Clinical Images Intramural duodenal diverticulum mimicking a periampullary neoplasm Gennaro Clemente, M.D.*, Gerardo Sarno, M.D., Marco Giordano, M.D., Agostino M. De Rose, M.D., Gennaro Nuzzo, M.D. Department of Surgery, A. Gemelli Medical School, Largo Gemelli, 8 – 00168 Rome, Italy Abstract A 34-year-old woman presented with epigastric pain, nausea, and dyspepsia. Contrast- enhanced computerized tomography revealed a small mass in the duodenal wall mimicking a periam- pullary neoplasm and, at endoscopic examination, a periampullary submucosal tumor was suspected. The diagnosis of intramural duodenal diverticulum (IDD) was made by an x-ray barium meal that showed a finger-like sac filled with barium, the so-called “windsock sign.” IDD is a rare congenital abnormality caused by an anomalous process of recanalization of the primitive foregut. The intermittent filling and emptying of the IDD is responsible for epigastric pain, nausea, and vomiting. When IDD is symptomatic, surgical or endoscopic treatment is recommended. © 2008 Elsevier Inc. All rights reserved. KEYWORDS: Duodenum; Intramural diverticulum; Periampullary neoplasms A 34-year-old woman had a 2-year history of occasional epigastric pain and other nonspecific upper abdominal symp- toms, such as nausea and dyspepsia. At physical examina- tion, no abnormalities were found and abdominal palpation was normal. Except for a moderate increase of gamma- glutamyl-transpeptidase (58 IU/L; normal range 5– 45), all biochemical data were within normal limits, including tumoral markers carcinoembryonic antigen (CEA) and Ca 19-9. An ultrasound showed a gallbladder without stones, and there was no dilatation of the intra- or extra- hepatic bile ducts. A submucosal tumor in the descending duodenum was suspected at the endoscopic examina- tion. A contrast-enhanced computerized tomography (CT) scan revealed a small mass in the duodenal wall at the level of the papilla of Vater (Figure 1). An x-ray barium meal was performed, which showed a finger-like sac filled with barium and surrounded by a radiolucent band (the “windsock sign”) (Figure 2). Diagnosis of intramural duodenal diverticulum (IDD) was made; a second, more accurate endoscopic examination confirmed this diagno- sis. The patient refused treatment because of her lack of symptoms. Comments IDD is a congenital abnormality caused by an anomalous process of recanalization of the primitive foregut and is less common than extramural duodenal diverticulum. 1 The de- fects of duodenal development range from duodenal webs to atresia; IDD could develop when an incomplete duodenal diaphragm becomes an intramural diverticulum under the force of peristalsis. 2 It can be differentiated from duodenal duplication because of the absence of a normal intestinal wall architecture. IDD is diagnosed in both sexes between the ages of 30 and 50 years 3 and is frequently associated with other abnormalities, such as annular pancreas, intesti- nal malrotation, and duplication of the papilla of Vater. 4 When IDD is symptomatic, clinical presentation is typically characterized by upper gastrointestinal symptoms, such as nausea, epigastric pain, and vomiting. The intermittent fill- * Corresponding author. Tel.: +39.06.30155187; fax: +39.06.3058586. E-mail address: gclemente@rm.unicatt.it Manuscript received July 4, 2007; revised manuscript October 11, 2007 0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.10.028 The American Journal of Surgery (2008) 196, e31– e32