Perforated duodenal diverticulitis causing pseudoaneurysm of the pancreaticoduodenal artery
Author(s):
Scarlett Hao, University of Maryland School of Medicine, Baltimore, MD; Dale Johnson, Easton Memorial Hospital, Easton MD; Adam Guyer, MedStar Georgetown University Hospital, Washington DC; Hugo Bonatti, University of Maryland Shore Health
Background: Duodenal diverticula tend to be asymptomatic incidental findings, however, a limited number of patients with duodenal diverticulitis have been published and in rare cases surgical intervention was required.
Hypothesis: Duodenal diverticulitis usually responds to antibiotics but secondary complications may require interventions.
Methods: A 66-year-old Caucasian man with a past medical history of gastroesophageal reflux disease presented to our emergency room with a two days history of continuous right-sided abdominal pain, chills, tachycardia, nausea and emesis. His white blood count, lactic acid and bilirubin were elevated. Computed tomography scan revealed an inflammatory process involving the gallbladder, the second portion of the duodenum and ascending colon and a soft tissue mass in the mesentery.
Results: A 2cm diverticulum of the second portion of the duodenum was also visualized. He was admitted and antibiotics were started. He improved clinical over the next 36 hours when a repeat triple contrast CT-scan showed that the soft tissue mass was a hematoma and the bleeding source was identified as a 2cm pseudoaneurysm of an inferior pancreaticoduodenal collateral artery. The inflammatory changes had significantly improved and the patient had no tachycardia or hypotension. Non operative management was continued and the patient was essentially symptom free with normalization of WBC and CRP. Repeat scan 3 days later demonstrated interval increase in size of the pseudoaneurysm and he was scheduled for angiography. The celiac access was cannulated and access through the gastroduodenal artery was attempted, hwoever, inflow to the pseudoaneurysm was predominantly from inferior pancreaticoduodenal artery. On cannulation of the superior mesenteric artery, a replaced rightbehpatic artery was found. Multiple attempts to advance the guidewire to the branch feeding the pseudoaneurysm failed and therefore the patient was transferred to a higher level of care facility. On first attempt there again the branch could not be accessed, however, on a second attempt successful embolization of the pseudoaneurysm was done. The patient recovered without any complication form this rare condition.
Conclusions: To the best of our knowledge this is the first case of duodenal diverticulitis causing a pseudoaneurysm of the pancreaticoduodenal artery. Ultimately antibiotic therapy together with percutaneous embolization of the lesion resulted in a good outcome.