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Case Reports
. 2012 May;6(2):523-9.
doi: 10.1159/000341955. Epub 2012 Jul 31.

Common bile duct obstruction secondary to a periampullary diverticulum

Anastasios J Karayiannakis  1 , Helen Bolanaki, Nikos Courcoutsakis, Georgios Kouklakis, Erchan Moustafa, Panos Prassopoulos, Constantinos Simopoulos
Affiliations
Case Reports

Common bile duct obstruction secondary to a periampullary diverticulum

Anastasios J Karayiannakis et al. Case Rep Gastroenterol. 2012 May.

Abstract

Periampullary duodenal diverticula are not uncommon and are usually asymptomatic although complications may occasionally occur. Here, we report the case of a 72-year-old woman who presented with painless obstructive jaundice. Laboratory tests showed abnormally elevated serum concentrations of total and direct bilirubin, of alkaline phosphatase, of γ-glutamyl transpeptidase, and of aspartate and alanine aminotransferases. Serum concentrations of the tumor markers carbohydrate antigen 19-9 and carcinoembryonic antigen were normal. Abdominal ultrasonography showed dilatation of the common bile duct (CBD), but no gallstones were found either in the gallbladder or in the CBD. The gallbladder wall was normal. Computed tomography failed to detect the cause of CBD obstruction. Magnetic resonance imaging and magnetic resonance cholangiopancreatography revealed a periampullary diverticulum measuring 2 cm in diameter and compressing the CBD. The pancreatic duct was normal. Hypotonic duodenography demonstrated a periampullary diverticulum with a filling defect corresponding to the papilla. CBD compression by the diverticulum was considered as the cause of jaundice. The patient was successfully treated by surgical excision of the diverticulum. In conclusion, the presence of a periampullary diverticulum should be considered in elderly patients presenting with obstructive jaundice in the absence of CBD gallstones or of a tumor mass. Non-interventional imaging studies should be preferred for diagnosis of this condition, and surgical or endoscopic interventions should be used judiciously for the effective and safe treatment of these patients.

Keywords: Ampulla of Vater; Complications; Diverticulum; Duodenum; Jaundice; Periampullary.

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Figures

Fig. 1
Fig. 1
The diverticulum as seen on MRCP compressing the distal end of the CBD and causing dilatation of its proximal part.
Fig. 2
Fig. 2
Hypotonic duodenography disclosed the diverticulum with a filling defect corresponding to the papilla.
Fig. 3
Fig. 3
Intraoperative photograph showing the neck of the diverticulum (arrows) protruding through the duodenal wall, compressing the CBD and distorting its course. D = Duodenum; P = pancreatic head.
Fig. 4
Fig. 4
Intraoperative photograph showing the opened diverticulum with the papilla (arrow) located inside the diverticulum.
See this image and copyright information in PMC

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