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Vol. 42. Núm. 3.
Páginas 186-187 (Marzo 2019)
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Vol. 42. Núm. 3.
Páginas 186-187 (Marzo 2019)
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DOI: 10.1016/j.gastrohep.2018.10.009
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Major duodenal diverticular bleeding
Hemorragia de divertículo duodenal
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...
Joana Rita Carvalhoa,1,
Autor para correspondencia
joana.rita.carvalho@gmail.com

Corresponding author.
, Inês Nogueira Fonsecab,1, Carlos Freitasa, Paula Moura Santosa, Luís Carrilho Ribeiroa, Rui Tato Marinhoa
a Department of Gastroenterology and Hepatology, North Lisbon Hospital Centre, Hospital de Santa Maria, Portugal
b Department of Internal Medicine, North Lisbon Hospital Centre, Hospital de Santa Maria, Portugal
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Duodenal diverticula (DD) are present in 20% of adults.1,2 Bleeding is a rare event (0.14% of upper gastrointestinal bleeding) and there is no defined gold standard method of haemostasis.3,4

A 64-year-old female patient presented with melena with hemodynamic instability. At physical examination, she was tachycardic and nasogastric intubation did not show blood. Laboratory workup revealed acute normocytic anemia of 8.6g/dL. An upper endoscopy (UE) was performed and revealed a giant diverticulum of the second duodenal portion, without blood. She presented a new episode of hemodynamic instability and a contrast CT revealed blood in the DD. A second UE was performed using a conventional colonoscope and revealed blood in the DD (Fig. 1A). During observation, an arterial spurting of the DD was seen (Fig. 1B); it was controlled with epinephrine and 3 hemoclips (Fig. 1C). A second look endoscopy was performed, without evidence of rebleeding (Fig. 1D). The patient was discharged 5 days later.

Figure 1.

(A) UE revealing blood in the giant DD; (B) during observation, an arterial spurting of the DD was seen; (C) the bleeding was controlled with epinephrine and 3 hemoclips; (D) a second look endoscopy was performed without evidence of rebleeding.

(0,16MB).

Most common endoscopic approaches include injection, thermal and mechanic methods alone or combined.4 Although there are no available comparative studies, theoretically, clipping seems to be better than injection methods.1 It was suggested that air removal before hemoclip may reduce perforation.5

Funding

No funding.

Conflicts of interest

No conflicts of interest.

References
[1]
Y. Onozato, S. Kakizaki, H. Ishihara, H. Iizuka, N. Sohara, S. Okamura, et al.
Endoscopic management of duodenal diverticular bleeding.
Gastrointest Endosc, 66 (2007), pp. 1042-1049
[2]
M. Khandelwal, P.A. Akerman, W.F. Jones, G.B. Haber.
Endoscopic therapy of a bleeding duodenal diverticulum.
Am J Gastroenterol, 90 (1995), pp. 1328-1329
[3]
E. Valdivielso Cortazar, L. Madarnás Alonso, S. Ortíz Marín, I. Couto Worner, P. Alonso Aguirre.
Duodenal diverticular bleeding: an endoscopic challenge.
Rev Esp Enferm Dig, 109 (2017), pp. 468-469
[4]
Y.Y. Chen, H.H. Yen, M.S. Soon.
Impact of endoscopy in the management of duodenal diverticular bleeding: experience of a single medical center and a review of recent literature.
Gastrointest Endosc, 66 (2007), pp. 831-835
[5]
S.Y. Lee, S.P. Hong, S.K. Hwang, P.W. Park, K.S. Rim.
Duodenal perforation after endoscopic hemoclip application for bleeding from Dieulafoy's lesion in a duodenal diverticulum.
Gastrointest Endosc, 62 (2005), pp. 781-782

Co-first authors.

Copyright © 2018. Elsevier España, S.L.U.. All rights reserved
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