What is the recommended diagnostic and treatment approach for an adult with duodenal diverticulitis?

Duodenal Diverticulitis: Diagnostic and Treatment Approach

For adults with suspected duodenal diverticulitis, obtain a contrast-enhanced CT scan of the abdomen as the primary diagnostic modality, and pursue conservative management with IV antibiotics, bowel rest, and close monitoring in hemodynamically stable patients without peritonitis, reserving surgery only for frank sepsis or generalized peritonitis. 1, 2, 3

Diagnostic Strategy

Initial Imaging: CT with IV Contrast

CT abdomen and pelvis with intravenous contrast is the diagnostic test of choice for suspected duodenal diverticulitis, achieving sensitivities of 92-99% and specificities of 97-100%. 1, 4, 5

• IV contrast is essential for characterizing subtle bowel wall abnormalities, detecting retroperitoneal fluid collections, identifying air-fluid levels around the duodenum, and distinguishing between contained perforation versus free perforation. 1, 4, 3

• CT findings in duodenal diverticulitis include: duodenal wall thickening, periduodenal fat stranding, retroperitoneal fluid collections with or without air-fluid levels, and extraluminal gas indicating perforation. 2, 3, 5

Alternative Imaging When CT Unavailable

If CT is contraindicated or unavailable, ultrasound or MRI can be considered as alternatives, though their diagnostic accuracy for duodenal pathology is less well-established than for colonic diverticulitis. 1, 6

• Ultrasound demonstrates sensitivity >90% for diverticulitis generally, but has significant limitations in detecting retroperitoneal pathology and is operator-dependent. 6

• MRI yields sensitivity of 94% and specificity of 88%, with advantages including no radiation exposure and superior soft tissue resolution for detecting abscesses. 6

Clinical Presentation Patterns

Duodenal diverticulitis presents with nonspecific symptoms that create diagnostic challenges: 2, 3, 5

• Epigastric or right upper quadrant pain (not the classic left lower quadrant pain of colonic diverticulitis)
• Low-grade fever and leukocytosis
• Nausea, vomiting, and postprandial discomfort
• Clinical presentations vary widely from mild abdominal discomfort to acute abdomen with generalized sepsis 3

Critical pitfall: Only 5% of patients with duodenal diverticula develop symptomatic complications, and symptoms are often indeterminate, leading to diagnostic delays. 2

Treatment Algorithm

Conservative Management (First-Line for Stable Patients)

In hemodynamically stable patients without peritonitis or frank sepsis, conservative management is the preferred approach, avoiding the significant morbidity of complex duodenal surgery. 2, 3

Conservative therapy includes:

• IV broad-spectrum antibiotics covering enteric organisms 2, 3, 5
• Bowel rest with nothing by mouth 3
• Parenteral nutrition for nutritional support during bowel rest 3
• Close clinical monitoring for signs of deterioration 2, 3

Evidence supporting conservative management: A 2025 case report demonstrated successful conservative treatment of a large retroperitoneal fluid collection (5.5 × 5.6 × 4.8 cm) with air-fluid level, initially interpreted as localized duodenal perforation, with good outcomes and avoidance of high-risk surgery. 2

Endoscopic Intervention (When Conservative Management Fails)

Endoscopic therapy can be effective when conservative management fails and represents a viable alternative to surgery. 7

• Side-viewing duodenoscopy can identify purulent drainage from the diverticular opening 7
• Endoscopic drainage involves enlarging the opening with an extraction balloon, followed by sweeping and saline irrigation to evacuate pus and debris 7
• A 2021 case demonstrated rapid recovery with discharge on day 5 post-hospitalization following endoscopic drainage 7

Surgical Management (Reserved for Specific Indications)

Surgery is indicated only for:

• Frank sepsis or hemodynamic instability 2, 3
• Generalized peritonitis 2, 3
• Failure of conservative or endoscopic management 3

Surgical approach for unstable patients requires complete diversion of gastric contents and biliary flow from the affected duodenal area, representing a technically challenging and high-risk procedure. 3

Adjunctive Interventions

Percutaneous drainage of peridiverticular abscesses can be performed under CT guidance when abscesses are accessible, reducing sepsis and potentially avoiding surgery. 5

Special Considerations and Complications

Portal Vein Thrombosis

Duodenal diverticulitis can be complicated by portal vein thrombosis, requiring anticoagulation (warfarin) in addition to antibiotics. 7 Follow-up imaging at 1 month should confirm resolution of both the diverticulitis and thrombosis. 7

Contrast-Induced Nephropathy Prevention

In patients requiring CT with IV contrast who have compromised renal function (GFR <40-45 mL/min/1.73 m²):

• Initiate isotonic saline hydration at 1 mL/kg/hour for 12 hours before and after contrast 8
• Minimize contrast volume (<350 mL or <4 mL/kg) 8
• Use low-osmolar or iso-osmolar contrast media 8

Do not use: Bicarbonate infusion, oral N-acetylcysteine, or prophylactic dialysis are not recommended. 8

Critical Pitfalls to Avoid

• Do not delay imaging in patients with atypical presentations, as diagnostic delay can lead to catastrophic complications including retroperitoneal perforation. 2, 3

• Do not skip IV contrast without compelling contraindications, as sensitivity for detecting complications drops significantly without contrast enhancement. 4

• Do not rush to surgery in stable patients, as conservative management can be highly effective and avoids the substantial morbidity of duodenal surgery. 2

• Do not rely on clinical examination alone, as elderly patients and those on corticosteroids may have limited physical findings even with severe disease. 9