Guidewire assisted Winsock diverticulotomy using hook knife electrocautery. Primary author, Zachary L. Pattison. Co-author, Abraham Matthew. These are our disclosures. A 36-year-old female with history of GERD, hyperlipidemia, and morbid obesity was referred to the gastroenterology clinic with postprandial nausea and right upper quadrant abdominal pain for approximately the past 5 months. Her symptoms resolved gradually and spontaneously 20-30 minutes after eating. Prior workup included an abdominal ultrasound which was consistent with moderate hepatic steatosis, negative for cholelithiasis or Murphy's sign, with a common bioduct of 2.7 mm in diameter. The gastric emptying study demonstrated moderate delay in gastric emptying with 80% gastric emptying at 4 hours. Celiac serologies were negative for celiac disease. The patient was referred for upper endoscopy, which revealed a large duodenal diverticulum located immediately post-pyloric in the duodenal bulb. The diverticulum was filled with food particulate, which obscured entry into the second portion of the duodenum. A subsequent upper GI series was ordered, which revealed a large intraluminal Winsock diverticulum. The patient elected for endoscopic management of her intraluminal duodenal diverticulum. During this procedure, the aperture of the intraluminal duodenal diverticulum was identified in the second duodenal segment, resulting in a double-barrel appearance of the duodenal lumen. The intraluminal duodenal diverticulum was intubated with an adult endoscope with cap to approximately 8 to 10 centimeters and cleared of debris, revealing a pinhole opening at the apex of the diverticulum. In order to maintain orientation during dissection, a soft-tip guide wire was advanced into the diverticular lumen. The guide wire ultimately passed through the pinhole opening at the apex of the diverticulum and was advanced into the distal duodenum. Endoscopic dissection was performed along the entire length of the free diverticular wall using hook-knife electrocautery, with careful attention paid to avoid involvement of the major duodenal papilla. Complete dissection of the diverticular septum was achieved with minimal bleeding, which was addressed directly at the time of intervention. Double-barrel appearance of the duodenal lumen. White arrow indicates diverticular lumen, red arrows the diverticular septum. continued dissection of the diverticular septum. Completed diverticulotomy with bisection of the free diverticular wall, as indicated by the red arrows, and native duodenal lumen, as indicated by the green arrow. Historically, symptomatic intraluminal duodenal diverticulum were managed by surgical diverticulectomy. However, with advancements in endoscopic technology and techniques, intraluminal duodenal diverticulum are now often managed endoscopically by either diverticulectomy or diverticulotomy. Several techniques for endoscopic diverticulotomy and diverticulectomy have been described previously. The technique described in this case, specifically the use of hook knife electrocautery and soft-tipped guide wire deployment to maintain operator orientation, adds to the growing collection of proven methods available to the endoscopist for addressing this anatomical abnormality. In this case, a successful diverticulotomy was achieved via endoscopic dissection utilizing hook knife electrocautery with guide wire assist in order to maintain orientation along the entire length of the dissection plane. This modified method of diverticulotomy proved a safe and effective approach for the treatment of a symptomatic intraluminal duodenal Winsock diverticulum and adds to the growing catalog of techniques available to endoscopists for management of this rare anatomic abnormality which can result in significant patient symptomology.

case study

postprandial nausea

right upper quadrant abdominal pain

intraluminal duodenal diverticulum

endoscopic management