Management of the perforated duodenal diverticulum

[摘要] A woman in her 70s presented to the emergencydepartment after having sudden-onset right lowerquadrant pain 2 hours earlier. She noted the pain tobe 10/10 in severity, non-radiating, and crampingin character. Vitals and labs including a basicmetabolic panel and complete blood count werewithin normal limits; however a lactic acid levelwas elevated at 3.4 (normal <2). A CT scan wasperformed with findings of free air and fluid in thelesser sac, a significantly distended stomach, andretroperitoneal debris (figure 1). General surgerywas consulted at this time; the patient was foundto be distended, tympanitic, and peritonitic onexamination. Intravenous fluid resuscitation andbroad-spectrum antibiotics were initiated. She wastaken directly to the operating room for operativeintervention, given her examination and imagingfindings. Laparoscopy was performed with minimalfindings, though a large collection of fluid was seenin the retroperitoneum surrounding the duodenum.Suspicion of a posterior duodenal perforation washigh, and therefore the prior laparoscopy wasconverted to an exploratory laparotomy. The rightcolon was mobilized and inspected, and no defectwas identified. A Kocher maneuver was performedand copious bilious fluid was encountered. A 3cm defect was evident on the lateral aspect of thesecond portion of the duodenum (figure 2). Onfurther mobilization, a very redundant duodenaldiverticulum (DD) was revealed.

[学科分类] 社会科学、人文和艺术（综合）

[关键词] management;duodenal;abdominal pain