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We present laparoendoscopic hybrid treatment of a patient with choledocholithiasis, cholecystitis and large duodenal diverticula. A 69-year-old patient underwent one-stage hybrid laparoendoscopic intervention. Despite the difficult situation caused by large duodenal diverticula and calculus in terminal part of common bile duct, hybrid technique with rendez-vous procedure allowed successful lithoextraction and cholecystectomy. The follow-up examination found no residual biliary calculi. Hybrid laparoendoscopic intervention in the treatment of a patient with choledocholithiasis, cholecystitis and large duodenal diverticula provided optimal clinical effect, reduced the risk of postoperative complications and shortened in-hospital treatment.

Perforation is the rarest complication of duodenal diverticulum but also one of its most serious complications. Mortality rate was reported to up to 30%. Clinical diagnosis is usually vague and non-specific. High clinical suspicion is important as rapid deterioration is likely. Consensus regarding management is lacking and currently guided by a small series of case reviews. Surgical treatment is historically the standard therapeutic option. However, more current literature suggests improvement in patients with non-surgical management. In this paper, we discuss a case of a patient in her early 60s who had a perforated duodenal diverticulum that was treated conservatively. It highlights the importance of a good history and a CT scan to help with diagnosis. Close clinical observation is essential to detect disease progression. A step-up approach to clinical deterioration with either percutaneous drainage or surgical management should be considered if the patient does not respond to conservative treatment., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The duodenum is the second most common location for a diverticulum to form after the colon. These duodenal diverticula (DD) are often found incidentally and rarely require intervention. In recent years, surgical management has been restricted to patients with significant complicated sequelae, such as perforation, abscess, or fistula formation. We present the rare case of a perforated broad-based diverticulum in the third portion of the duodenum necessitating surgical correction. The patient presented with persistent symptoms following failure of conservative management and underwent surgical resection. Due to difficulty visualizing the extent of the diverticulum, a novel intraoperative technique of bowel insufflation via nasogastric tube was used allowing for elucidation of the diverticular borders and complete resection. Although DD are common, there exists no consensus on when operative intervention is indicated. Given that significant morbidity and mortality can be associated with symptomatic DD, a systematic way to guide management decisions is needed. After conducting a review of the literature, we propose that the modified Hinchey classification can be used not only to categorize duodenal diverticulitis but to guide treatment choice in cases with unclear risk benefit profiles.

Duodenal diverticula are the second most common type of digestive diverticula after those in the colon. They are present in approximately 27% of patients who undergo upper digestive endoscopy. Most of these diverticula, especially those located near the papilla, are asymptomatic. However, in rare cases, they can be associated with obstructive jaundice (Lemmel Syndrome), bacterial infection, pancreatitis, or bleeding. In this report, we present two cases of acute obstructive pancreatitis caused by duodenal diverticulitis. Both patients were managed conservatively, resulting in a positive outcome., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

Background: Periampullary duodenal diverticula are rare and pancreaticobiliary complications infrequent, however, when they are diagnosed and associated with symptoms, they warrant urgent intervention. The aim of this article is to present a clinical case of severe cholangitis secondary to the presence of a periampullary diverticulum successfully treated endoscopically., Clinical Case: A 68-year-old man with a history of diabetes and hypertension, was admitted to the emergency room with symptoms of abdominal pain, fever, and tachycardia. With acute kidney injury and alterations in liver function tests, ultrasound with dilated common bile duct and gallstones. Magnetic resonance cholangiography is performed, showing duodenal diverticulum and choledocholithiasis. Antibiotic management is given, and endoscopic retrograde cholangiopancreatography is decided, finding a duodenal diverticulum with stones and pus inside, sphincterotomy, transpapillary dilation and multiple sweeps are performed. Cholecystectomy was performed 7 days later, and the patient was discharged without complications., Conclusions: In patients with signs of severe cholangitis, it is important not to delay endoscopic retrograde cholangiopancreatography, even when infrequent associated pathologies are evidenced, such as a periampullary duodenal diverticulum, since this represents the diagnostic and therapeutic method of choice with high rates of resolution in the case of an obstructive pathology of the bile duct., (© 2023 Revista Médica del Instituto Mexicano del Seguro Social.)

We report a case of a 73-year-old woman affected by Lemmel's syndrome, a rare type of obstructive jaundice caused by a periampullary duodenal diverticulum. The patient was admitted to the Emergency Department for pneumonia associated with mild epigastric pain and vomiting. While hospitalized for antibiotic treatment, the appearance of jaundice led us to discover a periampullary duodenal diverticulum by endoscopy and CT scan. The jaundice was successfully managed endoscopically with removal of food debris from the diverticulum., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Choledocholithiasis is a commonly encountered disease that is associated with various clinical presentations ranging from mild form of biliary colic to severe life-threatening acute cholangitis. Recently, peri-ampullary diverticulum (PAD) has been linked to the development of biliary diseases; however, data regarding its association with the development of acute cholangitis in the setting of choledocholithiasis are scarce., Aims: We aimed to identify predictors, specifically PAD, for the development of acute cholangitis in patients with choledocholithiasis., Methods: We performed a retrospective cross-sectional study of all patients admitted to Galilee Medical Center from 1 January 2010 to 31 December 2019 with different clinical presentations of documented choledocholithiasis including cholangitis, biliary pancreatitis, and biliary colic with abnormal liver enzymes., Results: Overall, 651 patients were included in the final analysis. Among them, 88 patients (13.5%) had choledocholithiasis associated with acute cholangitis (group A), as compared to 563 patients (86.5%) without acute cholangitis (group B). The average ages in groups A and B were 77.8 ± 13.6 and 62.4 ± 20.4 years, respectively (P < 0.0001). The rate of PAD was significantly higher in group A as compared to group B (35.2% vs. 19%, P = 0.0002). However, the rate of smoking, chronic liver diseases, hemolytic anemia, and post-cholecystectomy status were not different between the groups (P = 0.3, P = 0.3, P = 0.2, and P = 0.3), respectively. On univariate analysis, age (OR 1.05, P < 0.0001) and PAD (OR 2.32, P = 0.0006) were significantly associated with acute cholangitis. On multivariate logistic regression analysis, the effects of age and PAD were preserved (OR 1.05, 95% CI 1.03-1.07, P < 0.0001 and OR 1.64, 95% CI 1.02-2.72, P = 0.049), respectively., Conclusion: PAD showed a significant association with the development of acute cholangitis among patients with choledocholithiasis. Identification of gallbladder and biliary stones in patients with PAD is of paramount importance since early diagnosis and treatment might prevent further life-threatening complications., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Diverticula of the small bowel can be categorised as true, with Meckel's being the only example, or false. False small bowel diverticula (SBD) are acquired through herniation of the internal layers of the bowel wall through the muscularis propria. Peri-ampullary duodenal diverticula are a well-recognised example; however, the importance of more distal SBD in the jejunum and ileum is underappreciated, and they are under-reported on cross-sectional imaging. SBD are a known cause of anaemia, malabsorption, and diarrhoea, and there are myriad complications of SBD and Meckel's diverticula, which range in severity from inflammation and perforation to haemorrhage, tumour formation, and obstruction. Before the advent of computed tomography (CT), SBD were readily diagnosed on fluoroscopic oral contrast studies; however, radiologists are less comfortable with their cross-sectional imaging appearances. This imaging review combines our experience of multiple proven cases, with illustrative diagrams and radiological images of SBD to provide distinct imaging characteristics, allowing for confident diagnosis of SBD and their numerous complications. We discuss the importance of SBD as a cause of benign, non-surgical pneumoperitoneum. We additionally provide important pitfalls to be aware of such as SBD masquerading as other abnormalities., (Copyright © 2021 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

A 67-year-old man with massive hematemesis was transferred to the emergency unit of our hospital. The patient was diagnosed with primary aortoduodenal fistula (PADF) based on the CT findings. Upon emergent exploration, multiple duodenal diverticula were found and in situ abdominal aortic aneurysm (AAA) repair using polytetrafluoroethylene (PTFE) graft was performed. The third and fourth parts of the duodenum with multiple duodenal diverticula and the origin of jejunum were excised, and end-to-side duodenojejunostomy was performed. The patient was discharged on the 38th postoperative day with another 6 month oral antibiotic treatment. The duodenal diverticula may be the cause for PADF., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Diverticula are commonly observed in the duodenum. Duodenal Diverticulum (DD) usually does not give symptoms throughout life and is diagnosed by coincidence. However, it may present with different symptoms in patients., Objective: This study aims to evaluate the prevalence of DD and Juxtapapillary Duodenal Diverticulum (JDD) and its association with other possible pathologies and to determine its clinical impact by using Computed Tomography (CT)., Methods: This retrospective observational study, which was taken consecutively between the years of 2013-2020, was evaluated in the Radiology Department. The total number of cases was 4850 (male-2440; female-2410). CT images were evaluated by two experienced radiologists at the workstation. DD and JDD prevalence and clinical findings in the hospital registry system were examined., Results: The age of the patients included in the study ranged from 17 to 92 years (mean age 46.94±16.42). In patients with DD (female-130; male-101), mean age was 62.24 ± 12.69 (21-92). The prevalence of DD was 4.76% (n=231). The prevalence of JDD was 4.02% (n=195) and increased with age (p<0.01). The average diameter of the JDD was measured as 23.29±8.22 (9.5-55.3) mm. A significant positive correlation was found between age and DD diameter (p=0.039). DDs were found most commonly 84.42% (n=195) in the second segment of the duodenum as JDD. In patients with JDD, the mean diameter of choledochus and wirsung canal were 6.7 ± 2.4 (3-15.3) mm and 0.31 ± 0.1 (0.1-6.5) mm respectively. The choledochal diameter was correlated with the JDD size (p = 0.004). Cholelithiasis (n=56), choledocholithiasis (n=20), cholecystitis (n=52), diverticulitis (n=15), duodenitis (n=37), pancreatitis (n=5) and hiatal hernia (n=60) with JDD were observed. Periampullary carcinoma was detected in one patient., Conclusion: Our study shows that cholelithiasis, choledocholithiasis, cholecystitis, diverticulitis, duodenitis, pancreatitis may be associated with JDD. Therefore, in contrast-enhanced abdominal CT scans taken for various reasons, investigation of the presence and characteristics of JDD and detection of pathologies that may be associated with JDD are important for patients to benefit from early diagnosis and treatment opportunities and to take precautions against possible complications., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Lemmel's syndrome is an uncommon entity that causes obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledolithiasis or neoplasia. To date, there are few published cases and the etiopathogenesis remains unclear.

A man in his 70s visited our hospital for abdominal pain. Upon admission, abdominal computed tomography findings suggested a duodenal diverticular perforation. Upper gastrointestinal endoscopy revealed an incarcerated enterolith in the periampullary diverticulum. We achieved conservative management by inserting an endoscopic nasobiliary drainage tube into the duodenal diverticulum to aid drainage. The patient was discharged without serious complications 35 days after admission. We report a case of duodenal diverticular perforation with an incarcerated enterolith managed conservatively using endoscopic therapy.

Background: Endoscopic negative pressure therapy is a novel and successful treatment method for a variety of gastrointestinal leaks. This therapy mode has been frequently described for rectal and esophageal leakages. Duodenal diverticular perforations are rare but life-threatening events. The early diagnosis of duodenal diverticular perforation is often complicated by inconclusive symptoms. This is the first report about endoscopic negative pressure therapy in patients with perforated duodenal diverticula., Case Presentation: We present two cases of duodenal diverticula perforations treated with endoscopic negative pressure therapy as stand-alone treatment. Start of symptoms varied from one to three days before hospital admission. Early sectional imaging led to the diagnosis of duodenal diverticular perforation. Both patients were treated with endoluminal endoscopic negative pressure therapy with simultaneous feeding option. Three respective changes of the suction device were performed. Both patients were treated with antibiotics and antimycotics during their hospital stay and be discharged from hospital after 20 days., Conclusions: This is the first description of successful stand-alone treatment by endoscopic negative pressure therapy in two patients with perforated duodenal diverticulum. We thus strongly recommend to attempt interventional therapy with endoluminal endoscopic negative pressure therapy in patients with duodenal diverticular perforations upfront to surgery., (© 2021. The Author(s).)

Background: Periampullary diverticulum (PAD) is frequently come upon during endoscopic retrograde cholangiopancreatography (ERCP), especially in elderly patients. However, less is known about the role of PAD in biliary cannulation difficulty., Aim: This study aims to investigate the association of PAD and difficult cannulation and evaluate the impact of different types of PAD on the cannulation success rate and adverse events., Methods: Prospectively collected data on a total of 636 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) were divided into two groups based on the presence or absence of PAD. Besides, the patients were classified based on the PAD types into three groups. The primary outcomes were cannulation success rate, cannulation time, and ERCP-related adverse events. Further, the difficult cannulation and presence of PAD were analyzed using logistic regression models., Results: Significant higher rates of biliary stones, cholangitis, and biliary pancreatitis were observed in the PAD group. Successful selective cannulation was achieved in 97.6% in the PAD group and 95.3% in the control group. The cannulation time was significantly longer in the presence of PAD. There was no significant difference in the rate of overall adverse events and post-ERCP pancreatic PEP. Multivariate analysis showed that type 1 PAD, biliary stones, and cholangitis were factors related to difficult cannulation., Conclusion: The presence of PAD did not affect the duration or success of the ERCP procedure. However, it was associated with longer cannulation time and an increase in the cannulation difficulty, especially with PAD type 1. Clinical Trial Study Registration This study is approved by Nanjing Medical University and registered at ClinicalTrial.gov PRS with ID/NCT03771547/., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Lemmel's syndrome consists of obstructive jaundice due to compression of a periampular duodenal diverticulum (DDP), in the absence of choledocholithiasis or tumor. DDP are pseudodiverticula without a muscle layer within a radius of 2-3 centimeters from the ampulla of Vater. They rarely cause obstructive jaundice, although the prevalence is estimated at up to 22 % according to the sensitivity of the diagnostic test. They are usually incidental findings, but up to 1-5 % can be complicated with diverticulitis, bleeding, perforation, obstructive jaundice (Lemmel syndrome), choledocholithiasis, pancreatitis or cholangitis.

The duodenum is the second most common location of intestinal diverticula. Periampullary duodenal diverticulum rarely causes obstructive jaundice and this condition was first described by German surgeon Gerhard Lemmel in 1934. Lemmel's syndrome is defined as obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledocholithiasis or a neoplasm.

Background: The duodenal intussusception is rarely reported and usually occurs secondary to organic diseases of the duodenum such as polyps, tumors and duplication cysts. Herein we report a case of duodenal intussusception caused by duodenal diverticulum., Case Presentation: A 21-year old male patient presented with abdominal pain and vomiting for one day. A contrast enhanced computed tomography of the abdomen revealed duodenal intussusception. On emergency laparotomy, the intussusception had reduced spontaneously while an invaginated diverticulum was seen at the junction of the descending and horizontal segments of the duodenum. The diverticulum was resected and the patient had uneventful recovery., Conclusion: Duodenal intussusception is a rare complication of duodenal diverticulum. Being aware of this complication of diverticulum can help in timely diagnosis and treatment.

Background: The duodenum is a common site for diverticulum formation. Most of the duodenal diverticula are asymptomatic, incidental findings. Perforation is a rare but potentially lethal complication of duodenal diverticular disease. Surgery remains the mainstay of treatment for perforated duodenal diverticula. In recent years, a few cases were successfully managed either conservatively or with endoscopy., Case Presentation: We present two cases of female patients treated in our department for duodenal diverticulum perforation. The first case was treated surgically with a diverticulectomy. The second case was managed conservatively with bowel rest and intravenous antibiotics. Both patients had an uncomplicated postoperative course and were discharged home., Conclusions: Both surgical and conservative treatments are viable options for a perforated duodenal diverticulum in selected patients. Patients with a contained duodenal diverticular perforation can be managed conservatively at the outset. Possibly, the introduction of a classification system for duodenal diverticulum perforation may help clinicians in making essential therapeutic decisions.

We describe the case a 92-year-old woman who was admitted to our hospital with choledocholithiasis and periampullary diverticulum (PAD). Due to PAD, clear visualization of the ampulla of Vater could not be obtained. Although selective bile duct cannulation was difficult, a 7-Fr plastic stent was placed during the first session. Fifteen days later, endoscopic retrograde cholangiopancreatography was retried using traction devices, and the papilla became visible. Endoscopic sphincterotomy and stone extraction were performed without any complications. The application of traction devices in endoscopic submucosal dissection may be a promising technique in cases in which endoscopic biliary intervention is difficult due to PAD.

Aim: To investigate the effect of peri-ampullary duodenal diverticula (PAD) on extrahepatic bile duct (EHBD) dilatation before and after cholecystectomy., Materials and Methods: During a 5-year period, a total of 860 consecutive patients with prior cholecystectomy were examined using abdominal computed tomography (CT). After exclusion of those with other obstructive EHBD lesions, 61 patients with PAD were recruited for evaluation of EHBD dilatation before and after cholecystectomy and were compared with a randomly sampled control group (n=113) without PAD. EHBD diameter was measured on coronal reconstruction CT using electronic callipers on the picture archiving and communication system monitors by two reviewers in consensus., Results: There was no significant difference in EHBD diameter between PAD and non-PAD groups (8.2±2.8 versus 7.8±2.3 mm; p=0.276) before cholecystectomy. Compared with preoperative diameter, EHBD was significantly dilated after cholecystectomy (7.9±2.5 versus 9.8±3.4 mm, p<0.001), regardless of the presence of PAD; the degree of change was more prominent in the PAD group than in the non-PAD group (3.3±2.4 versus 1.1±1.6 mm; p<0.001) after surgery. The size of PAD did not affect the degree of EHBD dilatation after cholecystectomy (p=0.522). In the non-PAD group, the degree of EHBD dilatation was positively correlated with the follow-up interval after cholecystectomy (r=0.298; p=0.002), while the PAD group showed no significant correlation (r=-0.036; p=0.797). In patients with ≥2 mm postoperative EHBD dilatation, PAD incidence was higher than that in other patients (odds ratio, 8.739; p<0.001)., Conclusion: Regardless of their size or postoperative follow-up duration, PAD induce marked post-cholecystectomy biliary dilatation., (Copyright © 2019 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

An 89-year-old man presented to the emergency department with a 1-month history of upper right quadrant pain, worsened in the last 3 days and accompanied by fever and chills. On physical examination, he had scleral icterus and right upper quadrant tenderness. Laboratory findings showed hyperbilirubinemia, elevated liver enzymes and C reactive protein. The patient was admitted, suspecting of an acute cholangitis and started on antibiotics. An upper gastrointestinal endoscopy revealed the presence of a juxtapapillary diverticulum in the second portion of the duodenum, which was confirmed by a magnetic resonance cholangiopancreatography, along with upstream biliary tract ectasia. The imaging findings allowed us to diagnose a Lemmel's syndrome. Due to potential surgical risk, we decided for a conservative approach. The patient had a favourable course and was discharged home., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To demonstrate the prevalence, accompanying pathologies, imaging and follow up findings of Duodenal Diverticula (DD) with Multidetector Computed Tomography (MDCT)., Materials and Methods: Consecutive 2910 abdominal MDCTs were retrospectively reviewed on axial, coronal and sagittal planes. DD were evaluated for prevalence, location, number, size, contents, diverticular neck, accompanying pancreaticobiliary pathologies, jejunal and colonic diverticula, respectively., Results: DD were diagnosed in 157 cases (5.4%) and found mostly in the second part of the duodenum. Juxta-ampullary DD was the most common type (78.3%) and mostly located ventral (n:86, 69.9%) to the ampulla of Vater. DD was solitary in 123 patients (78.3%) and more than one in 34 patients (21.7%). The median diameter of DD was 2.5 cm (range 1.5-3.6 cm) in the long-axis. The lumen of DD contains air and contrast agent (n:96, 61.1%); air, contrast agent and debris (n:42, 26.7%) in most cases. Colonic diverticula (n:36, 22.9%), cholelithiasis (n:32, 20.4%), choledocholithiasis (n:7, 4.4%), and biliary dilatation (n:8, 5.1%) were the most common additional findings. Median follow-up time was 23 months (range 11 to 41 months). In three cases, new findings (cholelithiasis, n:3, choledocholithiasis, n:1) were detected., Conclusion: Accompanying pathologies with DD diagnosis are valuable for physicians in order to manage the patients. Following clinical and radiological features of well-diagnosed DD might reduce the possible complications., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Lemmel's syndrome is a very rare condition as a cause of obstructive jaundice secondary to the presence of a duodenal diverticulum. We report a case, a 68-year-old female patient with a cholestatic pattern, biliary tract dilatation, who underwent ERCP, with a juxtapapillary diverticulum compressing the distal bile duct, which was sphincterotomy.

Background/objectives: Studies have suggested that the presence of juxtapapillary duodenal diverticula (JDD) could be a predisposing factor for choledocholithiasis. This systematic review and meta-analysis was conducted with the aims to summarize all available evidence to better characterize the risk., Methods: A literature search was performed using MEDLINE and EMBASE database from inception to January 2018. Cross-sectional studies that reported odd ratios (OR) comparing the risk of choledocholithiasis among individuals with JDD versus individuals without JDD were included. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method., Results: Of 527 retrieved articles, 11 studies met our eligibility criteria and were included in analysis. We found a significant association between the presence of JDD and choledocholithiasis with the pooled OR of 2.30 (95% CI, 1.84-2.86). The statistical heterogeneity was moderate with an I 2 of 60%., Conclusions: A significantly increased risk of choledocholithiasis among individuals with JDD was observed in this study.

Background: Bleedings such as melaena are related to diseases in the upper gastrointestinal tract. In 0.06% - 5% of cases these incidents are due to the presence of diverticula of the small intestine, which are asymptomatic and unrecognized in most patients and are only fully diagnosed in cases when complications occur., Case Report: An 88-year old male patient presented with severe anaemia, asthenia and melaena in the previous days. An esophagogastroduodenoscopy (EGDS) was performed with evidence of stenosis in the second part of the duodenum and a blood clot in the posterior wall without signs of active bleeding. A complete CT scan was carried out of the thorax, abdomen and pelvis using a contrast medium, which revealed a dilation of the stomach and of the first part of the duodenum with a diverticulum of the second. On the fourth day following admission the patient suffered a haemorrhagic shock and underwent an emergency surgical procedure with a bleeding diverticulum on the posterior wall of the duodenum tightly adhering to the pancreas being found. Therefore an atypical duodenal-jejunal resection was performed using a gastrojejunal Roux-en-Y bypass and the closure of the duodenal stump., Conclusion: Diverticulosis of the duodenum and small intestine is considered a rare disease. According to the literature, treatment should be conservative, and surgical options considered only in those very rare cases of complicated and life-threatening diverticulosis.

Background: Many studies, almost all in an Endoscopic Retrograde Cholangiopancreatography (ERCP) setting, have been conducted to establish if a link exists between periampullary diverticula (PADs) and biliopancreatic diseases but the issue is still debated., Aims: The objective was to clarify the link between PADs and biliopancreatic disease, for the first time using Endoscopic Ultrasound (EUS)., Methods: We retrospectively reviewed our database seeking patients scheduled for EUS with an indication that entailed the exploration of the second duodenum. For each patient with a PAD enrolled in the study, 6 controls were randomly selected., Results: 2475 patients met the inclusion criteria. Among them, 185 subjects with a PAD were found (prevalence 7.5%), 1110 subjects served as controls. Patients with a PAD had more frequently a history of cholangitis (8.1 vs 2.2%; OR 3.99, p < 0.001), a higher prevalence of common bile duct (CBD) dilation (44.3 vs 28.2%; OR 2, p < 0.0001) and a higher prevalence of CBD stones (34.1 vs 19.6%; OR 2.1, p < 0.0001). No differences were found about history of jaundice, acute/recurrent pancreatitis or EUS signs of chronic pancreatitis., Conclusion: Whereas PADs were linked with history of cholangitis, CBD stones and dilation, no association was found with pancreatic diseases., (Copyright © 2018 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

We present the case of an 82-year-old man with a history of heart failure, mitral regurgitation, type 2 DM, hypertension, dilated cardiomyopathy and a paroxysmal atrial flutter. The patient was under treatment with Sintrom. The patient presented to the emergency department due to melenic depositions of a one day evolution and dietary vomiting. There was no rectal bleeding and the patient was admitted three months previously due to self-limited melena with a normal gastroscopy. Anemia of 8 g and an overdose of Sintrom was diagnosed. A gastroscopy was performed and a large duodenal diverticulum with a fresh clot was found that was washed. A Dieulafoy lesion was subsequently found underneath with jet bleeding, which was sclerotic with adrenaline and a hemoclip. There was a favorable evolution after correcting the coagulopathy.

In relation to the article published in this journal by Valdivielso Cortázar et al., we have recently diagnosed a massive digestive hemorrhage secondary to a Dieulafoy's lesion inside a duodenal diverticulum. This was successfully treated with endoscopy.

The authors present a rare case of perforated duodenal diverticulum diagnosed in an 80-year-old Caucasian woman with vomiting and abdominal pain localised to the epigastrium. CT scan showed thickening of the second portion of the duodenum with retroperitoneal fat stranding and perihepatic free fluid, with a presumptive diagnosis of a duodenal perforation. A laparotomy was performed which showed a perforated diverticulum in the second portion of the duodenum. A diverticulectomy with single-layer closure was performed, without complications. The postoperative course was uneventful., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Periampullary duodenal diverticula are common and are usually asymptomatic. However, complications like biliary or pancreatic obstruction, duodenal obstruction, perforation, or hemorrhage can occur occasionally. Obstructive jaundice is usually due to biliary stones and periampullary tumors. Rarely, duodenal diverticula may present with obstructive jaundice in the absence of cholelithiasis or other detectable obstacle. This condition is called Lemmel's syndrome. There are only few case reports of this rare condition. We report a case of 78-year-old man presenting with painless obstructive jaundice due to Lemmel's syndrome which was diagnosed on endoscopic ultrasonography.

Basis and Purpose: The presence of peripapillary diverticulum (PPD) can cause some biliary diseases, especially common bile duct stones, and also, literally, can change the technique of endoscopic retrograde cholangiopancreatography (ERCP) and affect the complication ratio of this procedure. In this study, we investigate the effect of localization and position of the papilla according to the diverticulum on the success of therapeutic ERCP procedures., Materials and Methods: The study was conducted prospectively in the patients with naive papillae, who underwent ERCP for a period of 16 months. In all patients, the position of papillae according to the diverticulum (the periphery of the diverticulum is thought as the clock circumference, and the position of papillae is defined as the dials of clock), the success rate of biliary cannulation, total procedure time, overall treatment success rate of ERCP, and the complications are investigated., Results: During this period, 222 (18.5%) of the 1205 enrolled patients who underwent ERCP had PPD. Of the patients with PPD, 123 (55.4%) were female and 99 (44.6%) were male, and the median age was 68.9±10.1 years. According to the position of the papilla by the diverticulum, 90 (40.5%) patients have it on 7 o'clock position, 64 (28.8%) patients have on 6 o'clock position, 63 (28.3%) patients have on 5 o'clock position, and 5 (2.3%) patients have on 1 o'clock position. In the cases of the papilla on 1 o'clock position according to the diverticulum, cannulation procedures were found to be more difficult than other patients (P<0.05). The presence of the diverticulum did not affect the success of therapeutic procedures and did not increase the ratio of complications., Conclusions: In the presence of PPD, additional cannulation techniques may be required for the procedure. Particularly, the aid of percutaneous techniques may be needed for the papilla on 1 o'clock position.