Duodenum and Duodenal Diverticulum

By

Munivenkatesh.P

Anatomy • C shaped

• Initial part of small

intestine

• Continuous with

stomach

• Situated in

epigastric and

umbilical region

Blood supply

Lymph drainage Pyloric node

Hepatic node

Celiac node

Superior mesenteric node

Pathology • Various disorders :

oDuodenal ulcer

oDuodenal diverticulum

oDuodenal obstruction

oDuodenitis

Duodenal Diverticulum• It is a pouch

attached to the

duodenum, the first

part of the small

intestine just pass

the stomach.

• 2 type : intramural

and extramural

Extramural diverticulum • The common type which is

present in at least 6% of individuals, is one that sticks out from the duodenum, similar to the more common colonic diverticula.

• This is referred to as an "extramural" diverticulum.

• Extramural diverticula may vary in size from a few millimeters to a few centimeters.

• They usually are located in the area around the Papilla of Vater where the bile and pancreatic ducts enter the duodenum.

Intramural diverticulum • A second, rare type of diverticulum is

referred to as an "intramural" diverticulum. It

does not protrude from the duodenum.

• Rather, it protrudes into the duodenal lumen

(the hollow inside of the duodenum through

which digesting food flows).

• Both types of diverticula, extramural and

intramural, communicate with the lumen of

the duodenum so that contents of the

duodenum can enter the diverticulum.

Symptoms • 80 to 90% of patients are asymptomatic

• One of the main symptoms include upper

abdominal pain, right upper quadrant tenderness

• Often accompanied by a sense of fullness or

discomfort, and may have nausea, vomiting, or

vomiting

• Symptoms tend to appear in the diet or exacerbate,

relieved by vomiting.

• Diverticulum oppression of the common bile duct in

addition to intermittent abdominal pain, and can be

intermittent jaundice.

Symptoms

Causes • The cause of extramural diverticula is not

definitely known; however, they are

believed to be acquired (not present from

birth) due to a herniation (protrusion) of the

duodenum through a defect in the muscle of

the wall of the duodenum, perhaps in an

area where arteries pass through the

intestinal muscle to nourish the lining of the

intestine.

• Due to the different types of diverticula, its

causes are also different.

Congenital diverticulum • Congenital diverticulum:

a rare congenital

developmental

abnormalities at birth that

exist.

• Intestinal mucosa

submucosa and muscular

the diverticular wall

structure including

identical with the normal

intestinal wall, also known

as a true diverticulum.

Primary and secondary diverticulum

• Primary diverticulum: congenital anatomical

defects due to part of the bowel wall, out

due to the the intestines increased pressure

leaving the premises intestinal mucosa and

submucosa tissue prolapse formation of

diverticula. Such diverticular wall muscularis

tissue is absent or weak.

• Secondary diverticulum: duodenal ulcer

scar contraction or the chronic cholecystitis

adhesions caused by traction, it occurred in

the duodenum, the first one, also known as

false diverticula.

Complications • If the diverticulum is very close to the Ampulla of Vater,

patients more frequently develop gallstones, particularly in the

bile duct, and may develop all of the complications of

gallstones:

o biliary colic (the typical pain of obstruction of the bile

ducts),

o cholecystitis (inflammation of the gallbladder), and

o cholangitis (inflammation of the bile ducts due to the

spread of bacteria into the ducts from the duodenum).

• Pancreatitis also may occur. These complications are believed

to be due to interference by the diverticula with the normal

function of the bile and pancreatic ducts.

Diagnosis • Barium X rays

• Endoscopy

• Ultrasonography

• Computerized tomographic (CT) scans

• Magnetic resonance imaging (MRI) studies

Barium X ray

CT scan and endoscopy

MRI scan

Treatment • If treatment is necessary, extramural diverticula can

be surgically removed from the outside of the

duodenum.

• The diverticula also may be inverted into the lumen

of the duodenum and removed through an incision

in the wall of the duodenum.

• (Sometimes, the diverticulum is inverted but left

attached to the wall of the duodenum and

protruding into the duodenum.)

• In case of multiple diverticula, billroth II

gastrectomy is performed

Removal of diverticulum

Billroth 2 gastrectomy