Management of a windsock diverticulum by the use of novel submucosal dissection scissors

Abstract

Figure 2. Diverticular base with a small orifice. The distal duodenum can be visualized through this orifice. A 41-year-old woman was referred for evaluation for a 2-year history of nausea, postprandial pain, dysphagia to solid food, and intermittent regurgitation. An esophagram demonstrated a 4-cm-long outpouching suggestive of an epiphrenic diverticulum. Endoscopic evaluation demonstrated the esophageal diverticulum identified on her fluoroscopic evaluation; however, the patient was also noted to have an intraluminal duodenal diverticulum (ie, windsock diverticulum) in the second portion of the duodenum (Fig. 1). Windsock diverticulum is a rare congenital anomaly resulting from incomplete recanalization of the embryologic foregut, leaving a membrane within the duodenum. Over time, continued peristalsis leads to elongation of the membrane and formation of a diverticulum. Windsock diverticula arise in the second portion of the duodenum near the ampulla of Vater and are described as such because of the pathognomonic appearance on upper-GI series. Most patients are asymptomatic, but some may have nausea, vomiting, postprandial abdominal pain, early satiety, and weight loss. They less commonly can present with GI bleeding, small-bowel obstruction, and pancreatitis. After identification, endoscopic diverticulectomy or diverticulotomy can be performed, and many techniques have been described. A variety of devices have been reported, including standard polypectomy