Duodenal Diverticular Bleeding Successfully Treated Using Transcatheter Arterial Embolization: a case report

We present a case of an 82-year-old man with duodenal diverticular bleeding (DDB) who was successfully treated using transcatheter arterial embolization (TAE). Initially, endoscopy results indicated duodenal bleeding; however, the exact bleeding site could not be located. A follow-up computed tomography (CT) scan revealed contrast extravasation from a periampullary duodenal diverticulum. Repeated endoscopy confirmed the bleeding site. However, hemostasis failed because excessive bleeding obscured the field of vision. As his condition worsened, the patient was transferred to the radiology department for TAE. His condition gradually improved after TAE. No obvious complication was observed after discharge. This case demonstrates TAE as a feasible alternative for managing complex DDB cases. J radiol sci 2015; 40: 71-74 Correspondence Author to: Chi-Jen Chen Department of Diagnostic Radiology, Taipei Medical University Shuang-Ho Hospital, New Taipei, Taiwan No. 291, Jhong-Jheng Road, Jhong-He, New Taipei 235, Taiwan 08_RAG_1699.indd 71 2015/8/28 下午 03:07:55 embolization for diverticular bleeding 72 J Radiol Sci June 2015 Vol.40 No.2 the duodenum; however, no active bleeding site could be observed. Because the bleeding source could not be identified, we performed diagnostic angiography. Angiography of the superior mesentery artery (SMA), celiac trunk, gastroduodenal artery, and inferior mesentery artery did not reveal obvious contrast extravasation. Finally, abdominal and pelvic CT was performed, and the CT scans revealed active bleeding from a periampullary duodenal diverticulum (Fig. 1a-1b). The patient was then transferred to the intensive care unit because of unstable hemodynamics. A third endoscopy was performed for hemostasis. However, the procedure was unsuccessful because of excessive bleeding despite administering several injections of diluted epinephrine and normal saline around the ampullary region, which obscured the field of vision. TAE was considered for DDB. The SMA angiogram indicated an active contrast extravasation from the inferior pancreaticoduodenal artery of the SMA (Fig. 2a-2b). We used 20% N-butyl-2-cyano-acrylate (NBCA), which was mixed with lipiodol at a 1:4 ratio, to embolize the target vessel until flow stasis. This was followed by adjunctive medical therapy involving the administration of a high dose of esomeprazole and octreotide in addition to blood transfusion. The patient’s condition gradually improved and tarry stool was no longer observed. The patient resumed oral intake soon after. His serum hemoglobin levels returned to normal by the time he was transferred back to the general ward. His condition was stable at discharge, and bleeding did not recur at follow-up. DisCussion Reviewed previous publications, the incidence of duodenal diverticulum ranges from 0.16% to 22% [2]. On the basis of its morphology, duodenal diverticulum can be categorized into an intraluminal or extraluminal type. In approximately 85%-90% of cases, duodenal diverticulum occurs in the second portion of the duodenum, particularly at the periampullary region, and is the most common location for this disorder [3, 4]. The pathogenesis of duodenal diverticula is not clearly understood. The most well-known theory is that the mucosa herniates into regions of mural weakness; in such regions, the vessel, biliary, or pancreatic duct enters the submucosa [5]. Upper gastrointestinal bleeding has several pathologic entities. Peptic ulcer, gastritis, duodenitis, and esophageal varices account for approximately 80% of cases of upper gastrointestinal bleeding [6]. DDB is a rare cause of upper gastrointestinal bleeding because most duodenal diverticula are asymptomatic. The first case of DDB was reported in 1951 [7]. DDB most commonly occurs at the third and fourth portions of the duodenum [8]. Although the etiology of DDB is not clearly understood, two mechanisms are observed. The first mechanism involves mucosal ulceration and blood vessel tear during sac distension. The second mechanism involves irritation by bowel contents [9]. The optimal therapeutic strategy for DDB has remained controversial because of the rarity of this condition. In most studies, patients were treated using endoscopic therapy or