Duodenal diverticulum with retroperitoneal perforation.

A 62-year-old woman had a 12-hour history of acute-onset epigastric and right upper quadrant pain with radiation to the back. She was febrile, had a diffusely tender abdomen with no peritoneal signs and a leukocytosis of 14.0 × 109/L. An abdominal series did not show evidence of free air. CT of the abdomen revealed peripancreatic fat stranding and retroperitoneal gas bubbles at the third and fourth stages of the duodenum (Fig. 1). Ruptured diverticulum of the distal duodenum was diagnosed. At operation, the duodenum was kocherized. Bile-stained fluid was found around a large, friable, perforated duodenal diverticulum, the neck of which was immediately distal to the ampulla of Vater, extending posteromedially behind the head of the pancreas. A feeding catheter introduced via the ampulla of Vater through an anterolateral longitudinal duodenotomy. The diverticulum was inverted within the lumen of the duodenum and stapled off. The duodenotomy was closed in 2 layers and a closed-suction drain placed lateral to the duodenotomy. The patient’s recovery was uncomplicated.