POLSKI
PRZEGLĄD CHIRURGICZNY
2011, 83, 1, 51–54
10.2478/v10035-011-0008-6
Duodenal diverticulum mimicking duodenal
stromal tumor
Stanisław Milnerowicz¹, Marta Strutyńska-Karpińska¹,
Ewa Nienartowicz²
Department of Gastrointestinal and General Surgery, Medical University in Wrocław1
Kierownik: prof. dr hab. K. Grabowski
Department of Radiology, Medical University in Wrocław2
Kierownik: dr hab. U. Zaleska-Dorobisz, prof. nadzw.
A patient with duodenal diverticulitis who was initially misdiagnosed with stromal tumor of the duodenum is presented. This case is of interest because it illustrates difficulties in the interpretation of
auxiliary investigations and the choice of the best treatment option. US and CT images revealed two
large ovoid masses of fluid density in the duodenal wall which may have suggested stromal tumor of
the duodenum as well as periampullary cystic neoplasm, the more so because intramural tumor of the
duodenum was seen in duodenoscopy. A similar picture may also be seen in duodenal diverticula, especially in diverticula which are not filled with gas or a combination of fluid and gas. This case demonstrates one such entity.
Key words: duodenal diverticulum, GIST
Duodenal diverticula are very common. In
clinical analysis their presence is described in
about 25% of people (1). Most duodenal diverticula are asymptomatic and autopsy studies
have revealed their prevalence to be as high
as 22% and in an upper gastrointestinal series,
duodenal diverticula were found in 6% and in
9-23% of ERCP procedures (2). Approximately
5% of patients with duodenal diverticula develop clinical symptoms most commonly because of complications such as hemorrhage,
acute diverticulitis, or perforation, but the
symptoms are usually nonspecific and can
mimic other intra-abdominal processes (1).
Duodenal diverticula are most frequently located in the second or third portion of the
duodenum and because of this it is difficult to
distinguish between pancreatic and duodenal
pathologies in preoperative diagnostic images
(2-5).
Case report
Patient L. T., a 52-year-old man (med. record no. 704/09, 730/09) was admitted to the
hospital with an initial diagnosis of stromal
duodenal tumor. The patient presented several episodes of nausea and dyspepsia, occasional epigastric pain, and other nonspecific
upper abdominal symptoms such as eructation
and vomiting associated with a 12 kg weight
loss. He had no history of alcohol or tobacco
abuse and his family history was noncontributory. So far he had no history of health problems.
Clinical examination revealed no cardiac,
respiratory, or urinary disorders. On physical
examination he was tender in the right epigastrium, but without peritoneal signs. The
only laboratory abnormality was PLT of
506×10³/µl.
An intramural tumor below the duodenal
bulb with an intact mucosa over the mass was
revealed by fiberoptic gastroduodenoscopy.
Moreover, narrowing of the duodenal lumen
and numerous mucosal erosions were seen
below the tumor. The remaining part of the
duodenum was normal. Barium gastrointestinal examination showed a widened duodenal
bulb with barium retention and with narrowUnauthenticated
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S. Milnerowicz et al.
ing below as long as ca. 3 cm (fig. 1). Upperabdominal ultrasound revealed:. in the duodenal wall directly adjacent to the right liver lobe,
cystic masses measuring 4.3 x 2 cm. Contrastenhanced computerized tomography showed
two large ovoid masses of fluid density closely
associated with the second portion of the duodenum (possibly duodenal stromal tumor) (fig.
2). The diagnosis of stromal tumor of the duodenum was made after discussion with radiologist and on the basis of radiological and
endoscopic examinations mentioned above.
The patient was operated. The duodenum
was mobilized by the Kocher maneuver.
Periduodenal and peripancreatic lymph
nodes were taken for intraoperative histopathology. Pathology examination revealed
reactive lymph nodes. The duodenum was
turned medially and an inflamed diverticulum came to view. Then a longitudinal duodenotomy through the anterior duodenal
wall between the second and third portion of
the duodenum was made. An elongated sac
of inflamed duodenal diverticulum surrounding three quarters of the duodenal wall as
long as 3-4 cm, narrowing the duodenal lumen, could be identified. To avoid injury to
the papilla of Vatera, a catheter was inserted into its opening and partial resection
of the duodenum by means of a Roux-en-Y
was made. The resection encompassed the
pylorus, proximal portion of the duodenum
Fig. 1. Barium gastrointestinal examination showing
widened duodenal bulb with barium retention and
narrowing below
along with the diverticulum and narrowing
below. The duodenal stump was closed with
two layers. After the operation, small leakage of the duodenal stump was observed. The
complication was successfully treated conservatively. Histopathological examination
of the specimen after the operation revealed
a duodenal diverticulum with chronic inflammatory process. Furthermore, active deep
inflammation and multiple erosions in the
duodenal wall were revealed below the diverticulum.
Discussion
In the first reports by Chomall in 1710 and
Morgagni in 1762, duodenal diverticula were
considered an anatomical curiosity. Almost
200 years later, Case was the first who demonstrated them in radiological examination
(4). Upper gastrointestinal and US studies,
CT, and MRI showed that duodenal diverticula are present in about 25% of people (1).
From an anatomic and histopatological point
of view there are two basic types of duodenal
diverticula: 1) acquired or false and 2) congenital or true, i.e. containing all layers of the
duodenal wall. Moreover, congenital diverticula occur in two forms: intraluminal and extraluminal (6). Acquired diverticula are more
common, of which there are two subtypes: the
so-called primary acquired and the secondary
Fig. 2. CT scan of abdomen showing two large ovoid
masses (arrows) closely associated with the second
portion of the duodenum mimicking a stromal tumor
or periampullary neoplasm
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Duodenal diverticulum mimicking duodenal stromal tumor
acquired. The first is caused by protrusion of
the duodenal mucosa through the weak points
of the duodenal wall (near the common bile
and pancreatic duct or blood vessels). The
secondary occurs as a result of outpouching of
the duodenal wall near a healing duodenal
ulcer (3, 6). The most common site of duodenal
diverticulum formation is the second (62%) and
the third (30%) portion of the duodenum. Only
about 8% of diverticula develop in the fourth
portion (3, 6).
Although duodenal diverticula are quite
common, the great majority are asymptomatic (1, 5). Symptoms, if they occur, can be
nonspecific and depend primarily on the size
or complications in the course of the disease
(2). The clinical presentation usually includes
abdominal pain in the epigastrium or right
upper abdomen, nausea, vomiting, and loss of
weight. In complicated cases, perforation,
hemorrhage, and common bile or pancreatic
duct obstruction can be seen (7). Attachment
of an intraluminal diverticulum to the duodenum usually involves less than one-half of the
wall circumference, although in a few cases it
has been reported to be attached to the entire
circumference (8). It seems probable that intermittent filling and emptying of the diverticulum with food may be responsible for the
above symptoms (9).
Duodenal diverticulum is easily diagnosed
in upper-gastrointestinal barium studies when
the diverticular orifice is wide enough and the
diverticulum is completely filled with contrast
medium. As pointed out by Macari et al., CT
or MR imaging can be helpful in cases in
which the diverticulum is filled with air or a
combination of fluid and air (2). If the diagnosis is doubtful, modern radiological techniques or endoscopic procedures should be
considered, i.e. ERCP, arteriography, and
scanning with Technetium 99, especially in
case of bleeding (3). Miller et al. stated that
on the base of radiological imaging that only
11-13% of duodenal diverticulitis is correctly
diagnosed before surgery (10). A duodenal
diverticulum that is entirely filled with fluid
may quite frequently mimic neoplastic tumor
arising from the pancreas. Cystic masses seen
on CT or MR imaging adjacent to the pancreatic head and the second portion of the duodenum should lead to the consideration of a
number of conditions in the differential diagnosis, such as cystic pancreatic neoplasm or
53
pseudocyst, metastatic lymph nodes, and
pancreatic abscess. Such observations were
reported in numerous studies (6, 10, 11, 12).
In some cases it is extremely difficult or even
impossible to distinguish duodenal diverticula on CT or MR if their content is purely
fluid (2).
The presented case demonstrates such an
entity: large ovoid masses of fluid density in
the duodenal wall simulated stromal tumor of
the duodenum. In the presented case, duodenal
ulcer combined with duodenitis and visible
submucosal intramural tumor narrowing the
duodenal lumen were seen in gastroduodenoscopy. The findings were confirmed by US and
CT images suggesting stromal tumor. That
was probably the main cause of misdiagnosis.
Histopathological examination of the resected
specimen showed an intraluminal diverticulum with chronic massive inflammation and a
duodenal ulcer below. Inflammation in the
diverticulum combined with the healing duodenal ulcer were perhaps the main cause of
the duodenal narrowing, as seen in the gastrointestinal barium study. Also, the intensity of
the inflammation was the main reason why
the diverticular neck was invisible in both
endoscopy and US images.
Asymptomatic diverticula do not require
surgical management (4). Only 1-5% of diagnosed duodenal diverticula require surgery
when complications have occurred, as in the
present case. Extramural diverticula can be
surgically removed from outside the duodenum
(1).
Intramural diverticula are surgically removed through an incision in the wall of the
duodenum, although there are reports of
treatment with the use of endoscopic procedures. The best option of treatment in patients with duodenal diverticula seems to be
surgical resection. The procedure consists of
removal of the diverticulum by laparotomy
and duodenotomy. Macari et al. indicated that
surgical resection is the most appropriate
treatment procedure in large diverticula and
in symptomatic patients (2). However, the
surgical approach in this area is difficult to
perform and, as noted by Mahajan et al., is
associated both with a high rate of postoperative complications and mortality (4). In the
literature a mortality rate of 30% after diverticulectomy in the postoperative period has
been reported. On the other hand, a delay in
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54
S. Milnerowicz et al.
diagnosis can lead to diverticulum perforation, which carries a mortality rate of 90%
(5).
Surgical resection with a safe oncological
margin is the best option of treatment for stromal tumor of the duodenum (13). Wedge resection is usually reserved for small tumors, although under favorable conditions, wedge resection or segmental resection of the third portion
of the duodenum is also possible in very large
tumors (20x30 cm) arising from the anterior
wall of the duodenum, as described by Milnerowicz and Sakamoto (14, 15). However, if there
is a preoperative suspicion of malignancy or for
some conditions which prove to be benign, more
extensive surgery is not unusual. The rate of
Whipple procedures for benign lesion of the
duodenum ranges to up to 9.2% (16).
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Received: 29.11.2010 r.
Adress correspondence: 50-366 Wrocław, ul. M. Skłodowskiej-Curie 66
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