(Radiology. 2001;218:749-750.)
© RSNA, 2001
The Duodenal Wind Sock Sign1
Roland Materne, MD
1 From the Department of Radiology, Université Catholique de Louvain, St-Luc University Hospital, Avenue Hippocrate 10, B-1200 Brussels, Belgium. Received May 24, 1999; revision requested July 20; revision received August 16; accepted August 25. Address correspondence to the author (e-mail: materne@rdgn.ucl.ac.be).
Index terms: Duodenum, abnormalities, 73.123, 73.279 • Duodenum, diverticula, 73.123, 73.279 • Signs in Imaging
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APPEARANCE
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The duodenal wind sock sign is a finding that may be seen on an upper gastrointestinal series. This sign consists of a barium-filled sac that lies entirely within the duodenum and that is surrounded by a narrow radiolucent line that is well demonstrated as the barium in the duodenum passes distal to the diverticulum (Figure).
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Figure 1. Duodenal wind sock sign in a patient with duodenal diverticulum. Image from an upper gastrointestinal series clearly demonstrates an intraluminal duodenal diverticulum (arrows) surrounded by a narrow radiolucent line (arrowheads). The diverticulum, arising in the second portion of the duodenum and extending to the third portion, was confirmed at surgery.
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EXPLANATION
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The duodenal wind sock sign has been described as a typical appearance of an intraluminal duodenal diverticulum (1). The narrow radiolucent line represents an intraluminal mucosal diaphragm or web caused by failure of normal recanalization of the duodenum after epithelial cell occlusion of the foregut lumen in the 7-week human embryo (2). Over time, the diaphragm passively elongates as a result of continual peristalsis to form the wind sock configuration of an intraluminal duodenal diverticulum. Because of the thin radiolucent stripe surrounding the diverticulum, the appearance on an upper gastrointestinal series has also been described as the halo sign (3).
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DISCUSSION
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An intraluminal duodenal diverticulum is a rare developmental anomaly usually found within the second portion of the duodenum (4). Most cases originate near the ampulla of Vater and lie in an isoperistaltic direction. Rarely, it may arise in the third portion of the duodenum or extend in an antiperistaltic direction. Attachment of the diverticulum to the duodenum usually involves less than one-half of the wall circumference, although in a few cases it has been reported (1) to be attached to the entire circumference. When the diverticulum is attached to the entire circumference of the duodenal wall, an aperture or fenestra located either centrally or peripherally may allow the distal passage of duodenal contents. In contrast to diverticula found elsewhere in the gastrointestinal tract, intraluminal duodenal diverticula are lined on both sides with intestinal mucosa. Only a thin layer of fibromuscular tissue underlying the epithelium can be seen, and the vascularity is poor.
The clinical manifestation of intraluminal duodenal diverticulum is nonspecific and consists of epigastric pain, vomiting, and abdominal fullness (5). Symptoms usually do not appear until the 3rd decade of life, although they can occur in childhood in 20% of patients (5). In these childhood cases, differential diagnosis of congenital obstruction should include a duodenal intrinsic defect (atresia, stenosis, or duplication), an extrinsic defect (annular pancreas or malrotation with congenital bands), or a combination of these (6). A 40% prevalence of coexisting congenital anomalies has been reported (1,7,8) with intraluminal duodenal diverticulum and its predecessor, the congenital duodenal diaphragm. These coexisting anomalies include annular pancreas, choledochocele, imperforate anus, Hirschsprung disease, congenital heart disease, omphalocele, hypoplastic kidney, exstrophy of the bladder, situs inversus, malrotation, Ladd band, portal vein anomalies, and Down syndrome. Duodenal obstruction may sometimes be suspected before birth, when ultrasonography (US) shows a fluid-filled duodenum (9).
Complications of an intraluminal duodenal diverticulum have been reported (1,2,10) in 20%–25% of adult patients. Complications include duodenal obstruction when the diverticulum becomes distended with food content, gallstones, or foreign bodies; peptic ulcer disease caused by stasis of food and gastric secretions; hemorrhage from ulceration within the diverticulum; and cholangitis or pancreatitis because of the proximity of the diverticulum to the ampulla of Vater.
Intraluminal duodenal diverticulum is usually diagnosed with an upper gastrointestinal series (11). Its typical appearance has been linked to that of a wind sock being blown into the duodenum. Radiographic findings are pathognomonic (5), and no other lesions should be considered in the differential diagnosis. However, if the diverticulum is already filled with fluid and/or other material and if it does not fill with barium, it may resemble a pedunculated polyp, submucosal tumor, or choledochocele. The endoscopic findings are also characteristic in that the diverticulum appears as a blind pouch lined with normal duodenal mucosa. Intraluminal duodenal diverticulum has been reported (10,12–15) in a few cases evaluated with computed tomography, endoscopic US, intravenous cholangiography, percutaneous transhepatic cholangiography, and endoscopic retrograde pancreatography.
The traditional treatment of an intraluminal duodenal diverticulum is surgery, but endoscopic incision has been more recently advocated and has a satisfactory outcome (16,17).
In conclusion, knowledge of the duodenal wind sock sign as a pathognomonic finding of an intraluminal duodenal diverticulum is important for the correct diagnosis of this rare developmental anomaly, which usually manifests in a nonspecific manner in adults.
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FOOTNOTES
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A trainee (resident or fellow) wishing to submit a manuscript for Signs in Imaging should first write to the Editor for approval of the sign to be prepared, to avoid duplicate preparation of the same sign.
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REFERENCES
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