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Duodenal Diverticula

M Stephen Ledbetter, MD
Harry Z Mellins, MD

August 23, 1996

Presentation

A 79-year-old woman presented with abdominal pain, distention, and guaiac positive stool.

Imaging Technique

The patient initially underwent abdominal computed tomography (CT) which suggested a mass in the right lower quadrant near the terminal ileum. Subsequently the patient had an upper gastrointestinal (UGI) series with small bowel follow-through.

Imaging Findings

Upper gastrointestinal series images

The esophagus and stomach are normal although incidental note is made of the "bayonette" configuration of the stomach. An approximately 2-cm x 4-cm lobulated lateral out-pouching of the bowel lumen (arrow), filled with contrast, is visible near the junction of the first and second portions of the duodenum. No other abnormality is demonstrated.

Differential Diagnosis

Two possible diagnoses are giant post-bulbar duodenal ulcer and duodenal diverticula.

Both can have a similar appearance on static films and should be considered in the differential diagnosis. While performing fluoroscopy during the UGI examination, however, one should be able to differentiate these diagnoses by the rigidity or lack of pliability and the persistence of the barium in an ulcer, as a diverticulum will generally change its configuration during the course of the examination. The lack of inflammatory reaction (spasm, distortion of mucosal folds) also helps to differentiate this case from a post-bulbar ulcer.

Diagnosis

Lateral duodenal diverticulum

Discussion

Diverticula of the duodenum are incidental findings in 1%-5% of barium examinations of the upper gastrointestinal tract. They are acquired lesions consisting of a sac of mucosal and submucosal layers herniated through a muscular defect in the bowel wall. They are found most commonly along the medial border of the descending duodenum where penetrating vessels cause potential weak spots in the bowel wall. Thirty to forty percent of diverticula arise in the third and fourth portions of the duodenum. As is demonstrated in this companion case of a 51-year-old man being evaluated for esophagitis, diverticula on the medial wall are usually limited in size by surrounding pancreatic tissue (arrow) and tend not to be as large as those arising on the lateral side of the duodenum. Note also the more common gastric configuration in the companion case (versus the "bayonette" configuration of the primary case).

No cause was found for the patient's guaiac-positive stool, and no mass was found near the terminal ileum.

References

1. Eisenberg RL. Gastrointestinal Radiology. Philadelphia: Lippincott. 1990; 529-534.

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