Duodenum - Endoscopic Management of a Windsock Diveticulum
Comments: A 24 year old female was referred for complaints intermittent nausea and vomiting and weight loss. The upper GI barium study demonstrates an enlarged diverticulum in the second portion of the duodenum. A thin radiolucent stripe is seen around the diverticulum which has been described as the halo sign. Upper endoscopy is performed which identifies a large diverticulum which intermittently obstructs the duodenal lumen. The endoscopic appearance is consistent with a windsock diverticulum. This intraluminal diverticulum is thought to result from incomplete recanalization of the duodenum during embryological development and with complete obstruction, symptoms present during childhood. In contrast, when there is a small aperture in the duodenum, patients may initially remain asymptomatic. However, the duodenal web that is present is stretched over time by peristalsis resulting in the development of an intraluminal diverticulum. As the diverticulum increases in size, it may cause intermittent obstruction or even pancreatitis. In contrast to diverticula located elsewhere in the gastrointestinal tract, these diverticula are lined on both sides by intestinal mucosa. Symptoms of nausea and vomiting can often be relieved if the narrow duodenal lumen is opened.
In this video, we present the endoscopic management of a windsock diverticulum using the needle knife sphincterotome. Initially, the narrow lumen of the duodenum is located adjacent to the diverticulum. The endoscope is advanced through his aperture into the distal duodenum. The guidewire is placed across this opening and a 10 French by 10 cm pigtail stent is subsequently deployed. Placement of the stent allows the endoscopist to easily locate the aperture, which may be difficult during the case. Next, the major papilla is identified. If visualization of the major papilla during the endoscopy, is difficult, a pancreatic stent can be placed to mark its location. This was not required in this patient. Next, the first endoscopic clip is placed. This clip is placed on the opposite wall of the papilla and along the diverticular rim. Subsequently, a second clip is deployed.
These clips are used to define the plane of resection for the needle knife incision. The needle knife is placed between the two endoscopic clips. Note that the direction of the incision is away from the major papilla and towards the diverticular rim. A series of short incisions are made for a total length of approximately 10 mm. Next two endoscopic clips will be placed at the extent of the prior incision. These clips identify where the next needle knife incision should be made. After placement of the clips, the needle knife is again used. In a direction towards the diverticulum, the diverticulotomy is extended until its total length is approximately 2 cm. The dilating balloon is then used to evaluate the diverticulotomy size. The balloon is fully inflated to 20mm and there is no resistance identified in the area of the prior stenosis. Both the endoscope and balloon pass through the diverticulotomy site. The pigtail catheter is removed and the procedure is complete.
| Contributed by: |
Rajesh N. Keswani, MD Washington University Steven A. Edmundowicz, MD Washington University |
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Citation: Keswani, RN & Edmundowicz, SA (Jan 19 2010). Duodenum - Endoscopic Management of a Windsock Diveticulum. The DAVE Project. Retrieved Jul, 30, 2010, from http://daveproject.org/viewfilms.cfm?film_id=785 Times viewed since Feb 2006: 2555 |
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