Clinical Endoscopy

Impact of Periampullary Diverticulum on ERCP Performance: A Matched Case-Control Study: Juan E. Corral, Omar Y. Mousa, Paul T. Kröner, Victoria Gomez, Frank J. Lukens; Clin Endosc 2019;52(1):65-71. Published online August 21, 2018; DOI: https://doi.org/10.5946/ce.2018.070

Background
/Aims: Periampullary diverticulum (PAD) is frequently encountered during endoscopic retrograde cholangiopancreatography (ERCP) and has been associated with stone formation in the bile duct. The effects of PAD on the ERCP procedure have been often debated. We aimed to compare the therapeutic success of ERCP between patients with PAD and matched controls.
Methods
We reviewed all ERCPs with findings of PAD in a national database (n=1,089) and compared them with age- and gendermatched controls in a 1:3 fashion (n=3,267). Demographics, endoscopic findings, visualization of main structures, and therapeutic success rates were compared between groups. Secondary analysis compared PAD cases and controls who had gallstone disease.
Results
The average cohort age was 68.4±14.3 years and 55.1% were male. ERCP success was similar in both groups, and no significant inter-group differences were found in the multivariate analysis. The presence of PAD did not affect the rates of sphincterotomy or visualization of main biliary structures. Secondary analysis showed similar success rates for gallstone removal between patients with PAD and controls.
Conclusions
PAD may not be considered a hinderance to ERCP success. Further research is needed to determine the best approach to cannulate the ampulla and provide endoscopic therapy for different subtypes of PAD.

Citations

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Hemoclipped Dieulafoy's Lesion in Giant Diverticulum in the 3rd Portion of Duodenum: Mo Se Kim, M.D., Sung Yeun Yang, M.D., Jae Hwan Kim, M.D., Su Kyoung Kwon, M.D., Tae Hee Kim, M.D., Sang Hoon Seol, M.D., Eun Ji Noh, M.D., Doo Gun Chae, M.D.* and Jung Hae Koh, M.D.; Korean J Gastrointest Endosc 2007;35(6):441-444. Published online December 30, 2007

Abstract PDF: A duodenal diverticulum is common in the second portion of the duodenum and can occur at any age. An obstruction, bleeding, perforation, diverticulitis are not an uncommon complicationa of duodenal diverticulum. As a rare complication, bleeding in the duodenal diverticulum may be massive, and duodenal diverticulum is resected primarily as a result of the difficulty in determining the site of bleeding. However, there has been a recent increase in endoscopic diagnosis and the treatment of diverticular bleeding. Band ligation increases the risk of duodenal diverticular perforation because of the thin diverticular wall. An endoscopic hemoclip is a preferable method for endoscopic sclerotherapy. We report a 48- year-old man with a giant duodenal diverticulum that was treated with a hemoclip. The duodenal diverticular perforation was treated effectively with supportive care. (Korean J Gastrointest Endosc 2007;35:441-444)

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A Case of a Bleeding Dieulafoy's Lesion in a Duodenal Diverticulum Treated by Endoscopic Hemoclipping: Nang Hee Kim, M.D., Kyu-Jong Kim, M.D., Seo Ryong Han, M.D., Ji Eun Park, M.D., Ji Hyeon Nam, M.D., Sung Hoon Kim, M.D., Eun Kyung Shin, M.D., Do Hyun Kim, M.D., Jun Young Song, M.D., Sung Eun Kim, M.D., Won Moon, M.D., Moo In Park, M.D. and Seun Ja Park,; Korean J Gastrointest Endosc 2007;35(4):258-261. Published online October 30, 2007

Abstract PDF: A duodenal diverticulum is common and usually originates in the second portion of the duodenum. The majority of diverticula are asymptomatic; however, they may sometimes present with symptoms such as obstruction, hemorrhage, perforation, jaundice and pancreatitis. Active bleeding from a duodenal diverticulum is rare, and moreover, Dieulafoy's lesion as a cause is quite rare with very few cases reported so far. The use of endoscopic methods instead of surgery in achieving hemostasis has been on the increase with the widespread use and improvement in endoscope instrumentation and accessories. Of these methods, the use of endoscopic hemoclipping for Dieulafoy's lesion is considered more effective and safe than the use of other methods, such as injection and thermal methods. We report here a case of a bleeding Dieulafoy's lesion in a duodenal diverticulum treated by endoscopic hemoclipping. (Korean J Gastrointest Endosc 2007;35:258-261)

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Duodenal Perforation due to Hemoclipping for the Dieulafoy's Lesion in a Duodenal Diverticulum: Hyeuk Park, M.D., Kwang Hyun Ko, M.D., Jeong Ki Kim, M.D., Hong Youp Choi, M.D., Sung Pyo Hong, M.D., Sung Kyu Hwang, M.D., Pil Won Park, M.D. and Kyu Sung Rim, M.D.; Korean J Gastrointest Endosc 2005;30(3):160-163. Published online March 31, 2005

Abstract PDF: Duodenal diverticulum usually originates in the second portion of the duodenum and occasionally causes duodenal obstruction, hemorrhage, perforation and diverticulitis. A bleeding from Dieulafoy's lesion in a duodenal diverticulum is rare. It is not easily dignosed and treated by forward viewing endoscopy. Recently, a case was reported describing the hemorrhage from the Dieulafoy's lesion in a duodenal diverticulum which was treated by hemoclip with forward viewing endoscopy. Hemoclip application is considered to be the most appropriate endoscopic treatment, because sclerotherapy, electrocoagulation or band ligation for Dieulafoy's lesion in the duodenal diverticulum may increase risk of duodenal perforation. We report a case of duodenal perforation due to hemoclip application for the treatment of Dieulafoy's lesion in a duodenal diverticulum. (Korean J Gastrointest Endosc 2005;30:160⁣163)

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Dieulafoy 양 병변에 의한 십이지장게실 출혈 1 예 ( A Case of a Bleeding Duodenal Diverticulum by a Dieulafoy - like Lesion ): Korean J Gastrointest Endosc 2001;23(1):41-44. Published online November 30, 2000

Abstract PDF: Duodenal diverticula are first reported by Chomel in 1710. Duodenal diverticula are relatively common in adults with a prevalence of 23% in SRCP. The most duodenal diverticulum is asymptomatic. Complications such as obstruction, cholangitis, blliary stones, ulceration, perforation and hemorrhage can occur in approximately 10%. However, relatively few cases of bleeding from a duodenal diverticulum have been reported. The cause of bleeding from a duodenal diverticulum is uncertain and various suspected etiologies were suggested, such as ectopic gastric mucosa, stasis-induced ulceration, erosion into major vessels, aortoenteric fistuias, intradiverticujar polyp, aspirin-induced erosion. We report a case of a bleeding duodenal diverticulum by a Dieulafoy-like lesion and suggest this 1esion as one of posslble causes of blee4ng in duodenal diverticulum. (Korean J Gastroiatest Endosc 2001;23:41-44)

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대량의 상부 위장관 출혈을 유발한 십이지장게실 1 예 ( A Case of Massive Upper Gastrointestinal Bleeding from a Duodenal Diverticulum ): Korean J Gastrointest Endosc 2000;21(3):746-749. Published online November 30, 1999

Abstract PDF: Duodenal diverticulum is well-known pathologic entity. The incidence of duodenal diverticulum varies from 5% to 23% in the general population. Most of diverticula are asymptomatic and have been incidentally observed in upper gastrointestinal series or upper gastrointestinal endoscopy. It usually occurs in the second portion and the medial side of duodenum. The complications of duodenal diverticulum are rare but often result in significant morbidity. They include obstruction, cholelithiasis, ascending cholangitis, ulcers, hemorrhage and perforation. Major gastrointestinal hemorrhage resulting from an inflamed or ulcerated duodenal diverticulum is an uncommon event and it can be treated endoscopically. We report a case of massive upper gastrointestinal bleeding from a duodenal diverticulum which was treated endoscopically.

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내시경적 지혈술로 치료된 십이지장게실 출혈 1예 ( A Case of Endoscopic Therapy of a Bleeding Duodenal Diverticulum ): Korean J Gastrointest Endosc 2000;20(3):203-206. Published online November 30, 1999

Abstract PDF: Duodenal divertula are relatively frequent findings in the adult gastrointestinal tract. The majority of them are asymptomatic, but vague gastrointestinal complaints have often been attributed to these lesions. These diverticula occasionally result in the obstruction of the biliary and pancreatic ducts, which leads to jaundice and pancreatitis. Other complications such as hemorrhage, perforation, sepsis, and death can occur. With the advent of therapeutic endoscopy, the diagnosis and primary treatment of duodenal diverticula associated with bleeding has changed dramatically since its first reported occurrence. Effectiveness of therapeutic endoscopy is very high in patients with diverticular bleeding in the medial aspect of sencond portion of the duodenum because of its high operative mortality. A cases of a patient suffering from gastrointestinal bleeding in the duodenal diverticulum who was diagnosed and managed by endoscopy alone is herein reported with review of relevant literature.

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