: 11th Oct 2016
Inclusion in quiz mode: Included

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