Iron Deficiency Anaemia Secondary to Bleeding Duodenal Diverticulum

Clinical History

A 64-year-old male presented with iron deficiency anaemia.

Imaging Findings

A full blood count and haematinics revealed an iron deficient anaemia, following symptoms of lethargy and breathlessness. Upper GI endoscopy and a barium enema were performed, both of which were found to be normal. A CT of the abdomen (GI protocol, 1 and 24 hour oral preparation) showed a fullness in the duodenal loop, adjacent to the pancreatic head (the 3-d reconstruction is shown). A duodenal diverticulum was suspected, and a barium meal arranged to confirm or exclude the diagnosis. The barium meal test results showed a well defined 2.5 cm sized diverticulum arising from the medial wall of the 2nd part of the duodenum (as shown). A repeat endoscopy showed severe inflammation in the region of the diverticulum, with the old blood being visible within the diverticular cavity. Iron therapy, combined with high dose proton pump inhibitors, led to the resolution of this patient's symptoms. Further endoscopy showed an effective response of the duodenitis to the proton pump inhibitors.

Discussion

A diverticulum is an out-pouching of an epithelial lined cavity, beyond its normal boundaries. The term ‘diverticulum’ has been referred to as a ‘house of ill-repute by the wayside’, but a more accurate derivation is from the Latin term ‘divere’, literally meaning to divert from, or leave a straight course or passage. Duodenal diverticua occur in up to 1%–5% of GI studies. They may be primary or secondary. Primary diverticula represent a mucosal prolapse through the muscularis propria, and most occur in the 2nd, 3rd and 4th parts of the duodenum in a decreasing order of frequency. The medial wall of the 2nd part, in the peri-ampullary region, is by far the most common site, representing 88% of primary cases. Secondary duodenal diverticula involve all layers of the bowel wall, and are considered a complication of duodenal or peri-duodenal inflammation. They are invariably located in the first part of the duodenum. Complications of duodenal diverticula include perforation, with subsequent peritonitis, bowel obstruction, biliary obstruction, true diverticulitis and, rarely, bleeding. Treatment of bleeding duodenal diverticula maybe conservative, with high dose proton pump inhibitors, endoscopic, or occasionally surgical, with ligation and removal of the diverticulum.

Differential Diagnosis List

Final Diagnosis

Duodenal diverticulum.

URL:	https://www.eurorad.org/case/3225
DOI:	10.1594/EURORAD/CASE.3225
ISSN:	1563-4086