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Clinical case: Duplication of the duodenum: want to learn more about it?

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Clinical case: Duplication of the duodenum

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

It has been modified and reviewed by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

Objectives

After reviewing this case you should be able to describe or do the following:

  • How the patient’s symptoms and signs are associated with her diagnosis.
  • The significance of bile pooling in the duodenum.
  • The anatomical distinctions among the four parts of the duodenum.
  • Why the surgeon did an end-to-side anastomosis rather than an end-to-end anastomosis.
  • How imaging could be used to differentiate between a cystic and tubular duplication.
  • Label on the cadaver image attached here the relevant parts of the GI tract to this case and describe using this image the surgical procedure.
Figure (1) - Cadaver photograph showing the normal anatomy of the duodenum including its four parts (1-4) after reflecting up the stomach, and you can notice how “end to side anastomosis” could be done.

Case description

History

A 59-year-old female was seen for evaluation following several months of:

  • increasing postprandial abdominal pain
  • early satiety
  • reflux
  • unexpected weight loss
Figure (2) - A Frontal view of the duodenum of the patient described in this report (right) versus that of a normal patient during an upper GI radiographic exam (left), it demonstrates the pronounced dilation of the duodenum in the frontal plane. Evaluate using cadaver photograph in Figure (4). Note marked dilation of C-loop of the duodenum in the patient.

Investigations

The patient’s laboratory evaluation was unremarkable, and she did not have any prior medical or surgical history that could account for her complaints. An upper GI radiographic exam suggested an abnormality involving the duodenum because the duodenal C-loop appeared to be markedly dilated (Figure 2-B and Figure 3 compared to normal - Figure 2-A).

Figure (3) - Lateral view of the patient during upper GI examination shows that the dilation is similarly pronounced in the sagittal plane.

Differential diagnosis

Initially, the patient’s physicians considered two clinical diagnoses:

  • Duodenal dilation was occurring secondary to a stricture, or an extrinsic compression in the fourth portion of the duodenum or at the duodenal-jejunal junction.
  • The patient had GI duplication of some kind.
Figure (4) - Cadaver photograph showing the normal anatomy of the duodenum including its four parts (1-4).

Diagnosis

In order to determine if one of these diagnoses was correct an upper endoscopic exam was performed (Figure 5). This exam revealed that there were three downstream orifices just distal to the Ampulla of Vater (hepatopancreatic ampulla) suggesting that duodenal duplication was the correct diagnosis.

Figure (5) - Endoscopic view showing the three openings (asterisks) leading from the 2nd to the 3rd parts of the duodenum. Two of these openings represent the duplications and end blindly.

Management

There was bile pooling in the duodenum. A decision was then reached to proceed with surgical exploration.

During the surgery, the duodenum was freed from its attachment to the posterior abdominal wall (remember the most of the duodenum is in retroperitoneum) and it became apparent that the duplication extended superiorly in front of the body of the pancreas.

Examination of the duodenum intraoperatively revealed that two of the orifices were blind with only one connection to the jejunum. Thus, the duplicated portions of the duodenum were fully mobilized and resected (Figure 6).

Figure (6) - Photograph of the mobilized third and fourth parts of the duodenum during the surgical procedure.

A proximal transection was made just distal to the ampulla with a distal resection occurring at the entrance to the jejunum. A hand-sewn end-to-side duodenojejunostomy was then done to a slightly more downstream part of the jejunum (Figures 7+1).  The surgical exploration confirmed duplication of the third and fourth portions of the duodenum.

Figure (7) - (a) Schematic of operative proceedings.The cystic duct was identified and a biliary Fogarty catheter was inserted into the duodenum. A duodenotomy was created and point of transection was chosen just distal to the ampulla so as to fully resect the duplication. The distal resection line occurring at the jejunum just beyond the ligament of Treitz. (b) Schematic of end-to-side duodenojejunostomy used for operative reconstruction on this patient.

Anatomical and embryological considerations

Duplications of the gastrointestinal (GI) tract are uncommon congenital anomalies that occur in either cystic or tubular form. Characteristics shared by all enteric duplications include their close attachment to the GI tract, epithelial mucosal lining, and a well-developed visceral muscle layer. Abdominal GI duplications are hypothesized to result from recanalization errors of the neonatal solid GI tract. All enteric duplications are believed to occur with an incidence of about 1 per 4000–5000 live births. Relative to other alimentary tract duplications, duodenal duplications are comparatively rare (about 6%).

Clinical case: Duplication of the duodenum: want to learn more about it?

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