Duodenal diverticula are mainly caused by poor congenital development, resulting in limited outward protrusion of the duodenal intestinal wall in the form of a sac (primary diverticula) or by scar pulling caused by gastroduodenal ulcers (secondary diverticula). The disease occurs mostly in middle-aged people aged 40-60 years, with slightly more men than women. Most diverticulae are not symptomatic and are detected on barium x-ray or gastroscopy. Only a few patients may present with symptoms such as obstruction, perforation, bleeding, or secondary complications such as cholangitis, pancreatitis, or cholelithiasis.
Etiology.
The exact cause of diverticula is not known, most believe that it is due to congenital intestinal wall limited muscle layer underdevelopment or weakness, in the intestine suddenly high pressure or long-term sustained or repeated pressure increase, intestinal wall weakness, intestinal wall mucosa and submucosal layer tissue prolapse and form diverticula. May also be due to the formation of adhesion scar outside the intestinal wall inflammatory tissue leading to the occurrence of diverticula.
1, congenital diverticula.
Rare, is a congenital developmental abnormality is present at birth. The structure of the diverticulum wall includes the submucosa and muscle layer of the intestine, which is identical to the normal intestinal wall, also known as true diverticula.
2.Primary diverticula.
Because part of the intestinal wall has congenital anatomical defects, the intestinal mucosa and submucosal layer of the intestine due to increased intestinal pressure and the tissue outward to form diverticula. This kind of diverticulum wall of muscle layer tissue is mostly absent or weak.
3.Secondary diverticulum.
Mostly because of the contraction of duodenal ulcer scar or chronic cholecystitis adhesions pulling, so all occur in the first part of the duodenum, also known as pseudodiverticula.
Clinical manifestations.
There are no typical clinical manifestations of duodenal diverticula, and the symptoms that occur are mostly due to complications. Epigastric fullness is the more common symptom and is due to diverticulitis. It is accompanied by belching and vague pain. The pain is irregular and is not relieved by acid control drugs. Nausea or vomiting is also common. When the diverticulum is full of food and distended, it can compress the duodenum and cause partial obstruction. The vomit is initially gastric contents, followed by bile or even blood, which can be relieved by vomiting. When the diverticulum is complicated by ulceration or bleeding, the symptoms resemble ulcer disease or blood in the stool, respectively. When the diverticulum compresses the opening of the common bile duct or pancreatic duct, it can cause cholangitis, pancreatitis, or obstructive jaundice. After perforation of the diverticulum, symptoms of peritonitis present.
Examination.
1, barium X-ray examination.
Duodenal diverticulum can be found as a pouch-shaped niche shadow protruding from the intestinal wall, with a neat and clear outline and smooth edges. After pressure is applied, mucosal texture is seen in the niche shadow continuing into the duodenum, and some niches are seen as larger diverticula with barium shadows remaining in the diverticular cavity after the barium is emptied, and the neck is wider, and the gas-liquid surface is sometimes visible within the diverticula.
2, fiberoptic duodenoscopy.
In addition to finding the opening of the diverticulum can also understand the relationship between the diverticulum and the duodenal papilla, to provide a basis for deciding the surgical plan.
3.Cholangiography.
Intravenous cholangiography, percutaneous transhepatic percutaneous cholangiography (PTC), transduodenoscopic retrograde cholangiography (ERCP) and other methods can be used to understand the relationship between the diverticulum and the bile duct-pancreatic duct, which has reference significance for the selection of surgical treatment methods.
4.CT examination.
Diverticula usually appear as a round or ovoid cystic bag-like shadow protruding outside the duodenal intestinal wall, with a smooth contour of the plasma membrane surface. Since diverticula are mostly connected to the intestinal lumen by a narrow neck, CT can show positive contrast shadows entering it, in addition to the often visible gas shadows contained within it. It is important to note that when positive contrast enters the diverticulum located in the medial part of the descending duodenum, it may be mistaken for a stone in the lower bile duct.
Complications.
1. Diverticulitis and diverticular hemorrhage.
As the contents of the duodenal diverticulum retain bacterial multiplication and inflammatory infection, diverticulitis can be caused. Subsequently, the diverticular mucosa erosion bleeding, but also diverticula ectopic gastric mucosa ectopic, pancreatic tissue caused by bleeding, or diverticular inflammation erosion or penetration of nearby blood vessels bleeding, as well as rare diverticular mucosa malignant bleeding.
2, diverticular perforation.
Due to the retention of diverticular contents, mucosal inflammatory erosion complicated by ulceration, perforation is mostly located in the retroperitoneum, and the symptoms are not typical after perforation, and even dissection is still not easily detected, usually accompanied by retroperitoneal abscess, pancreatic necrosis, and pancreatic fistula.
3, duodenal obstruction.
Duodenal obstruction due to diverticula is mostly seen in intraluminal diverticula, which block the intestinal lumen due to filling of the diverticula to form a polyp-like pouch. Or larger extraluminal diverticula due to retention of contents, compression of duodenum caused by obstruction, but most of them are incomplete obstruction.
4.Biliary and pancreatic duct obstruction.
Mostly seen in parapapillary diverticula intra-luminal type or extra-luminal type can occur. Due to the opening of the common bile duct and pancreatic duct below or on both sides of the diverticulum or even at the edge of the diverticulum or within the diverticulum, resulting in dysfunction of the sphincter of Oddi; diverticulum mechanical compression of the common bile duct and pancreatic duct resulting in bile, pancreatic fluid retention luminal pressure increase, duodenal papilla edema, edema at the end of the common bile duct, increasing the chance of retrograde infection complicating bile duct infection or acute and chronic pancreatitis.
Treatment
1.Treatment principles.
When there are certain clinical symptoms and no other lesions exist, medical treatment should be used first, including the regulation of diet, acidulants, antispasmodics, etc., and can be taken in a lateral position or change to a variety of different positions to help the evacuation of food accumulated within the diverticulum. Because the diverticulum is located in the second part of the duodenum, or even buried in the pancreatic tissue, surgical excision is more difficult, so only in the internal treatment is ineffective and repeatedly complicated by diverticulitis, bleeding or compression of adjacent organs to consider surgery.
2.Surgical treatment.
In principle, diverticulectomy is the most ideal. Smaller diverticula can be a single inversion. At the same time there are multiple diverticula and encounter technical difficulties in resection, can be used to reroute surgery, that is, Billroth II type partial gastrectomy and selective vagotomy.