duodenal diverticulum
Introduction
Introduction to the duodenal diverticulum The diverticulum can occur anywhere in the gastrointestinal tract. It is a round, elliptical or tubular bag that protrudes beyond the intestinal wall. The duodenaldiverticulum is the second in the gastrointestinal diverticulum. Common parts of the colonic diverticulum. However, because many duodenal diverticulum have no typical clinical symptoms, it is not easy to find in time. The duodenal diverticulum is mainly caused by poor congenital development, which causes the duodenal intestinal wall to be limited to outward saccular protrusion (primary diverticulum) or caused by scar traction caused by gastroduodenal ulcer ( Secondary diverticulum). basic knowledge The proportion of illness: 0.003%--0.007% Susceptible people: no specific population Mode of infection: non-infectious Complications: chronic pancreatitis duodenal ulcer colonic jaundice intestinal obstruction
Cause
Duodenal diverticulum
(1) Causes of the disease
The exact cause of the diverticulum is unclear. It is a congenital intestinal wall with hypoplastic dysplasia or weakness. When the sudden high pressure in the intestine or long-term continuous or repeated pressure increases, the intestinal wall is weak, the mucosa and mucosa of the intestinal wall The lower layer of tissue is separated to form a diverticulum, and the adhesion of the inflamed tissue formed by the inflamed tissue outside the intestinal wall may cause the diverticulum to occur. Therefore, the causes of different types of diverticulum are also different.
1. Congenital diverticulum is rare, is congenital dysplasia, exists at birth, the structure of the diverticulum wall includes the intestinal mucosa, submucosa and muscle layer, exactly the same as the normal intestinal wall, also known as the true diverticulum.
2. The primary diverticulum has congenital anatomical defects in some intestinal walls. Due to the increase of intestinal pressure, the intestinal mucosa and submucosal tissue are outwardly dislocated to form a diverticulum. The muscle layer of the diverticulum wall is mostly lacking. If it is weak or weak.
3. Secondary diverticulum is mostly caused by scar contraction of duodenal ulcer or adhesion of chronic cholecystitis, so it occurs in the first part of the duodenum, also known as pseudodural diverticulum.
(two) pathogenesis
1. The duodenal diverticulum in the predilection site is more common in single hair, and there are few multiple cases. 70% of the primary diverticulum is located in the second part of the duodenum, and 20% of the diverticulum is located in the duodenum. In the third part, 10% is in the fourth part, the secondary diverticulum is in the first part of the duodenum, and about 85% of the diverticulum is located in the second inner side of the duodenum, most of which are located near the nipple. Because the diverticulum is closely related to the blood vessels and the common bile duct passing through the medial edge of the duodenum, it is considered that the duodenal diverticulum is gradually protruded from the intestinal wall through this weak point, where the diverticulum is mostly located on the surface of the pancreas or Behind the pancreas, even embedded in the pancreatic tissue, often causes obstruction, resulting in complications such as cholangitis and pancreatitis.
2. Pathological changes The size and shape of the diverticulum vary, depending on the anatomical location, the influence of intestinal pressure and the length of time that the diverticulum is produced, generally 0.5 to 10 cm in size, and the shape can be round, elliptical or tubular, etc. The size of the part is related to the occurrence of symptoms. If the neck opening is wide, the contents of the diverticulum are easily drained and can be asymptomatic for a long time; if the opening is narrow, or the opening is narrow due to inflammatory reaction, the diverticulum is enlarged, then the intestinal content or After the food enters the diverticulum, it is retained, causing food residue to be spoiled. Bacterial infections cause diverticulitis, intestinal stones and other complications.
3. Pathological classification According to the relationship between the direction of the diverticulum and the duodenal cavity, it can be divided into the intraluminal diverticulum and the extraluminal diverticulum (Fig. 1). The clinical common is the extraluminal diverticulum, and the intraluminal diverticulum is rare.
classification
(1) intraluminal diverticulum: the diverticulum wall is composed of two layers of intestinal mucosa and a little submucosal connective tissue, which is attached to the duodenal papilla in the form of polyps or capsular, and touches the intestine outside the intestine. Intracavitary polyps, in some cases, the duodenal papilla is located in the sacral cavity, so it is easy to cause biliary tract, pancreatic disease and duodenal occlusion, and gastroduodenal ulcer, such cases are often accompanied by the congenital nature of other organs deformity.
(2) Extraluminal diverticulum: the diverticulum is mostly round or lobulated, the neck can be wide or narrow, mostly single, about 10% of patients can have more than two extraluminal diverticulum or coexisting other digestive tract chambers, 70 % is located on the medial side of the duodenum and is closely related to the pancreas, 30% in the lateral or ascending part.
Prevention
Duodenal diverticulosis prevention
There are no clinical symptoms in the duodenal diverticulum. Therefore, the diverticulum is found in the digestive tract barium meal examination. Do not sloppyly combine with the "upper abdominal symptoms" to judge, but to examine the organs in detail, and finally make the duodenum. Diagnosis of the diverticulum.
Complication
Duodenal diverticulum complications Complications chronic pancreatitis duodenal ulcer colonic jaundice intestinal obstruction
The size and shape of the diverticulum are different, but most of them have smaller entrances. Once the contents of the intestines enter the diverticulum and are not easily discharged and remain, they can cause various complications. Or, although there is no intestinal content in the chamber, it is also It may compress the adjacent organs and cause complications. Therefore, it is important to understand some pathological changes secondary to the diverticulum. There are more complications in the duodenal diverticulum, such as partial obstruction of the duodenum, diverticulitis, and inflammation around the diverticulum. , indoor calculus, acute or chronic pancreatitis, gastroduodenal ulcer, malignant transformation, major bleeding, perforation, cholangitis, common bile duct fistula, duodenal colon fistula, obstructive jaundice.
Diverticulitis
With diverticulum hemorrhage due to duodenal diverticulum contents retention, bacterial reproduction, inflammatory infections, can cause diverticulitis followed by diverticulum mucosal erosion, also indoor ectopic gastric mucosa, ectopic pancreatic tissue, causing bleeding, or diverticulum Inflammation erodes or breaks through the nearby blood vessels, and rare malignant hemorrhage in the mucosa.
2. Chamber perforation
Due to the retention of diverticulum contents, mucosal inflammatory erosion and perforation of ulcers, mostly located in the retroperitoneum, symptoms are not typical after perforation, and even laparotomy can not be found, usually retroperitoneal abscess, pancreatic necrosis, pancreatic fistula, if laparotomy Refers to the para-intestinal cellulitis or bile, pancreatic juice exudation, should consider the perforation of the diverticulum, need to cut the side of the peritoneum carefully explored.
3. Duodenal obstruction
Duodenal obstruction caused by diverticulum is more common in endoluminal diverticulum, because the diverticulum is filled to form a polypoid capsular bag and block the intestinal lumen, or the larger extraluminal diverticulum is obstructed by the duodenum due to the retention of contents, but large Most are incomplete obstruction.
4. Gallbladder, pancreatic duct obstruction
More common in the nipple paraventricular, intraluminal or extraluminal can occur, because the common bile duct, pancreatic duct opening under the or both sides of the diverticulum, even in the diverticulum margin or sacral chamber, resulting in Oddi sphincter dysfunction; diverticulum mechanical compression Bile duct, pancreatic duct, bile, pancreatic juice retention, increased intraluminal pressure, duodenal papilla edema, edema of end of common bile duct, increased chance of retrograde infection and bile duct infection or acute, chronic pancreatitis, Lemmel once had duodenal diverticulum The group of symptoms manifested when combined with liver, gallbladder, and pancreatic diseases is called Lemmel syndrome, and some people call it duodenal diverticulum syndrome.
5. With onset
Patients with duodenal diverticulum are often accompanied by biliary tract disease, gastritis, peptic ulcer, pancreatitis, stones, parasites, etc., and their mutual influence is concurrent or concomitant, and there is no dispute. % to 50%, among which biliary tract disease should be the first, often one of the reasons for "biliary tract syndrome", so in the treatment of duodenal diverticulum, care should be taken not to miss the presence of these associated diseases.
The formation of fecal stone and gallstones in the sputum, especially the incidence of gallstones, is due to the duodenal diverticulum repeatedly causing retrograde common bile duct infection, resulting in lower common bile duct stones, large Western English and other collection of some world literature, statistics ten The incidence of diverticulum diverticulum combined with gallstones ranged from 6.8% to 64.2% (Table 1). It can be seen that the incidence of Japanese is higher than that of British and Americans. It is pointed out that in the treatment of cholelithiasis (the duodenal diverticulum was not found beforehand), At the same time, the treatment of diverticulum is increasingly common. In the case of a fatal nipple opening just in the sputum and/or with cholelithiasis, the treatment is more difficult and should be estimated before surgery.
Symptom
Duodenal diverticulum symptoms Common symptoms Nausea inflammation Peritonitis Abdominal distension Abdominal discomfort Diarrhea
There is no typical clinical symptom in the duodenal diverticulum. Only X-ray barium examination, fiber endoscopy, laparotomy or autopsy found that the size of the diverticulum is not positively correlated with the degree of symptoms. When the diverticulum is complicated by inflammation, Abdominal discomfort, upper right abdomen or umbilical pain, nausea, vomiting, snoring, bloating, diarrhea, even hematemesis and blood in the stool, diarrhea may affect the function of the pancreas or excessive absorption of bacteria in the sputum, if the diverticulum Perforation can cause peritonitis symptoms, embedded in the perforation of the pancreas, severe pain can cause symptoms of acute pancreatitis, blood, urine amylase increased, if the diverticulum compresses the common bile duct, bile duct obstruction, fever, jaundice, upper abdominal distension, etc., if The upper abdomen is fixed in the diverticulum area with limited deep tenderness, which may indicate the presence of chronic inflammation in the diverticulum.
Because there is no typical symptom in the duodenal diverticulum, it is difficult to make a correct diagnosis in clinical practice. Even if some symptoms are caused by complications, it is often confused with the clinical symptoms of ulcer disease, biliary tract disease and pancreatitis, and it is not easy to identify. Duodenal diverticulum The diagnosis must be carefully excluded from other diseases that can cause the corresponding symptoms and signs, and depends on X-ray examination, duodenoscopy and cholangiography to confirm.
Examine
Duodenal diverticulum examination
When the diverticulum causes biliary obstruction, it can cause severe abdominal pain. If the pancreas is involved, serum and urine amylase will increase.
1. X-ray barium meal inspection
The duodenal diverticulum can be found, which is a bag-like shadow that protrudes from the intestinal wall. The contour is neat, clear, and the edges are smooth (Fig. 2). After the pressure, there is a mucosal texture in the shadow that continues to the duodenum. The shadow of the sputum is seen after the sputum is empty. It is the shadow of the sputum remaining in the sacral cavity. The larger diverticulum and the neck are wider. The gas-liquid surface is sometimes seen in the sacral cavity. When the sacral mucosa around the diverticulum is thickened, The contour is not neat, the local irritative signs or diverticulum emptying, or limited local tenderness, can be considered as the manifestation of diverticulitis, such as diverticulum fixation can not move, is the performance of inflammation around the diverticulum.
Secondary duodenal diverticulum, often accompanied by irregular deformation of the duodenal bulb and widened shadow of the intestine. When the diverticulum is small or the neck is narrow, the opening is often covered by the intestinal mucosal folds, or the chamber is filled with a large amount of food residue, and the presence of the diverticulum is not easily found. If a small amount of tincture enters the diverticulum or a complete or incomplete ring is visible. Shadow, the use of low-end duodenal X-ray sputum angiography can increase the rate of diverticulum.
2. Fiber duodenoscopy
In addition to the opening of the diverticulum, the relationship between the diverticulum and the duodenal papilla can be understood to provide a basis for determining the surgical plan.
3. Cholangiography
Intravenous cholangiography, percutaneous transhepatic cholangiography (PTC), duodenoscopy retrograde cholangiography (ERCP) and other methods to understand the relationship between diverticulum and bile duct, pancreatic duct, surgical treatment The choice has a reference meaning, the general diverticulum and gallbladder, pancreatic duct relationship may have 1 gallbladder, pancreatic duct opening at the bottom of the diverticulum (Fig. 3A); 2 gallbladder, pancreatic duct opening in the diverticulum side wall or neck (Fig. 3B), these Biliary, abnormal opening of the pancreas is often accompanied by abnormal function of the Oddi sphincter, which is likely to cause reflux or obstruction of the contents of the diverticulum and lead to cholangitis or pancreatitis.
4. CT examination
The diverticulum usually appears as a round or oval capsular shadow that protrudes beyond the duodenal wall. The serosal contour is smooth. Since the diverticulum is connected to the intestine by a narrow neck, CT can be displayed in it. The positive contrast agent inside is often seen, and it is often seen that it contains gas shadow. It should be noted that when the positive contrast agent is placed inside the duodenal descending chamber, it may be mistaken for the lower common bile duct stone.
The duodenal descending diverticulum is mostly located near the duodenal papilla, and the CT manifests itself as a capsular contrast agent outside the duodenal descending segment and the pancreatic head, which protrudes beyond the contour of the descending segment; When the positive contrast agent fails to enter the chamber, it exhibits a low-density liquid shadow (Fig. 4).
The diverticulum of the horizontal section and the ascending section is characterized by a sac pocket shadow appearing above or below the main layer of the intestine, and the chamber in the upper wall contains more gas. When the diverticulum is larger, it can resemble the shape of the intestine. At this time, attention is paid to the continuous layer. Observe, can clearly determine its relationship with the intestine
When combined with diverticulitis or periorbital inflammation, the diverticulum wall is thickened, edema is present in or around the intestinal wall of the diverticulum, the density is reduced, accompanied by cord-like shadows, and the fat gap density is increased, which occurs in the diverticulum of the descending side wall. Inflammation, mainly manifested as a widening of the distance between the duodenum and the head of the pancreas, with a low-density shadow appearing between them, and the outer wall of the descending segment is normal; while the thickening of the edema caused by duodenal ulcer is the whole week with the intestine as the center. Sexual change.
Diagnosis
Diagnosis and identification of duodenal diverticulum
Relying on gastrointestinal barium examination, some small and concealed diverticulum can still be found in low duodenal angiography.
The diagnosis of this disease needs to be differentiated from duodenal ulcer, gastritis, peptic ulcer, duodenal inflammation, cholangitis, and abdominal gland inflammation.
