Thursday, September 18, 2008

Duodenal Diverticulum and Jaundice

Elderly lady comes in with recurrent RUQ pain and jaundice. US shows gallstones and a dilated common bile duct. No stones seen in the CBD on MRCP. The GI consultant attempts an ERCP but the common duct cannot be cannulated secondary to a peri-ampullary diverticulum, noted to be full of food matter. I obtain the Upper GI barium study shown above.

Intermittent jaundice has been described in association with peri-ampullary duodenal diverticula, although it's quite rare. Options include formally excising the diverticulum versus simply bypassing the distal segment of the CBD with a biliary-enteric anastomosis.

My stance is always to do the safest surgery when feasible. This diverticulum was on the mesenteric aspect of the duodenum, bulging into the pancreas. Formal excision and sphincteroplasty would have been a complicated, potentially dangerous, operation. Even in the hands of the experts at Mayo, there is a substantial mortality/morbidity rate with such an endeavour. So I simply did the cholecystectomy and bypassed the obstruction with a choledochoduodenostomy. Post-operatively, her liver function tests normalized. Five weeks later she's still symptom free.


walt dandy said...

Very nice case.

Bongi said...

well done.

Skyhigh said...

I am sure biliary enteric bypass was the right choice for this patient as it was embedding deep into the pancreas
Its a very good film u have provided and from it the diverticulum looks to be in the 3rd part of duodenum but i am not sure.
The operating surgeon knows the best about his patients,excision would have beemn the best course but you have done a good job

Jeffrey Parks MD FACS said...

Actually there are several small bowel diverticuli. Look at the second part of the duodenum; there's a smaller one that was the cause of the obstruction.

Anonymous said...

From surgquestions

Oh yeah now i do see it, paravaterian duodenal diverticulum does cause jaundice.