Major duodenal diverticular bleeding

Duodenal diverticula (DD) are present in 20% of adults.^1,2 Bleeding is a rare event (0.14% of upper gastrointestinal bleeding) and there is no defined gold standard method of haemostasis.^3,4

A 64-year-old female patient presented with melena with hemodynamic instability. At physical examination, she was tachycardic and nasogastric intubation did not show blood. Laboratory workup revealed acute normocytic anemia of 8.6 g/dL. An upper endoscopy (UE) was performed and revealed a giant diverticulum of the second duodenal portion, without blood. She presented a new episode of hemodynamic instability and a contrast CT revealed blood in the DD. A second UE was performed using a conventional colonoscope and revealed blood in the DD (Fig. 1A). During observation, an arterial spurting of the DD was seen (Fig. 1B); it was controlled with epinephrine and 3 hemoclips (Fig. 1C). A second look endoscopy was performed, without evidence of rebleeding (Fig. 1D). The patient was discharged 5 days later.

Figure 1.

(A) UE revealing blood in the giant DD; (B) during observation, an arterial spurting of the DD was seen; (C) the bleeding was controlled with epinephrine and 3 hemoclips; (D) a second look endoscopy was performed without evidence of rebleeding.

Most common endoscopic approaches include injection, thermal and mechanic methods alone or combined.⁴ Although there are no available comparative studies, theoretically, clipping seems to be better than injection methods.¹ It was suggested that air removal before hemoclip may reduce perforation.⁵

Funding

No funding.

Conflicts of interest

No conflicts of interest.