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A5182 - Duodenal Diverticulum: A Rare Cause of Pancreatitis
Author Block: A. A. Abbasi1, P. Macauley1, S. S. Gupta2, C. Seneviratne2; 1Internal Medicine, Maimonides Medical Center, Brooklyn, NY, United States, 2Critical Care Medicine, Maimonides Medical Center, Brooklyn, NY, United States.
Introduction
Incidence of acute pancreatitis increases with age. Gall stones and alcoholism are the two most common causes of acute pancreatitis. Duodenal diverticulum is a rare cause of pancreatitis which usually presents in the elderly. To treat pancreatitis appropriately and to prevent a relapse, it is important to correctly identify the cause. We describe one such case of an elderly male with recurrent pancreatitis due to duodenal diverticula.
Case Report
An 80-year-old male with a past medical history of hypertension, hyperlipidemia and diabetes mellitus presented to the emergency room (ER) complaining of epigastric pain that started a week prior to presentation and worsened over the last 1 day. The patient had presented with similar complaints in the past. In the ER the patient had a blood pressure of 96/53 millimeters of Mercury, pulse of 102, respiratory rate of 32 and temperature of 100.7 degrees Fahrenheit. Lab values were significant for a lactic acid of 2.1 millimoles per liter, white blood cell count of 14,800 with predominant neutrophils, elevated liver function tests and creatinine, and a lipase of 9985 units per liter. The lipid panel was within normal limits. Ultrasound of the gall bladder did not reveal any gall stones. There was no reported history of alcohol consumption. Blood culture was positive for Escherichia Coli. Computed tomography scan of the abdomen showed inflammatory changes in the uncinate process of the pancreas and a 2.3 cm duodenal diverticulum along the medial descending duodenum. Magnetic resonance cholangiopancreatography showed two small-moderate sized duodenal diverticula, arising in close proximity from the second portion of the duodenum, the medial one draping over the portion where the distal common bile duct and pancreatic duct join. The patient was managed conservatively in the intensive care unit with intravenous fluids, broad spectrum antibiotics and analgesics. He improved clinically, and was discharged within a week.
Discussion
Duodenal diverticula are associated with a wide range of pancreaticobiliary complications including but not limited to pancreatitis, cholangitis, bezoar formation, obstruction, perforation and bacteremia. There is an increased rate of duodenal contamination with bacteria which can lead to sepsis, as the case above demonstrates. After the initial management of pancreatitis secondary to duodenal diverticulum, the prevention of recurrent attacks entails endoscopic sphincterotomy. If that does not prevent relapses then surgical management may be considered. The surgical approach depends on the location and the size of the diverticulum. Our patient opted for conservative management.