Pancreatic abscess due to perforation of duodenal diverticulum

Introduction
Duodenal diverticula are uncommon radiological findings, but rarely give rise to complications. Herein, we report a rare case concerning the development of pancreatic abscess caused by perforated diverticulum, arising from the distal end of the second part of the duodenum.

Case report
A 68 year old man, alcoholic for the last 10 years, was admitted to our Surgical Department with a 16 day history of epigastric pain and vomiting. All this time the patient was living in a small Greek island without medical care. On admission, he was pale and too thin with a cachectic aspect. On clinical examination, the patient presented the signs of pancreatic inflammation: epigastric tenderness, palpable mass, pain radiation to the back and meteorism. Furthermore, he reported weight loss of 7 kg in two the last weeks rather of the fear of eating and he had fever of 38.8°C with rigors. From hematological tests, the hematocrit was 30%, the hemoglobin 9.4 gr/dl and the white blood cell count was 20.2x109/L, with 74% polymorphonuclears. The serum amylase was increased at 360 IU/L (reference value 0-90 IU/L) and the alboumin value was decreased at 2.8 gr/ L). Computed tomography showed a mass in the head of the pancreas (Fig. 1). An upper gastrointestinal gastrographin barium series revealed the presence of duodenal diverticulum on the second part. The plain radiograph of the abdomen showed a diverticulum at the junction of the second and third part of the duodenum. Despite intensive medical care the condition of the patient was deteriorated and surgical intervention was decided with the tentative diagnosis of pancreatic abscess. At laparotomy, a mass arising from the head of the pancreas and protruding through the transverse meso-colon was found. By a finger inserted the mass was opened and pus was revealed. Finally the finger passed through the cavity to the second part of the duodenum. After the cavity was thoroughly cleaned a large tube for drainage was inserted and connected with continuous aspiration. Resection of duodenal tissue was not required. In addition gastro-jejunostomy and cholecysto-jejunostomy were performed in order to diminish the amount of bile and gastric outlet passing to the duodenum. The result of our surgical procedure was gratifying and the patient gradually recovered. The duodenum-pancreatic fistula was finally closed in 53 days. Parenteral feeding, broad-spectrum antibiotics and somatostatin were employed during the treatment.

Comments
Pancreatic abscess occurs in 5 to 10% of patients with acute pancreatitis. An abscess may be caused by inadequate drainage of a pancreatic pseudocyst which is a complication associated with pancreatitis. The incidence 4 out of 100.000 people / pancreatic abscess due to trauma to the pancreas / is an additional risk factor resulting in pancreatic abscess.
Diverticula are common in all parts of the digestive tract. Duodenal diverticula may be congenital or acquired and if acquired may be primary, secondary or intraluminal (1). Usually, these are incidentally found out as their presence is not associated with significant symptomatology. Complications, which are rare, may be caused by pressure, resulting in jaundice, cholangitis, pancreatitis and duodenal obstruction or by inflammation leading to ulceration, hemorrhage and perforation, which in turn may result in abscess and fistula(2,3).To our knowledge this is the second case reporting to a pancreatic abscess resulting from perforation of the diverticulum. The diversion of the bile and gastric outlet achived by our surgical procedure, as well as the large drainage of the abscess cavity contributed to favorable outcome evolution of the patient postoperative course. The death rate from undrained pancreatic abscesses is very high, as sepsis is not an unusual complication in these cases.

References
1. Jones, T.W., Merendino, K.A. - The perplexing duodenal diverticulum. Surgery, 1960, 48:1068.
2. Wells, F. - Pancreatic abscess complicating a perforated duodenal diverticulum. Br. J. Surg., 1983, 70:292.
3. Eggert, A., Teichman, W., Wittman, D. - The pathologic implication of duodenal Diverticula. Surg. Gynecol. Obstct., 1982, 154:62.

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