Novel diagnostic procedure

CASE REPORT

Severe upper gastrointestinal bleeding

in extraluminal diverticula in the third part
of the duodenum
Michael Wilhelmsen,1 Johnny Fredsbo Andersen,2 Morten Laksafoss Lauritsen1
1
Department of Surgical SUMMARY admitted to our department due to melaena. Besides
Gastroenterology, Hvidovre The successful management of upper gastrointestinal (GI) tachycardia the patient had BP 154/90 mm Hg and
Hospital, Hvidovre, Denmark
2
Department of Radiology, bleeding requires identification of the source of bleeding haemoglobin level 6.4 mmol/L. He used the anti-
Glostrup Hospital, Glostrup, and when this is achieved the bleeding can often be coagulant drug ‘Edoxaban’ as part of a randomised
Denmark treated endoscopically. However, the identification of the controlled trial. Treatment with this drug was
bleeding can be challenging due to the location of the stopped at admittance. An emergency gastroscopy
Correspondence to
bleeding or technical aspects. Therefore it might be came out normal and therefore the patient was
Dr Michael Wilhelmsen,
[email protected] necessary to use other measures than endoscopy such as planned for a colonoscopy that was impossible to
CT angiography. Duodenal diverticula is a rare cause of complete due to stool and melena. Because of the
Accepted 21 April 2014 upper GI bleeding and can be challenging to diagnose as continuous need for blood transfusion, a CT angiog-
they often require specialised endoscopy procedures such raphy was performed. This was normal (figure 1).
as endoscopy with a side-viewing scope. This case The patient suddenly became hypotensive with BP
describes the first successful management of this rare level 60/40 mm Hg and the haemoglobin level fell
condition with an upper GI endoscopy with a to only 1.9 mmol/L. An acute CT angiography was
colonoscope and afterwards intravascular coiling. preformed showing extravasation from an unname-
able branch from the superior mesenteric artery,
into the third part of the duodenum via an extra-
BACKGROUND luminal diverticula without relation to the major
Upper gastrointestinal (GI) bleeding is a common papillae (figure 2). An acute gastroscopy was incon-
condition. There are several causes of this condi- clusive, and an upper GI endoscopy with a colono-
tion that have to be considered, that is, scope was performed. This approach revealed the
Helicobacter pylori infection, drugs such as non- extraluminal diverticula and the bleeding was
steroidal anti-inflammatory drugs (NSAIDs) or stopped with injection of epinephrine saline. The
anticoagulation agents. Most cases of GI bleeding patient was thereafter transferred to another hos-
can be treated endoscopically although in up to pital with interventional radiology services for
10 % of patients there is a tendency for recurrence coiling of the artery and transferred back to our
and will need several endoscopic procedures before department. He had no further bleeding recurrences
there is adequate haemostasis; and the mortality is and was discharged a week later.
also around 10 % so all possible methods of
haemostasis have to be used.1
Duodenal diverticula are a rare cause of upper INVESTIGATIONS
GI bleeding although they occur in up to 22 % of Gastroscopy is usually the initial treatment for sus-
people in autopsy studies and are mostly solitary.2 pected GI bleeding. This is a fast, easy and safe
It is estimated that they are responsible for 0.14 %
of all upper GI bleeding.3 Duodenal diverticula are
most often seen with endoscopic retrograde cholan-
giopancreatography (ERCP) procedure or a side
viewing duodenoscope but can also be diagnosed
by other modalities such as CT or MRI3 5
Treatment is only recommended if the diverticula is
symptomatic.4 The most serious complication is
perforation and demands acute laparotomy, but
bleeding also occurs.3 5 The duodenal diverticula
are most often seen around the ampulla in the
second part of the duodenum.3 The distribution
between genders is unclear and ranges from 1:1 to
an abundance in men but persons around 50 or
To cite: Wilhelmsen M, 60 years of age seem to be mostly affected.3 4
Andersen JF, Lauritsen ML.
BMJ Case Rep Published
online: [ please include Day CASE PRESENTATION
Month Year] doi:10.1136/ A 69-year-old man known to be suffering from dia- Figure 1 Axial CT of the abdomen with no sign of
bcr-2013-202516 betes and previous deep venous thrombosis was bleeding.

Wilhelmsen M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-202516 1

 Novel diagnostic procedure

to be kept in mind that the side-viewing modalities such as duo-

denoscopy, (ERCP) or push endoscopes are not always available
and often require specialists, whereas colonoscopy and gastros-
copy can be performed by all endoscopically trained doctors,
and we find the method useful in selected cases.
The most important aspect is to control the bleeding, and if
this can be achieved by endoscopy and radiological procedures,
the physiological stress and potential complications in terms of
morbidity and mortality12 when performing an emergency
laparotomy can be avoided. The possibility for laparotomy is
important to have in mind but a laparotomy might include
major resections, that is, Whipple procedures.5

Learning points

▸ ‘Gastroscopy’ with a colonoscope may prevent laparotomies

Figure 2 Axial CT of the abdomen with bleeding into the duodenum. for grastrointestinal (GI) bleeding in the most distal part of
the duodenum/proximal part of jejunum which traditionally
is a difficult area for surgeons.
examination that also makes it possible to treat the bleeding if ▸ Epinephrine saline injection followed by intravascular coiling
identified. If the gastroscopy is inconclusive and there is doubt has proven efficient.
with regard to the source of bleeding a colonoscopy or sigmoid- ▸ CT angiography or bleeding scintigraphy can be used to
oscopy can be performed. These methods can also treat and diagnose some cases of severe bleeding if there is active
identify the sources of bleeding. bleeding.
If none of these methods can identify the bleeding a CT angi-
ography or a bleeding scintigraphy can be performed. These
methods are limited by the fact that the bleeding has to be
ongoing to be detected and are also often limited by the fact that Contributors MW treated the patient and wrote the article. JFA conducted the
they are not always available 24 h in emergency situations.6 7 radiological diagnosis of bleeding in the duodenum and analysed the manuscript
critically. MLL treated the patient and analysed the manuscript critically.
DIFFERENTIAL DIAGNOSIS Competing interests None.
Upper GI bleeding of other causes. Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
TREATMENT
▸ Epinephrine saline injection
▸ Intravascular coiling
REFERENCES
OUTCOME AND FOLLOW-UP 1 Nip rapport 2011 Akut kirurgi. 2012. Ref Type: Generic.
After 12 months the patient is still alive. 2 Ackermann W. Diverticula and variations of the duodenum. Ann Surg
1943;117:403–13.
DISCUSSION 3 Chen YY, Yen HH, Soon MS. Impact of endoscopy in the management of duodenal
diverticular bleeding: experience of a single medical center and a review of recent
To our knowledge this is the first case where a patient with literature. Gastrointest Endosc 2007;66:831–5.
major bleeding from an extraluminal duodenal diverticula 4 Bach AG, Lubbert C, Behrmann C, et al. Small bowel diverticula—diagnosis and
without relation to the major papillae has been treated initially complications. Dtsch Med Wochenschr 2011;136:140–4.
using a colonoscope and afterwards final treatment by the use of 5 Schnueriger B, Vorburger SA, Banz VM, et al. Diagnosis and management of the
symptomatic duodenal diverticulum: a case series and a short review of the
intravascular coiling following bleeding identification through a
literature. J Gastrointest Surg 2008;12:1571–6.
CT angiography. Normally this condition is diagnosed and 6 Winzelberg GG, McKusick KA, Strauss HW, et al. Evaluation of gastrointestinal
treated by side-viewing modalities such as duodenoscope3 5 but bleeding by red blood cells labeled in vivo with technetium-99 m. J Nucl Med
can also be managed using push endoscopy.8 1979;20:1080–6.
For identification of the source of bleeding several alternatives 7 Bearn P, Persad R, Wilson N, et al. 99mTechnetium-labelled red blood cells
scintigraphy as an alternative to angiography in the investigation of gastrointestinal
exist. We chose a CT angiography prior to further treatment, bleeding: clinical experience in a district general hospital. Ann R Coll Surg Engl
because extravasation possibly could identify the location and 1992;74:192–9.
vessel causing the bleeding, following several endoscopy proce- 8 Muscarella LF. Endoscopic shuffling, infection control, and the clinical practice of
dures that had failed to stop the bleeding. It has to be kept in push enteroscopy. Gastroenterol Nurs 2007;30:109–15.
9 Balci NC, Akinci A, Akun E, et al. Juxtapapillary diverticulum: findings on CT and
mind that other good alternatives exist such as bleeding scintig-
MRI. Clin Imaging 2003;27:82–8.
raphy with Technetium 99m-labelled RBG or MRI but these are 10 McKusick KA, Froelich J, Callahan RJ, et al. 99mTc red blood cells for detection of
more readily available in the ambulatory setting,9 10 and we find gastrointestinal bleeding: experience with 80 patients. AJR Am J Roentgenol
that CT angiography is a good way to visualise the vessels prior 1981;137:1113–18.
to eventual coiling procedures. 11 de Perrot T, Poletti PA, Becker CD, et al. The complicated duodenal diverticulum:
retrospective analysis of 11 cases. Clin Imaging 2012;36:287–94.
This approach raises an important question as the colono- 12 Byrge N, Barton RG, Enniss TM, et al. Laparoscopic versus open repair of perforated
scope might produce infections such as endoscopic shuffling.8 gastroduodenal ulcer: a National Surgical Quality Improvement Program analysis.
This is however a rare complication in a rare condition.11 It has Am J Surg 2013;206:957–63.

2 Wilhelmsen M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-202516

 Novel diagnostic procedure

Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit
http://group.bmj.com/group/rights-licensing/permissions.
BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.
Become a Fellow of BMJ Case Reports today and you can:
▸ Submit as many cases as you like
▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles
▸ Access all the published articles
▸ Re-use any of the published material for personal use and teaching without further permission

For information on Institutional Fellowships contact [email protected]

Visit casereports.bmj.com for more articles like this and to become a Fellow

Wilhelmsen M, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-202516 3