Perforation of a duodenal diverticula.

The duodenal diverticulum is a relatively frequent entity whose diagnosis has been increased over time with the development of new diagnostic and exploratory techniques. Periampullary diverticula (PAD) were classified as type 1, 2, or 3 according to the position of the major papilla from the endoscopic view: type 1, the major papilla was located inside of the diverticula; type 2, the major papilla was located at the edge of the diverticula; type 3, the major papilla was located outside of the diverticula. Complications of duodenal diverticula include ulceration, bleeding, perforation and inflammation with intestinal obstruction. Perforation of duodenal diverticula due to both local ischemia or mechanical obstruction, is exceedingly rare, however, this entity has a high associated mortality. Duodenal perforations can either be free or contained. The optimal management of which has not been well established. We describe the case of a 61-year-old male with a diagnosis of acute pancreatitis due to abdominal pain, elevation of pancreatic enzymes and computed tomography (CT) findings of inflammatory peri and pancreatic changes. However, he presented a severe elevation of acute phase reactants and poor control of the pain. Given lack of improvement, the abdominal CT was repeated and revealed a probable perforation of the duodenal diverticulum with local inflammatory changes which would explain the elevation of pancreatic enzymes but the lack of response to treatment. With the new diagnosis of duodenal diverticulum and spontaneous perforation, evaluation was performed with General Surgery indicating conservative management. Absolute diet, parenteral nutrition and empirical antibiotic therapy with ciprofloxacin and metronidazole were started with improvement, allowing the progressive reintroduction of the diet, being well tolerated. Analytically and radiologically improvement was finally also observed.