Endoscopic radial incision and cutting method for adult congenital duodenal webs: A case report

Abstract

Background: Congenital duodenal webs are rare in adults and can lead to various symptoms such as nausea, vomiting, and postprandial fullness. The treatment for this disease is mostly surgical. Endoscopic treatment techniques have been developed and attempted for this disease. Endoscopic radial incision and cutting (RIC) techniques are reportedly very effective in benign anastomotic stricture. This case report highlights the effectiveness and safety of endoscopic RIC as a minimally invasive treatment for adult congenital duodenal webs.

Case summary: A 23-year-old female patient with indigestion was referred to a tertiary hospital. The patient complained of postprandial fullness in the epigastric region. Previous physical examinations or blood tests indicated no abnormalities. Computed tomography revealed an eccentric broad-based delayed-enhancing mass-like lesion in the second portion of the duodenum. Endoscopy showed an enlarged gastric cavity and a significantly dilated duodenal bulb; a very small hole was observed in the distal part of the second portion, and scope passage was not possible. Gastrografin upper gastrointestinal series was performed, revealing an intraduodenal barium contrast-filled sac with a curvilinear narrow radiolucent rim, a typical "windsock" sign. Endoscopic RIC was performed on the duodenal web. The patient recovered uneventfully. Follow-up endoscopy showed a patent duodenal lumen without any residual stenosis. The patient reported complete resolution of symptoms at the 18-month follow-up.

Conclusion: Endoscopic RIC may be an effective treatment for congenital duodenal webs in adults.

Keywords: Case report; Congenital duodenal web; Endoscopic treatment; Radial incision and cutting method; Surgery.

Figure 1

Abdominopelvic computed tomography findings. An eccentric broad-based delayed-enhancing mass-like lesion in medial wall of the second duodenum (arrow).

Figure 2

Initial endoscopic findings. A: Despite a long period of fasting, large amounts of vegetable food residues are observed in the gastric cavity; B: Beyond the pylorus, food residues are retained in the duodenal bulb; C: The lesion is invaginated proximally and observed as a subepithelial tumor in the gastric cavity; D: The lumen of the duodenal bulb is significantly dilated; E and F: A hole is observed eccentrically in the elongated web.

Figure 3

Gastrografin upper gastrointestinal series. A: Intraduodenal barium contrast-filled sac with a curvilinear narrow radiolucent rim; B: An enlarged version of the photograph inside the square in panel A, showing a typical "windsock" sign.

Figure 4

Endoscopic incision and cutting procedure. A: Food residues retained in the duodenal bulb through the pylorus are observed; B: Retained food residues were expelled into the gastric cavity; C: The web is projected distally, so that the end appears like a blind pouch, and the aperture is observed at 12 o'clock; D: After attaching a transparent cap to the tip of the endoscope, a small radial incision was carefully made into the web using a IT2-knife; E: In the center, toward the duodenal wall, a long radial incision was made; F: The web was cut circumferentially along the duodenal wall.

Figure 5

Last follow-up of endoscopy. A: As in previous tests, food retention is not observed; B: The duodenal bulb is also not significantly dilated as in the previous examinations; C and D: A portion of the residual web is observed at 6 o’clock, although a sufficient width of the lumen is secured.