gi bleeding

esophageal varices

gastrointestinal bleeding

gastric varices

british journal surgery

diverticular disease

The American Journal of Gastroenterology

Purpose: Hemorrhage from a duodenal diverticulum is a rare cause of upper gastrointestinal bleeding, requiring a high level of clinical suspicion and adequate endoscopic view for diagnosis. Although historically treated with surgery, bleeding duodenal diverticulae have been effectively managed endoscopically in select patients; nonetheless, complications do occur. A 59-year-old male presented with clinically significant melena. His adominal exam was benign. Upper endoscopy revealed an actively bleeding diverticulum in the third portion of the duodenum (Figure 1A). Attempts at hemostasis were unsuccessful, and embolization could not be achieved due to aberrant vasculature. A second EGD was performed utilizing an upper endoscope with a larger, 6mm port working channel, and the area was cleared via suction and lavage. A pediatric colonoscope was passed through the mouth of the diverticulum, revealing a bleeding vessel within its interior. Three endoclips were deployed to achieve hemostasis, although this maneuver caused the scope to repeatedly occlude the mouth of the diverticulum. Post-procedure, the patient developed a perforation at the site of the diverticulum and was managed conservatively with surgical consultation (Figure 1B). CT imaging 1 week later revealed a large mid-abdominal abscess (Figure 1C). A percutaneous drain was placed, and the perforation resolved 4 months later. Duodenal diverticulae have a bleeding incidence of 7%. In recent years, endoscopy has become a recognized alternative to surgery for achieving hemostasis, although one should be aware of potential pitfalls. The wall of a diverticulum is by nature thin and fragile. We propose that the therapeutic upper endoscope used here may have occluded the mouth of the diverticulum, leading to increased internal pressure and barotrauma. The gathering of tissue with clips may have been made more difficult by this internal pressure, making tissue approximation more challenging and possibly inciting further trauma. Therefore, we encourage caution and t...

Endoscopic Treatment of a Bleeding Duodenal Diverticulum: A Demonstration of the Efficacy of Endoscopic Treatment and a Note of Caution