Multiple Duodenal Diverticula: A Rare Cause of Massive Upper Gastrointestinal Bleeding and Hemodynamic Instability

Abstract

Duodenal diverticula are usually asymptomatic and identified incidentally on imaging studies. In this report, we present a case of massive gastrointestinal (GI) bleeding from multiple duodenal diverticula. A 43-year-old man was evaluated for lightheadedness, hematemesis, and melena. Patient was hypotensive and resuscitated with intravenous fluids and blood products. Upper endoscopy revealed multiple diverticula in the bulb, sweep and second portion of the duodenum with active bleeding from specific diverticulum. Epinephrine was injected around the bleeding diverticulum and multiple endoclips were applied. Patient continued to have persistent melena and required multiple units of packed red blood cells. Repeat endoscopy showed active bleeding from another duodenal diverticulum controlled with endoclips. Patient still had persistent bleeding, thus angiography was performed. Celiac artery stenosis was visualized with poststenotic dilatation. Embolization of the gastroduodenal artery could not be performed due to its retrograde flow supplying the hepatic artery proper. Patient underwent exploratory laparotomy with no further bleeding visualized through a gastrostomy. Duodenum diverticulum is a rare cause of massive upper GI hemorrhage. Endoscopy might not be successful in identifying the bleeding site. There is a high incidence of re-bleeding with endoscopic interventions. Surgery remains the definitive treatment in cases with life-threatening hemorrhage.




J Med Cases. 2015;6(10):444-446
doi: http://dx.doi.org/10.14740/jmc2229w