Endoscopic signs of diverticulum of the duodenum

Diverticula duodenum - blindly terminating protrusion of the wall of the duodenum. It most often captures all layers of the intestinal wall. The main factor in the formation of diverticula is duodenal hypertension.

Contributing factors: weakness of the wall in places of vascular entry (along the medial wall), admission of adipose tissue, heterotopia of pancreatic tissue, malformations. In frequency, they occupy the second place after diverticula of the large intestine. Often combined with the diverticula of the small and large intestine, and sometimes the entire digestive tract.

Classification.

1. a) pulsion, b) traction.
2. a) true, b) false.
3. a) congenital, b) acquired.

True diverticula are most often located along the medial wall (97%), mainly in the middle third of the descending part of the duodenum in the immediate vicinity of the head of the pancreas and the common bile duct ("embedded" in the pancreatic tissue). Such an advantageous localization of diverticula is explained by the weakness of the intestinal wall in this area due to the entry of the vessels. The second most frequent localization site is the lower horizontal part. Often there are multiple (2-4) diverticula.

The sizes of diverticula are various, to define them it is difficult, since. They change against the background of peristalsis. The form is more often oval or round, less often they are cylindrical or funnel-shaped. The mucous membrane of the diverticulum is pale pink with a pronounced vascular pattern, the surrounding mucosa is not changed. The lumen of the isthmus is narrow, which causes the stagnation of intestinal contents in the diverticulum and the development of inflammatory changes in the mucous membrane (diverticulitis). The entrance to the diverticulum is not always found freely. Research complicates the folding of the mucous membrane of the duodenum, the rigidity of the wall at the base of the diverticulum in connection with the inflammatory reaction and increased peristalsis. Clinical manifestations only with complications.

In addition to true diverticula, endoscopic examination can reveal false diverticula localized in the bulb of the duodenum near the pyloric pulp. This traction diverticula, formed as a result of deformation of the bulb after scarring of the previously existing ulcer. Their form can be varied.

Differential diagnosis of diverticulum and pseudo diverticulum

Diverticulum	Pseudodiverticle
1. More often in the descending part along the medial wall 2. There is a neck 3. Round or oval shape 4. Acidity is reduced or normal	1. More common in the bulb along the front wall 2. No neck 3. The shape is irregular or cylindrical 4. Acidity is increased, can be erosive-ulcer duodenitis

When endoscopy is determined by the location, shape, size, condition of the mucosa, location relative to the OBD: the OBD can be located peridiverticular (at the edge of the diverticulum) or intradiverticular (inside the diverticulum). With the location of the OBD at the bottom of the diverticulum, a longitudinal fold that extends into the diverticulum is visible, and the OBD is not visible. At a diverticulitis the diagnostics is complicated, full inspection is possible only after depression of edema.

Complications of diverticula can arise due to pathological changes within the diverticulum (diverticulitis, ulceration, bleeding) or as a result of pressure on the surrounding organs (torsion of the isthmus of the diverticulum with infringement, perforation, involvement in the inflammatory process of neighboring organs, malignant degeneration, deformation and stenosis ). Endoscopically it is necessary to be able to differentiate the diverticulitis from the penetrating ulcer: when the penetrating ulcer on the bottom of the defect, the fibrin overlay is determined, its shape is funnel-shaped, there is an inflammatory shaft, the convergence of the folds toward the defect. With diverticulitis, there is hyperemia, edema, mucus, pus. Soy duodenal papilla.

[1], [2], [3], [4]