Current Problems in Diagnostic Radiology
Volume 41, Issue 1 , Pages 20-29, January 2012

Imaging of Duodenal Diverticula and Their Complications

Department of Radiology, University of Washington, Seattle, WA

Article Outline

Duodenal diverticula are common and are often incidentally found during routine imaging. Complications can occur but few require surgical intervention. We present a review of duodenal diverticula and their complications.

 

The duodenum is the second most common location for diverticula after the colon,1 and duodenal diverticula are found in 5%-22% of the population.1, 2 Most diverticula are asymptomatic and incidentally found, but complications do occur. Approximately 10% of duodenal diverticula are symptomatic, but only 1%-2% will require surgical intervention.2 Complications include acute diverticulitis, hemorrhage, and perforation, biliary obstruction, and pancreatitis.

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Types of Duodenal Diverticula 

Congenital and Acquired Diverticula 

Both true (congenital) diverticula and, more commonly, acquired (pseudodiverticula) diverticula arise from the duodenum.

True (congenital) diverticula contain all 3 layers of the duodenal wall and are less common. They are thought to result from failed recanalization at approximately 7-10 weeks gestation. They are located in the medial wall of the second and third portions of the duodenum (Fig 1) and are less common than acquired diverticula.3

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  • FIG 1. 

    A 58-year-old woman presenting with dysphagia. Abdominal radiograph from an upper gastrointestinal barium study demonstrates an incidental duodenal diverticulum (arrow) in the third portion of duodenum.

Acquired diverticula (or, more correctly, pseudodiverticula) are most commonly pulsion diverticula in which the mucosa, muscularis mucosa, or submucosa herniates through a focal defect in the bowel wall. Ninety-five percent of these diverticula arise from the medial duodenal wall with 62% from the second portion of the duodenum. They commonly occur at the entry of the common bile duct and pancreatic duct and are termed periampullary or “perivaterian” if located within 2.5 cm of the papilla of Vater.4 Acquired traction diverticula may occur as sequelae of ulcer disease or cholecystitis.5

Intraluminal Diverticula 

Intraluminal true diverticula occur in the second or third portion of the duodenum. They result from incomplete luminal recanalization of the duodenum and comprise a diaphragm that spans the inner circumference of the duodenum (Fig 2).6 A fenestration allows passage of some luminal contents through the diaphragm, but duodenal peristalsis and the pressure of food lead to progressive enlargement and ballooning of the diaphragm. These diverticula are usually detected in adults.7 Intraluminal diverticula have been associated with other congenital abnormalities, including Down's syndrome, choledochocele, and annular pancreas.8 In addition to causing obstruction, intraluminal diverticula may also cause recurrent epigastric pain and cramping, vomiting, and recurrent pancreatitis.8

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  • FIG 2. 

    Diagram demonstrating an intraluminal diverticulum. Intraluminal diverticulum results from failed embryonic recanalization of the duodenum. A web or flap usually arises in the second portion of the duodenum near the ampulla of Vater and forms a diaphragm that may contain variable fenestrations (arrow). Due to chronic antegrade enteric propulsive pressure, a diverticulum (arrowhead) within the duodenal lumen may develop. The white asterisk indicates the dilated stomach.

Although these lesions have been described as true diverticula, some authors report that they do not contain the muscularis propria and thus do not meet the strict criteria for true diverticula. As they are covered on both sides by the duodenal mucosa, they are best classified at duodenal mucosal webs.

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Appearance of Uncomplicated Duodenal Diverticula 

Uncomplicated duodenal diverticula can be single or multiple. These diverticula appear as saccular outpouchings on barium contrast examinations (Fig 3). On computed tomography (CT) and magnetic resonance (MR) imaging, the diverticula are more frequently identified by gas, a gas-fluid/contrast level, or debris in the diverticulum, adjacent to the normal duodenal lumen (FIG 4, FIG 5). Because duodenal diverticula may mimic a cystic neoplasm of the pancreatic head, they should be considered when a cystic lesion is identified between the duodenum and the head of the pancreas on CT and MR imaging (Fig 6).9 Similarly, a duodenal diverticulum filled with gas and debris may mimic a pancreatic head neoplasm (Fig 7). For clarification, the use of negative oral contrast for magnetic resonance cholangiopancreatography (MRCP) has been suggested.10 The ultrasound appearance has been described as a persistent bright linear or concave echo that obscures visualization of the normal pancreatic head.11

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  • FIG 3. 

    A 44-year-old-male with epigastric pain. Spot radiograph from an upper gastrointestinal barium study demonstrates four duodenal diverticula (arrows). In addition, there were multiple jejunal diverticula, one of which is marked (arrowhead).

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  • FIG 4. 

    A 65-year-old-man with abdominal pain and bloating. (A) Spot radiograph from an upper gastrointestinal barium study demonstrates a large duodenal diverticulum with a small neck (arrow) arising from the third part of the duodenum. (B) Contrast-enhanced CT shows an air-fluid level in the duodenal diverticulum (asterisk), with mild compression of the second part of the duodenum (arrows). Subsequent endoscopy demonstrated extrinsic mass effect on the duodenum and gastric antrum without obstruction.

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  • FIG 5. 

    A 64-year-old woman presenting with nonspecific abdominal pain. (A) Axial and (B) coronal contrast-enhanced CT images demonstrate a large debris-filled duodenal diverticulum (asterisks) arising from the third portion of the duodenum.

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  • FIG 6. 

    A 42-year-old-woman presenting with right upper quadrant pain. (A) Axial contrast-enhanced CT demonstrates a cystic area in the region of head of the pancreas (arrow) that was initially reported as suspicious for a cystic pancreatic neoplasm. (B) Subsequent thin-section contrast-enhanced CT ordered 2 days later to characterize the mass demonstrates air within the “cystic pancreatic mass” (arrow), typical of a duodenal diverticulum. CT of the abdomen a week later showed stability in the duodenal diverticulum.

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  • FIG 7. 

    A 63-year-old-woman presenting with right lower quadrant abdominal pain. (A) Axial and (B) coronal contrast-enhanced CT images demonstrate an incidental pancreatic head region duodenal diverticulum containing impacted debris and gas (arrows), mimicking a necrotic pancreatic head mass. Reactive thickening of the cecum from cecal diverticulitis is seen.

The “windsock” sign is pathognomonic of intraluminal diverticula and is depicted by barium contrast examinations. A radiolucent line surrounds the barium-filled sac of the intraluminal diverticulum (Fig 8).12 Multidetector CT with multiplanar and curved planar reformations may assist in the diagnosis, where the diverticulum may appear as a “target” or “halo” on CT.6, 7, 13 Although the windsock sign (resembling an airport windsock, with a central distal opening) is typically demonstrated for these lesions, the opening in the web is more commonly located eccentrically.

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  • FIG 8. 

    A 66-year-old woman presenting with abdominal pain. Spot radiograph from an upper gastrointestinal barium study demonstrates an intraluminal diverticulum. The classic “wind sock” filling defect (arrow) is present in the second portion of the duodenum.

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Pseudointraluminal Diverticula 

We have observed examples of barium mixing phenomena that may have the appearance of intraluminal diverticula. We believe that these are large bubbles of viscous mucus containing barium, appearing as a transient filling defect similar in appearance to intraluminial diverticula (Fig 9A, B). These may be termed “duodenal pseudo-intraluminal diverticula.” Dynamic or delayed images demonstrate spontaneous disappearance of the filling defect, differentiating these pseudolesions from true intraluminial diverticula. Follow-up endoscopy in one instance has confirmed a normal duodenum (Fig 9C).

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  • FIG 9. 

    A 52 year-old man presenting with abdominal pain. (A) Spot radiograph from an upper gastrointestinal barium study demonstrates the “wind sock” filling defect (arrow) in the second portion of the duodenum. A few minutes later during the same examination (B), the filling defect has disappeared. Endoscopy (C) was normal. (Color version of figure is available online.)

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Duodenal Diverticulitis 

Duodenal diverticulitis may occur from stasis and impaction of bowel contents, usually when the diverticulum has a small neck, which limits emptying of its contents.9 Foreign bodies and enteroliths are also predisposing factors.13 Duodenal diverticulitis is a difficult clinical diagnosis due to lack of specific signs and symptoms and may mimic more common causes of acute right upper quadrant pain, such as pancreatitis, acute cholecystitis, ulcer disease, and colitis.9 Imaging findings may be nonspecific as well. CT findings of duodenal diverticulitis are similar to diverticulitis in other portions of the bowel and include adjacent fat stranding, wall thickening, and periduodenal abscess (Fig 10). Coronal reformatted images may be particularly useful in identifying the diverticulum neck. Just as duodenal diverticulitis can be a difficult clinical diagnosis, the imaging findings invoke a fairly broad differential diagnosis, including acute pancreatitis, pancreatic head neoplasms, Crohn's disease, infected duplication cyst, ulcer disease, and lymphadenopathy.9

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  • FIG 10. 

    A 64-year-old woman with fever, vomiting, and right upper quadrant pain. (A) Axial and (B) coronal contrast-enhanced CT images demonstrate acute duodenal diverticulitis with extensive periduodenal and retroperitoneal inflammation (asterisks). There is relative nonenhancement of the diverticulum wall, which is lateral to the second portion of the duodenum (arrowheads).

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Bleeding Duodenal Diverticulum 

Bleeding from a duodenal diverticulum is a rare complication14 and often requires surgical intervention. These patients may present with hematemesis or melena. Several sources for bleeding within a diverticulum have been described, including ulcer disease, erosion into major vessels, neoplasia, angiodysplasia, and drugs.12 A high clinical suspicion of a duodenal diverticular source of bleeding will aid in the correct diagnosis, as both clinical and imaging findings may be confusing. Angiographic findings may be mistaken for artifact, colonic, or jejunal bleeding12 and endoscopic findings may be obscured by ongoing hemorrhage from the bleeding source. On CT, active extravasation of contrast or hemorrhage may be identified along with thickening of the diverticulum wall and adjacent fat stranding (Fig 11). A careful search for the neck of the diverticulum is necessary.

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  • FIG 11. 

    A 65-year-old woman with a bleeding duodenal diverticulum resulting in massive upper gastrointestinal bleeding requiring 19 units of blood before surgery. (A) Axial and (B) coronal CT angiography images of the upper abdomen show active contrast extravasation within the duodenum (arrow) from a duodenal diverticulum (white arrow). (C) Catheter angiography demonstrates a contrast blush in the region of active hemorrhage (black arrow).

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Duodenal Diverticulum Perforation 

Duodenal diverticulum perforation is a serious complication with a mortality rate up to 30%.1 Clinical presentation is highly variable. Imaging features of perforation are similar to perforation elsewhere in the bowel with extraluminal gas and extraluminal fluid or contrast identified (FIG 12, FIG 13). Visualization of the diverticulum or neck assists in the correct diagnosis. Surgical repair of these lesions are typically a diverticulectomy or Roux loop duodenojejunostomy.1 Surgical complications include fistula and abscess formation, pancreatitis, and bile duct injury.1

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  • FIG 12. 

    A 55-year-old man with 3 days of fever and abdominal and back pain. (A) Axial and (B) coronal contrast-enhanced CT images demonstrate a perforated duodenal diverticulum (arrow) with extraluminal fluid (arrowheads) and gas (asterisks) in the retroperitoneum.

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  • FIG 13. 

    A 81-year-old man with 1 day of abdominal and back pain and fever. (A) Axial and (B) coronal contrast-enhanced CT images show communication (arrow) between the duodenal lumen, a duodenal diverticulum, and extraluminal gas in the retroperitoneum (arrowhead) with standing in the retroperitoneum, indicating a perforated duodenal diverticulum. Due to comorbidities, the patient was treated conservatively.

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Biliary and Pancreatic Complications 

Duodenal diverticula may also cause biliary and pancreatic duct obstruction because they are commonly juxtapapillary in location (Fig 14). Increased duodenal lumen pressure may lead to distension of the duodenum, compressing the distal common bile duct, resulting in biliary obstruction.1 The term “Lemmel's syndrome” has been applied to a juxtapapillary diverticulum causing obstructive jaundice.12, 15 Cholangitis may also occur.16

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  • FIG 14. 

    A 63-year-old man with recent acute pancreatitis and a dilated distal common bile duct due to a juxtapapillary duodenal diverticulum. (A) Coronal fast imaging with steady-state precession (true FISP) and (B) axial half Fourier acquisition single-shot turbo spin-echo (HASTE) MRCP demonstrates low signal gas (arrows) in a duodenal diverticulum without evidence of a neoplasm or calculus.

Many17, 18, 19, 20 have found that juxtapapillary duodenal diverticula are also associated with choledocholithiasis (Fig 15), perhaps due to the combined effects of biliary stasis20 and bacterial contamination,18 particularly larger diverticula.21 Some, but not all, suggest that diverticula are associated with an increased rate of cholecystolithiasis and a higher complication rate for endoscopic sphincteromy.17 During endoscopic retrograde cholangiopancreatography (ERCP), cannulation of the common bile duct (CBD) can be more difficult in patients with periampullary diverticula, and diverticula increase the risk of retained calculi.22

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  • FIG 15. 

    A 56-year-old man with right upper quadrant pain. (A) Sagittal and (B) coronal thick-slab HASTE MRCP demonstrates a large periampullary diverticulum containing an air-fluid level (asterisks) with displacement and dilation of the common bile duct (black arrow). Filling defect distally in the CBD is a calculus (white arrow).

Both intraluminal diverticula10, 11 and extraluminal diverticula23 have been associated with an increased risk of acute pancreatitis. Acute pancreatitis is thought to result from reflux of duodenal contents through the papilla. The distended diverticulum and sphincter of Oddi dysfunction contribute to partial obstruction of the duodenum.23

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Conclusions 

Although duodenal diverticula occur frequently, their complications are rare. Most duodenal diverticula are asymptomatic and incidentally found during routine imaging. Complications include diverticulitis, bleeding, perforation, and pancreatitis or biliary obstruction. A high index of suspicion both clinically and radiologically is essential to make the correct diagnosis.

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References 

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PII: S0363-0188(11)00067-3

doi:10.1067/j.cpradiol.2011.07.001

Current Problems in Diagnostic Radiology
Volume 41, Issue 1 , Pages 20-29, January 2012

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