Clinical Impacts of Juxtapapillary Duodenal Diverticulum Detected on Computed Tomography.

BACKGROUND: Diverticula are commonly observed in the duodenum. Duodenal Diverticulum (DD) usually does not give symptoms throughout life and is diagnosed by coincidence. However, it may present with different symptoms in patients. OBJECTIVE: This study aims to evaluate the prevalence of DD and Juxtapapillary Duodenal Diverticulum (JDD) and its association with other possible pathologies and to determine its clinical impact by using Computed Tomography (CT). METHODS: This retrospective observational study, which was taken consecutively between the years of 2013-2020, was evaluated in the Radiology Department. The total number of cases was 4850 (male-2440; female-2410). CT images were evaluated by two experienced radiologists at the workstation. DD and JDD prevalence and clinical findings in the hospital registry system were examined. RESULTS: The age of the patients included in the study ranged from 17 to 92 years (mean age 46.94±16.42). In patients with DD (female-130; male-101), mean age was 62.24 ± 12.69 (21-92). The prevalence of DD was 4.76% (n=231). The prevalence of JDD was 4.02% (n=195) and increased with age (p<0.01). The average diameter of the JDD was measured as 23.29±8.22 (9.5-55.3) mm. A significant positive correlation was found between age and DD diameter (p=0.039). DDs were found most commonly 84.42% (n=195) in the second segment of the duodenum as JDD. In patients with JDD, the mean diameter of choledochus and wirsung canal were 6.7 ± 2.4 (3-15.3) mm and 0.31 ± 0.1 (0.1-6.5) mm respectively. The choledochal diameter was correlated with the JDD size (p = 0.004). Cholelithiasis (n=56), choledocholithiasis (n=20), cholecystitis (n=52), diverticulitis (n=15), duodenitis (n=37), pancreatitis (n=5) and hiatal hernia (n=60) with JDD were observed. Periampullary carcinoma was detected in one patient. CONCLUSION: Our study shows that cholelithiasis, choledocholithiasis, cholecystitis, diverticulitis, duodenitis, pancreatitis may be associated with JDD. Therefore, in contrast-enhanced abdominal CT scans taken for various reasons, investigation of the presence and characteristics of JDD and detection of pathologies that may be associated with JDD are important for patients to benefit from early diagnosis and treatment opportunities and to take precautions against possible complications.

Association of juxtapapillary duodenal diverticulum with pancreaticobiliary diseases and with diagnosis and treatment of endoscopy / 中华消化内镜杂志

Objective To study the relationship between juxtapapillary duodenal diverticulum (JPDD) and pancreaticobiliary diseases, and the effect of JPDD on the diagnosis and treatment of ERCP. Methods A retrospective analysis was performed on data of 1230 patients who had received ERCP in general surgery departments of Shengjing Hospital of China Medical University from January 2012 to January 2017. The patients were divided into JPDD group ( n=360) and non-JPDD group ( n=870) according to whether JPDD was found. Patients with JPDD were divided into intradiverticular papilla group ( n=41) and non-intradiverticular papilla group ( n=319) according to whether the papilla located in diverticulum. The incidence of pancreaticobiliary diseases, success rate of cannulation, success rate of stones removal, and incidence of postoperative complications among each group were compared by using chi-square test or Fisher's exact probability. P < 0. 05 was statistically significant. Results The incidence of choledocholithiasis, primary choledocholithiasis and recurrent choledocholithiasis were 87. 78％ (316/360), 31. 11％ (112/360), and 6. 67％ (24/360), respectively, in the JPDD group, and 75. 52％ (657/870),19. 08％ (166/870), and 4. 02％ (35/870), respectively, in the non-JPDD group. There were significant differences between the two groups (χ2=23. 158, P<0. 001; χ2=21. 068, P<0. 001; χ2=3. 897, P=0. 048) . No significant differences were observed in the success rate of cannulation and complete stones removal during the first ERCP session, as well as the incidence of postoperative hemorrhage, pancreatitis and hyperamylasemia between the two groups ( all P>0. 05) . The incidence of recurrent choledocholithiasis in the intradiverticular papilla group and the non-intradiverticular papilla group were 14. 63％ ( 6/41) and 5. 64％ (18/319), respectively, with significant difference (χ2 =4. 721, P=0. 030). There were no significant differences between the two groups in the incidence of choledocholithiasis and primary choledocholithiasis, the success rate of cannulation and complete stones removal during the first ERCP session, as well as the incidence of postoperative hemorrhage, pancreatitis and hyperamylasemia ( all P>0. 05) . Conclusion JPDD is associated with the occurrence of primary choledocholithiasis. JPDD patients, especially the patients with intradiverticular papilla, are more likely to have recurrent choledocholithiasis after ERCP treatment.

Edwardsiella tarda-associated cholangitis associated with Lemmel syndrome.

Edwardsiella tarda is an unusual human pathogen. Gastroenteritis is the most frequently reported manifestation of E.tarda infection and extraintestinal infection including cholangitis has rarely been reported. The overall mortality rate for E.tarda bacteremia is, however, reported to be up to 50% (Janda and Abbott, 1993). We describe a 80-year-old diabetic woman with cholangitis and E.tarda bacteremia with a biliary obstruction associated with a large juxtapapillary duodenal diverticulum (Lemmel syndrome) in the setting of past partial hepatectomy and cholecystectomy. She was successfully treated with endoscopic biliary drainage and antibacterials.

Hemostatic clips to facilitate intubation during ERCP with ampulla around duodenal diverticulum / 中国内镜杂志

Objective To investigate the effectiveness of hemostatic-clip-assisted method during ERCP with ampulla around duodenal diverticulum. Methods 25 patients with ampulla around duodenal diverticulum encountered cannulation difficulty, 11 cases underwent with clip-assisted method, 14 cases with ordinary ways. Number of successful cases, cannulation time, post-operation complication were analyzed. Results All the 11 cases succeeded in clip group. 12 patients succeeded in none-clip group. Cannulation time between the two groups were discrepant. There was no difference in number of successful cases and post-operation complication rate. Conclusion Successful application of hemostatic clip help to expose and facilitate cannulation of an ampulla around a duodenal diverticulum.

Juxtapapillary Duodenal Diverticulum Impacted with Enterolith.

A 64-year-old man underwent abdominal computed tomography (CT) as periodic follow-up following a distal gastrectomy with lymphadenectomy for gastric cancer and mucosal-associated lymphoid tissue (MALT) lymphoma conducted 31 months earlier. Contrast-enhanced CT demonstrated a well-circumscribed mass lesion with heterogeneous density measuring 2.2 cm in diameter located between the second segment of the duodenum and uncinate process of the pancreas. Esophagogastroduodenoscopy revealed no remarkable findings in the remnant stomach; however, the scope could not reach the duodenum due to altered anatomy by Roux-en-Y reconstruction after the distal gastrectomy. The patient underwent surgical resection of the mass lesion under the clinical diagnosis of MALT lymphoma relapse. An orange calculus was apparent in the thinly extended duodenal wall on stretching, and the hall was closed by meticulous primary suture after the duodenal resection. Macroscopically, the extracted calculus was solid and quite hard, measured 2.2 × 2.1 × 2.1 cm, and the cut surface revealed a layered structure in the outer areas with granulated contents in the center. Although duodenal diverticula are relatively common, an enterolith developing within a juxtapapillary duodenal diverticulum is rare, and to the best of our knowledge, this is the first such case due to altered anatomy after gastrectomy reported in the English literature.

Carcinoma of the ampulla of Vater diagnosed after surgical treatment for Lemmel's syndrome.

Lemmel's syndrome encompasses a range of conditions in which a juxtapapillary duodenal diverticulum exerts mechanical and functional effects on the common bile and pancreatic ducts, leading to jaundice and pancreatitis. In this report, we describe a very rare case of carcinoma of the ampulla of Vater that was detected during postoperative follow-up in a patient who had undergone choledochojejunostomy following a diagnosis of Lemmel's syndrome. We present our clinical and pathological experiences with the diagnosis and treatment of this case as well as a review of the present literature concerning Lemmel's syndrome.

Clinical analysis of 51 choledocholithiasis patients combined with juxtapapillary duodenal diverticular treated by endoscopic sphincterotomy / 中国医师进修杂志

Objective To investigate the relationship between juxtapapillary duodenal diverticular (JPDD) and choledocholithiasis,and the effects of JPDD on endoscopic sphinctemtomy(EST) in treatment of choledocholithiasis.Methods Fifty-one cases of choledocholithiasis combined with JPDD (choledocholithiasis combined with JPDD group) and 210 cases of choledocholithiasis without JPDD (choledocholithiasis without JPDD group) were treated by EST,and the clinical data of patients in the two groups were retrospectively analyzed.The relationship between JPDD and choledocholithiasis was studied.The JPDD' influence on the intubation success rate of endoscopic retrograde cholangiopancreatography (ERCP),the success rate of the stone removal by EST and complication were analyzed.Results The incidences of choledocholithiasis in patients of JPDD diameter ＜ 1 cm,1-3 cm and ＞ 3 cm were 39.3％(11/28),53.2％ (33/62) and 7/8 respectively.The larger the JPDD diameter,the higher the incidence of choledocholithiasis,and there was statistical difference (P ＜ 0.01).The incidence of choledocholithiasis in peripheral type JPDD was significantly higher than that in parallel type and circumvolution type [81.0％(17/21) vs.41.9％(26/62) and 8/15],and there were statistical differences (P ＜0.05).There was no statistical difference in the intubation success rate of ERCP between the two groups (P ＞ 0.05),but the success rate of the stone removal by EST in choledocholithiasis combined with JPDD group was significantly lower than that in choledocholithiasis without JPDD group [91.8％ (45/49) vs.99.5％ (208/209)].The incidence of EST incision bleeding was significantly higher than that in choledocholithiasis without JPDD group [11.1％ (5/45) vs.1.9％ (4/208)],and there was statistical difference (P ＜ 0.01) ; there were statistical differences in the incidences of others complication between the two groups (P ＞ 0.05).Logistic regression analysis showed that JPDD was independent risk factor for EST incision bleeding (P =0.043).Conclusions JPDD is relative with choledocholithiasis.JPDD makes EST a little more difficult and risky,while EST is still a safe and effective therapy for choledocholithiasis patients combined with JPDD.

An evaluation of surgical treatment for juxtapapillary duodenal diverticula combined with biliopancreatic diseases / 中国微创外科杂志

Objective To study the long-term effect of different surgical procedures for juxtapapillary duodenal diverticula accompanying biliopancreatic diseases. Methods The study included 86 cases of juxtapapillary duodenal diverticula accompanying biliopancreatic diseases treated with different operations from April 1982 to October 2001.The 5-year incidence of postoperative cholangitis was retrospectively analyzed using the life table method. Results There were 45 cases of treatment of biliopancreatic diseases without management of the diverticula,9 cases of Roux-en-Y choledochojejunostomy,11 cases of subtotal gastrectomy with gastrojejunostomy(Billroth Ⅱ),and 13 cases of sphincteroplasty,with their incidences of cholangitis in 5 years being 52.0%,40.0%,75.0%,and 66.7%,respectively. Other procedures were carried out in 8 cases.There was no statistically significant difference in incidences of cholangitis in 5 years among these procedures(?~2=1.49,P=0.8287). Conclusions Management of juxtapapillary duodenal diverticula is not required in patients without the stenosis of the papilla.If postoperative cholangitis cannot be explained with biliary diseases,surgical procedures should be performed depending on the patient's individual condition and the surgeon's experience.The incidences of cholangitis in 5 years among these procedures are not significantly different.