Endoscopic management of intraluminal duodenal diverticulae

BACKGROUND: An intraluminal duodenal diverticulum is a congenital anomaly consisting of a mucosal sac usually present within the second portion of the duodenum. Surgery has traditionally been recommended for relief of obstructive symptoms due to this anomaly. AIMS: To demonstrate that endoscopic management of intraluminal duodenal diverticulae is feasible and effective, but without the associated risks of surgery. METHODS: A 45-year-old female underwent evaluation for a 6-month history of postprandial epigastric discomfort. Upper gastrointestinal barium study suggested an intraluminal duodenal diverticulum. The patient underwent upper gastrointestinal endoscopy to confirm the diagnosis and attempt therapy. The diverticulum was most completely seen by the side-viewing duodenoscope. The ampulla was identified on the bridge of tissue comprising the luminal wall of the diverticular sac. A guidewire was passed through the base of the diverticulum and a double pigtail stent was passed over the guidewire to traverse the diverticular wall. The diverticular wall was incised from the outside using a needle knife sphincterotome. The incision was extended following stent removal to 3 cm with a standard bowed sphincterotome. The patient was free of obstructive symptoms following the procedure and follow-up endoscopic exam 3 weeks later demonstrated the incision to be well-healed. Four previous reports of endoscopic management of symptomatic intraluminal duodenal diverticulum exist. In one case (1979) a snare was used to excise the base of the diverticulum. This is potentially dangerous unless the papilla and bile duct are clearly identified ahead of time. In a second case (1983) the diverticulum had a small opening in its base, which was broadened by passage of an endoscope through it. In two other cases (1993 and 1994) the diverticulum was opened with a needle knife without the assistance of a guiding stent. In all cases the patients were asymptomatic following endoscopic therapy. CONCLUSIONS: Symptomatic intraluminal duodenal diverticulum can be effectively managed endoscopically, saving the patient the risk and expense of surgery. Incising the sac over a stent provides an extra measure of safety and represents an improvement over previously reported methods. Endoscopic therapy should be considered the first line of therapy for symptomatic intraluminal duodenal diverticulae.