Side-viewing endoscope for diagnosis of bleeding from a duodenal diverticulum

The majority of duodenal diverticula are asymptomatic and seldom cause gastrointestinal hemorrhage. We observed a 58-year-old woman who presented with melena. On admission her vital signs were stable and hematocrit was 27.5 %. Emergency upper endoscopy using a forward-viewing endoscope (Olympus XQ 20, Olympus America Inc., Lake Success, N.Y.) was performed but there was no evidence of bleeding. Conservative treatment was initiated and her condition remained stable until she had a maroon stool the next morning. Upper endoscopy using the same endoscope was repeated but there was no evidence of bleeding again. Angiography also failed to demonstrate extravasation. Duodenoscopy using a side-viewing endoscope (Olympus JF 1T-20) revealed a diverticulum in the beginning of the third portion with a blood clot at the base. After irrigation, a red protuberance with a glistening surface was observed, and heater-probe therapy was applied to this area. Unfortunately, this application provoked further bleeding and the patient required an emergency laparotomy. Following duodenotomy, she was treated with diverticuloplasty. Recovery was uneventful. Duodenal diverticulum is a rare source of gastrointestinal bleeding and when it occurs it is difficult to diagnose. Usually the diagnosis is considered by exclusion of other bleeding sources and repeated examinations may be necessary. Endoscopic verification of bleeding duodenal diverticula and endoscopic management with injection therapy have been reported previously. 13 Duodenoscopy with a side-viewing endoscope is recommended, as in our case.