Abstract

Background: Diverticula of the gastrointestinal tract are common in older adults, most often affecting the colon. While typically asymptomatic, acute diverticulitis represents the most frequent complication and may lead to severe outcomes, including perforation, abscess formation, and diffuse peritonitis. Duodenal diverticula on the other hand is a rare clinical entity, and is frequently detected incidentally during proximal endoscopy. While most cases are asymptomatic, inflammation of periampullary duodenal diverticula may result in serious complications. Acute pancreatitis secondary to duodenal diverticulitis is exceedingly rare and has been described almost exclusively in isolated case reports. Clinical obesity, particularly increased visceral adiposity, has been associated with more severe inflammatory responses in complicated diverticular disease and may influence disease progression and outcomes. Objective: The aim of this article was to present a case of severe acute pancreatitis with peripancreatic fat necrosis caused by acute duodenal diverticulitis in a patient with clinical obesity. Case presentation: A patient presented with diffuse abdominal pain and was diagnosed with severe acute pancreatitis based on laboratory findings and radiological imaging. Comprehensive diagnostic evaluation, including radiological studies, proximal endoscopy, and endoscopic ultrasound (EUS), excluded common etiology. Further assessment identified a markedly enlarged periampullary duodenal diverticulum as the most likely trigger, associated with peripancreatic visceral fat necrosis and with signs of multiorgan dysfunction. Subsequent anthropometric and body composition assessment confirmed clinical obesity with increased visceral fat area, which was considered a contributing factor to disease severity. Targeted pharmacological therapy combined with individualized nutritional intervention resulted in complete clinical remission. Conclusion: Complicated diverticular disease has been shown to be associated with obesity and increased visceral adipose tissue. Periampullary duodenal diverticulitis complicated by peripancreatic fat necrosis in patients with clinical obesity and increased visceral fat area is rarely described in the literature. Appropriate pharmacological treatment combined with a targeted dietary regimen aimed at reducing visceral adiposity may result in complete remission of severe acute pancreatitis. In patients with acute pancreatitis of unknown etiology and concomitant clinical obesity, duodenal diverticulitis and peripancreatic fat necrosis should be considered as potential underlying causes.

Key words: Duodenal diverticulitis, acute pancreatitis, peripancreatitis fat necrosis, clinical obesity, nutrition, prevention, therapy.