Endoscopic Submucosal Dissection for Pediatric Intraluminal Duodenal Diverticulum Presenting with Acute Pancreatitis: A Case Report

Endoscopic Submucosal Dissection for Pediatric Intraluminal Duodenal Diverticulum Presenting with Acute Pancreatitis: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Endoscopic Submucosal Dissection for Pediatric Intraluminal Duodenal Diverticulum Presenting with Acute Pancreatitis: A Case Report Lei Liu, Bi-Ning Yang, Han Pan, Rui-Xue Ma, Wen-Hai Luo, Zan Zuo, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8156506/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract A 10-year-old boy presented with recurrent abdominal pain and vomiting for Over a 20-month period. He had previously been diagnosed with recurrent acute pancreatitis at local hospitals and treated conservatively, but the symptoms continued to recur. Upon admission to our hospital, recurrent acute pancreatitis was confirmed. Endoscopic ultrasonography revealed a large diverticulum in the descending part of the duodenum. After resolution of the pancreatitis, the patient underwent duodenal diverticulum reconstruction via a submucosal tunnel combined with endoscopic submucosal dissection (ESD) under endoscopic guidance. The procedure was well tolerated, and the patient recovered uneventfully. Endoscopic submucosal dissection (ESD) duodenal diverticulum pancreatitis Figures Figure 1 Figure 2 Case Report Over a 20-month period, a 10-year-old boy exhibited a recurrent pattern of acute pancreatitis, the clinical presentation during each attack consistently included epigastric pain and vomiting.Blood amylase (344 U/L) and lipase (634 U/L) levels were approximately three times the upper limit of normal.Abdominal CT demonstrated findings suggestive of a duodenal diverticulum (Fig. 1 a), no abnormalities were detected in the pancreatic duct on both MRI and CT scans (Fig. 1 b). Gastroscopy showed a large diverticulum in the descending part of the duodenum. Common causes of pancreatitis in children were excluded for this patient. The patient’s symptoms were relieved by conservative medical treatment, and he was subsequently discharged. After two further bouts of acute pancreatitis, On January 15, 2025, he was admitted for the fourth time, presenting with abdominal pain similar to previous episodes and projectile vomiting. On January 20, 2025, submucosal tunnel duodenal diverticulum reconstruction and endoscopic submucosal dissection (ESD) were performed following completion of preoperative preparation and exclusion of contraindications. During surgery, a limited outward bulging was observed on the anal side of the duodenal papillary plane. The diverticulum measured approximately 3 × 5 cm, with ridge-like septa showing mucosal congestion and erosion, and containing food residue. The intestinal lumen proximal to the diaphragm was widened (Fig. 2 a、2b). A submucosal injection of physiological saline mixed with methylene blue was administered at the mucosal crest of the duodenal diverticulum to establish a submucosal tunnel. An electrosurgical unit set at 30 W high-frequency current, in combination with a disposable electrosurgical knife (Dual Knife), was used to incise the mucosal layer along the glandular ridge and dissect the submucosal plane. Because the operative space in the descending duodenum was limited, an insulation-tipped diathermic knife (IT knife) was subsequently employed to minimize the risk of injury to surrounding tissues. The mucosal crest was fully incised until it was released without intraoperative bleeding and the intestinal lumen became unobstructed (Fig. 2 c、2d). At the end of the procedure, 27 clips were applied in succession to achieve complete closure of the mucosal defect (Fig. 2 e). The child was followed up at 3 and 6 months after discharge, with no discomfort reported. Repeat tests showed normal serum amylase and lipase levels. Follow-up gastroscopy demonstrated satisfactory healing of the surgical site (Fig. 2 f), and ongoing follow-up is being conducted. Discussion Intraluminal duodenal diverticulum (IDD) was first described by Boyd in 1845 as a rare congenital abnormality [ 1 ] . In 1947, Nelson further characterized its distinctive radiographic appearance, which was initially referred to as the “windsock sign” or described as a diaphragm or incomplete diaphragm. The term “IDD” was later introduced by Kinzer in 1949 [ 2 ] . Pathologically, IDD is a cystic intraluminal structure lined by duodenal mucosa on both its luminal and diverticular surfaces.It is partially or completely circumferentially attached to the duodenal wall, most frequently in the periampullary region, and usually measures from a few centimeters to approximately 10 cm in length. The diverticulum typically communicates with the duodenal lumen through an opening at either its base or apex, and its size may further increase after ingestion of food or foreign material. Proximal duodenal dilation occurs in nearly half of the reported cases [ 3 – 6 ] . The exact mechanism underlying the development of IDD remains unclear. Most scholars agree that, during early embryogenesis, the duodenal lumen is initially occluded by proliferating epithelium, followed by a process of recanalization. Incomplete recanalization of the duodenal lumen during early embryogenesis may result in duodenal obstruction, stenosis, or diaphragm formation. Over time, peristaltic forces can cause the affected segment to invaginate, eventually forming an IDD, which most commonly occurs in the second portion of the duodenum near the papilla of Vater [ 4 – 6 ] . The symptoms of patients with IDD are often nonspecific, typically including mild upper abdominal pain or a sensation of fullness, physical examination is usually unremarkable. Symptoms often persist despite years of targeted treatment, and children with IDD may be asymptomatic. Nearly one-third of patients experience nausea and vomiting, particularly after meals, with some symptoms relieved by emesis. Approximately one-fourth of patients present with gastrointestinal bleeding. Most cases are diagnosed incidentally when managing these complications, which often leads to a delayed diagnosis of IDD [2、6、7] . IDD may progress with age or enlarge due to food accumulation or repeated peristaltic activity. It behaves like a large intraluminal foreign body, which can lead to partial or intermittent duodenal obstruction, accounting for the early symptoms of fullness and intermittent postprandial abdominal pain and vomiting [ 8 ] . The diagnosis of IDD is typically established through barium radiography and endoscopy, with endoscopy playing an increasingly important role in both the diagnosis and management of the condition. The main complications of IDD include duodenitis, gastrointestinal bleeding, gastrointestinal obstruction, acute perforation, pancreatic or biliary diseases, local abscess formation, among others. Acute pancreatitis may occur in approximately 20% of adults, but it is particularly rare in children [2、5] . In our case, the child experienced multiple episodes of pancreatitis. Chronic pancreatitis was excluded based on imaging studies, and no further episodes occurred following submucosal tunnel duodenal diverticulum reconstruction and ESD. Therefore, the pancreatitis was considered a complication of IDD. The pathogenesis of pancreatitis in patients with IDD remains unclear. Possible mechanisms include retrograde flow of retained food into the pancreatic duct via the papilla of Vater, or traction on the neck of the diverticulum at the level of the papilla during duodenal peristalsis, combined with partial duodenal obstruction and deformation of the ampulla of Vater, leading to reflux of duodenal contents into the pancreatic duct [9、10] . IDD is a rare cause of pancreatitis in children. When the etiology is not identified by standard diagnostic tools, or common causes have been excluded in cases of recurrent acute pancreatitis, IDD should be considered [8、10] . In cases of diverticulitis, almost all patients require inpatient management. Initial interventions include bed rest, fasting, nasogastric tube placement, intravenous fluids, and broad-spectrum antibiotic therapy, under the supervision of a specialist [ 7 ] . In most cases of IDD, surgical treatment is preferred. Symptomatic intraluminal diverticula can be managed endoscopically using electrocoagulation with a loop, or surgically via duodenotomy and diverticulectomy. Care must be taken to avoid injury to the ampulla of Vater during the procedure. For patients at high surgical risk or who are asymptomatic, conservative management may be considered. However, large diverticula generally require surgical intervention due to the increased risk of infection and perforation [2、7、9] . IDD in children is extremely rare, and reports of surgical management are particularly scarce. Literature review indicates that endoscopic electrocoagulation resection using loop electrosurgical forceps under a double-channel endoscope has been reported more frequently in adults. Notably, a Japanese report described a 33-year-old woman with IDD and refractory pancreatitis in 2013 who was successfully treated with double-channel endoscopic resection [ 11 ] . In contrast, duodenotomy with diverticulectomy remains the more common approach in pediatric patients. Several pediatric cases of IDD treated surgically have been reported: in 1971, a 16-year-old girl underwent gastric exploration and duodenotomy [ 6 ] ; in 1976, an 18-year-old Mongolian male underwent duodenotomy [ 12 ] ; in 1998, an 11-year-old girl with IDD and pancreatitis was treated by duodenotomy [ 3 ] ; and in 2014, an 8-year-old girl with a coin retained in a duodenal diverticulum causing pancreatitis underwent duodenotomy [ 8 ] . However, duodenotomy carries risks such as a large surgical wound, delayed recovery, and hemorrhage. With the development of minimally invasive surgery, a 17-year-old girl was treated using a laparoscopic approach combined with endoscopic guidance for duodenectomy in 2018 [ 13 ] . Compared with open duodenal surgery, minimally invasive laparoscopic techniques offer smaller wounds and faster recovery; however, the duodenal wall still needs to be incised, and complications such as anastomotic leakage and intestinal adhesions remain possible. To date, no cases in China have reported the use of ESD for treating pediatric IDD. However, ESD has demonstrated remarkable clinical efficacy in the management of other pediatric gastrointestinal disorders, including congenital duodenal membranous stenosis, gastric duplication malformations, and ectopic pancreas [ 14 – 16 ] . As a novel minimally invasive technique, ESD enables precise resection of superficial gastrointestinal lesions while avoiding open surgery and preserving organ integrity. ESD is commonly used to treat mucosal lesions larger than 2 cm, such as early gastrointestinal cancers and precancerous lesions in adults. Compared with open surgery, ESD offers several advantages, including smaller wounds, complete resection under direct visualization, faster recovery, improved safety, fewer complications, and greater cost-effectiveness [ 17 ] . In our case, during diverticulectomy using the ESD technique, a submucosal injection of physiological saline mixed with methylene blue was first administered at the mucosal ridge of the duodenal diverticulum to create a submucosal cushion and facilitate tunnel formation. An electrosurgical knife was then used to carefully incise the mucosa, minimizing the risk of perforation while providing hemostasis and ensuring no intraoperative bleeding, with particular attention to protecting the ampulla of Vater. Duodenal diverticula are composed of mucosal layers without a muscular layer, allowing ESD to achieve complete lesion removal. Although cases using this technique in pediatric gastrointestinal diseases remain limited and clinical experience is still evolving, ESD demonstrates considerable potential and may be a valuable minimally invasive option in clinical practice. Abbreviations ESD Endoscopic submucosal dissection IDD Intraluminal duodenal diverticulum IT knife Insulated-tip knife Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board (IRB) of The First People's Hospital of Yunnan Province (Approval Number:KHLL2024-KY108). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin. The study was conducted in compliance with the ethical standards of the Declaration of Helsinki and its subsequent amendments or comparable ethical standards. Clinical trial number not applicable. Consent for publication Written informed consent was obtained from the parents of the patient for the publication of any potentially identifiable images or data included in this article. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The other authors have no conflicts of interest to disclose. Funding No funding was secured for this study. Authors' contributions Lei Liu and Yun-Fen Tian :conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript. Bi-Ning Yang :collected data, carried out the initial analyses, and critically reviewed and revised the manuscript. Zuo Zan : endoscopic surgical procedures and data collection. Han Pan ,Rui-Xue Ma and Wen-Hai Luo: collected data, carried out the initial analyses. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. *These authors contributed equally to this work. A cknowledgments We would like to express our sincere gratitude to all those who contributed to the successful completion of this study. We are particularly indebted to the medical staff at The First People's Hospital of Yunnan Province for their steadfast support and assistance throughout the research process. We also extend our heartfelt thanks to the patients and their families for their utmost trust and willingness to share their experiences and data, providing invaluable contribution to the advancement of pediatric gastrointestinal diseases. References Boyd R. Description of a malformation of the duodenum,with notices of analogous cases.[J].Med Chir Trans.1845.1(28):329–35. https://doi.org/10.1177/095952874502800111 al-Mulhim AA, al-Quorain AA, Wosornu L, Abou Ghzala OM, al-Tamimi DM. Intraluminalduodenal diverticulum causing recurrent acute pancreatitis: case report and review of the literature[J]. Eur J Gastroenterol Hepatol 1997,9(4):397–401 https://doi.org/10.1097/00042737-199704000-00015 Huang FC, Chuang JH, Ko SF. Intraluminal duodenal diverticulum presenting as obstructive chronic pancreatitis[J]. 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Chin J Pediatr Surg 2021,42(11):980–4 https://doi.org/10.3760/cma.j.cn421158-20200509-00319 Libânio D, Pimentel-Nunes P, Bastiaansen B et al. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical-Review[J].ENDOSCOPY.2022,54(6):591–622 https://doi.org/10.1055/a-1811-7025 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8156506","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":557507638,"identity":"8bdc06a3-88f1-408e-9db7-c430f5dad14f","order_by":0,"name":"Lei Liu","email":"","orcid":"","institution":"The First People’s Hospital of Yunnan Province","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Liu","suffix":""},{"id":557507639,"identity":"e4de9528-c826-4041-bb11-111e98751b63","order_by":1,"name":"Bi-Ning Yang","email":"","orcid":"","institution":"Sichuan 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16:42:24","extension":"xml","order_by":27,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":48708,"visible":true,"origin":"","legend":"","description":"","filename":"a7b7c0e71ff7473da0d7bf921b8c9e7c1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8156506/v1/60365b38facf2384b61299bc.xml"},{"id":98074849,"identity":"81ed0b44-9bed-4534-8475-7da3474b625f","added_by":"auto","created_at":"2025-12-12 13:28:59","extension":"html","order_by":28,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":56856,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8156506/v1/fe756d325ac1f8ca55b84298.html"},{"id":98428480,"identity":"c2773367-46f2-495e-a6c5-3448a276f6a2","added_by":"auto","created_at":"2025-12-17 16:42:02","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":53815,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(a) Gas–fluid level observed in the descending portion and medial wall of the duodenum, suggestive of a duodenal diverticulum.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(b) No pancreatic duct abnormalities were detected.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8156506/v1/e8347764bf7d73fedacf4eed.jpg"},{"id":98429834,"identity":"276c6da5-dfaa-4450-a8d2-f56429adefab","added_by":"auto","created_at":"2025-12-17 16:44:12","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":227680,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e(a) A large, pouch-like diverticulum measuring approximately 3 × 5 cm was observed in the descending portion of the duodenum.\u003cbr\u003e\n(b) Food residues were present within the diverticulum.\u003cbr\u003e\n(c) The mucosal fold was completely incised using an insulated-tip knife (IT knife) .\u003cbr\u003e\n(d) Postoperative examination showed an intact ampulla of Vater.\u003cbr\u003e\n(e) The mucosal incision was closed using a rotatable, reopenable soft tissue clip.\u003cbr\u003e\n(f) Follow-up at 6 months demonstrated good healing of the incision site.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8156506/v1/177abd642076cd87e655574b.jpg"},{"id":98444726,"identity":"42e9acd0-d39c-4e04-b86f-d21b097cd87d","added_by":"auto","created_at":"2025-12-17 17:17:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":906226,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8156506/v1/9ed15bc6-dc2b-4280-96ff-77f89f8108ff.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endoscopic Submucosal Dissection for Pediatric Intraluminal Duodenal Diverticulum Presenting with Acute Pancreatitis: A Case Report","fulltext":[{"header":"Case Report","content":"\u003cp\u003eOver a 20-month period, a 10-year-old boy exhibited a recurrent pattern of acute pancreatitis, the clinical presentation during each attack consistently included epigastric pain and vomiting.Blood amylase (344 U/L) and lipase (634 U/L) levels were approximately three times the upper limit of normal.Abdominal CT demonstrated findings suggestive of a duodenal diverticulum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea), no abnormalities were detected in the pancreatic duct on both MRI and CT scans (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Gastroscopy showed a large diverticulum in the descending part of the duodenum. Common causes of pancreatitis in children were excluded for this patient. The patient\u0026rsquo;s symptoms were relieved by conservative medical treatment, and he was subsequently discharged. After two further bouts of acute pancreatitis, On January 15, 2025, he was admitted for the fourth time, presenting with abdominal pain similar to previous episodes and projectile vomiting. On January 20, 2025, submucosal tunnel duodenal diverticulum reconstruction and endoscopic submucosal dissection (ESD) were performed following completion of preoperative preparation and exclusion of contraindications.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDuring surgery, a limited outward bulging was observed on the anal side of the duodenal papillary plane. The diverticulum measured approximately 3 \u0026times; 5 cm, with ridge-like septa showing mucosal congestion and erosion, and containing food residue. The intestinal lumen proximal to the diaphragm was widened (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea、2b). A submucosal injection of physiological saline mixed with methylene blue was administered at the mucosal crest of the duodenal diverticulum to establish a submucosal tunnel. An electrosurgical unit set at 30 W high-frequency current, in combination with a disposable electrosurgical knife (Dual Knife), was used to incise the mucosal layer along the glandular ridge and dissect the submucosal plane. Because the operative space in the descending duodenum was limited, an insulation-tipped diathermic knife (IT knife) was subsequently employed to minimize the risk of injury to surrounding tissues. The mucosal crest was fully incised until it was released without intraoperative bleeding and the intestinal lumen became unobstructed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec、2d). At the end of the procedure, 27 clips were applied in succession to achieve complete closure of the mucosal defect (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe child was followed up at 3 and 6 months after discharge, with no discomfort reported. Repeat tests showed normal serum amylase and lipase levels. Follow-up gastroscopy demonstrated satisfactory healing of the surgical site (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ef), and ongoing follow-up is being conducted.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIntraluminal duodenal diverticulum (IDD) was first described by Boyd in 1845 as a rare congenital abnormality\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. In 1947, Nelson further characterized its distinctive radiographic appearance, which was initially referred to as the \u0026ldquo;windsock sign\u0026rdquo; or described as a diaphragm or incomplete diaphragm. The term \u0026ldquo;IDD\u0026rdquo; was later introduced by Kinzer in 1949\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Pathologically, IDD is a cystic intraluminal structure lined by duodenal mucosa on both its luminal and diverticular surfaces.It is partially or completely circumferentially attached to the duodenal wall, most frequently in the periampullary region, and usually measures from a few centimeters to approximately 10 cm in length. The diverticulum typically communicates with the duodenal lumen through an opening at either its base or apex, and its size may further increase after ingestion of food or foreign material. Proximal duodenal dilation occurs in nearly half of the reported cases\u003csup\u003e[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe exact mechanism underlying the development of IDD remains unclear. Most scholars agree that, during early embryogenesis, the duodenal lumen is initially occluded by proliferating epithelium, followed by a process of recanalization. Incomplete recanalization of the duodenal lumen during early embryogenesis may result in duodenal obstruction, stenosis, or diaphragm formation. Over time, peristaltic forces can cause the affected segment to invaginate, eventually forming an IDD, which most commonly occurs in the second portion of the duodenum near the papilla of Vater\u003csup\u003e[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe symptoms of patients with IDD are often nonspecific, typically including mild upper abdominal pain or a sensation of fullness, physical examination is usually unremarkable. Symptoms often persist despite years of targeted treatment, and children with IDD may be asymptomatic. Nearly one-third of patients experience nausea and vomiting, particularly after meals, with some symptoms relieved by emesis. Approximately one-fourth of patients present with gastrointestinal bleeding. Most cases are diagnosed incidentally when managing these complications, which often leads to a delayed diagnosis of IDD\u003csup\u003e[2、6、7]\u003c/sup\u003e. IDD may progress with age or enlarge due to food accumulation or repeated peristaltic activity. It behaves like a large intraluminal foreign body, which can lead to partial or intermittent duodenal obstruction, accounting for the early symptoms of fullness and intermittent postprandial abdominal pain and vomiting\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. The diagnosis of IDD is typically established through barium radiography and endoscopy, with endoscopy playing an increasingly important role in both the diagnosis and management of the condition.\u003c/p\u003e\u003cp\u003eThe main complications of IDD include duodenitis, gastrointestinal bleeding, gastrointestinal obstruction, acute perforation, pancreatic or biliary diseases, local abscess formation, among others. Acute pancreatitis may occur in approximately 20% of adults, but it is particularly rare in children\u003csup\u003e[2、5]\u003c/sup\u003e. In our case, the child experienced multiple episodes of pancreatitis. Chronic pancreatitis was excluded based on imaging studies, and no further episodes occurred following submucosal tunnel duodenal diverticulum reconstruction and ESD. Therefore, the pancreatitis was considered a complication of IDD.\u003c/p\u003e\u003cp\u003eThe pathogenesis of pancreatitis in patients with IDD remains unclear. Possible mechanisms include retrograde flow of retained food into the pancreatic duct via the papilla of Vater, or traction on the neck of the diverticulum at the level of the papilla during duodenal peristalsis, combined with partial duodenal obstruction and deformation of the ampulla of Vater, leading to reflux of duodenal contents into the pancreatic duct\u003csup\u003e[9、10]\u003c/sup\u003e. IDD is a rare cause of pancreatitis in children. When the etiology is not identified by standard diagnostic tools, or common causes have been excluded in cases of recurrent acute pancreatitis, IDD should be considered\u003csup\u003e[8、10]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn cases of diverticulitis, almost all patients require inpatient management. Initial interventions include bed rest, fasting, nasogastric tube placement, intravenous fluids, and broad-spectrum antibiotic therapy, under the supervision of a specialist\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. In most cases of IDD, surgical treatment is preferred. Symptomatic intraluminal diverticula can be managed endoscopically using electrocoagulation with a loop, or surgically via duodenotomy and diverticulectomy. Care must be taken to avoid injury to the ampulla of Vater during the procedure. For patients at high surgical risk or who are asymptomatic, conservative management may be considered. However, large diverticula generally require surgical intervention due to the increased risk of infection and perforation\u003csup\u003e[2、7、9]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIDD in children is extremely rare, and reports of surgical management are particularly scarce. Literature review indicates that endoscopic electrocoagulation resection using loop electrosurgical forceps under a double-channel endoscope has been reported more frequently in adults. Notably, a Japanese report described a 33-year-old woman with IDD and refractory pancreatitis in 2013 who was successfully treated with double-channel endoscopic resection\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In contrast, duodenotomy with diverticulectomy remains the more common approach in pediatric patients. Several pediatric cases of IDD treated surgically have been reported: in 1971, a 16-year-old girl underwent gastric exploration and duodenotomy\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e; in 1976, an 18-year-old Mongolian male underwent duodenotomy\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e; in 1998, an 11-year-old girl with IDD and pancreatitis was treated by duodenotomy\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e; and in 2014, an 8-year-old girl with a coin retained in a duodenal diverticulum causing pancreatitis underwent duodenotomy\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. However, duodenotomy carries risks such as a large surgical wound, delayed recovery, and hemorrhage. With the development of minimally invasive surgery, a 17-year-old girl was treated using a laparoscopic approach combined with endoscopic guidance for duodenectomy in 2018\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Compared with open duodenal surgery, minimally invasive laparoscopic techniques offer smaller wounds and faster recovery; however, the duodenal wall still needs to be incised, and complications such as anastomotic leakage and intestinal adhesions remain possible.\u003c/p\u003e\u003cp\u003eTo date, no cases in China have reported the use of ESD for treating pediatric IDD. However, ESD has demonstrated remarkable clinical efficacy in the management of other pediatric gastrointestinal disorders, including congenital duodenal membranous stenosis, gastric duplication malformations, and ectopic pancreas\u003csup\u003e[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. As a novel minimally invasive technique, ESD enables precise resection of superficial gastrointestinal lesions while avoiding open surgery and preserving organ integrity.\u003c/p\u003e\u003cp\u003eESD is commonly used to treat mucosal lesions larger than 2 cm, such as early gastrointestinal cancers and precancerous lesions in adults. Compared with open surgery, ESD offers several advantages, including smaller wounds, complete resection under direct visualization, faster recovery, improved safety, fewer complications, and greater cost-effectiveness\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. In our case, during diverticulectomy using the ESD technique, a submucosal injection of physiological saline mixed with methylene blue was first administered at the mucosal ridge of the duodenal diverticulum to create a submucosal cushion and facilitate tunnel formation. An electrosurgical knife was then used to carefully incise the mucosa, minimizing the risk of perforation while providing hemostasis and ensuring no intraoperative bleeding, with particular attention to protecting the ampulla of Vater. Duodenal diverticula are composed of mucosal layers without a muscular layer, allowing ESD to achieve complete lesion removal. Although cases using this technique in pediatric gastrointestinal diseases remain limited and clinical experience is still evolving, ESD demonstrates considerable potential and may be a valuable minimally invasive option in clinical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eESD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Endoscopic submucosal dissection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIDD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intraluminal duodenal diverticulum\u003c/p\u003e\n\u003cp\u003eIT knife \u0026nbsp; \u0026nbsp; \u0026nbsp;Insulated-tip knife\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board (IRB) of The First People's Hospital of Yunnan Province (Approval Number:KHLL2024-KY108). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin. The study was conducted in compliance with the ethical standards of the Declaration of Helsinki and its subsequent amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the parents of the patient for the publication of any potentially identifiable images or data included in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published\u003c/p\u003e\n\u003cp\u003earticle.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe other authors have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was secured for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLei Liu and Yun-Fen Tian :conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eBi-Ning Yang :collected data, carried out the initial analyses, and critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eZuo Zan : endoscopic surgical procedures and data collection.\u003c/p\u003e\n\u003cp\u003eHan Pan ,Rui-Xue Ma and Wen-Hai Luo: collected data, carried out the initial analyses.\u003c/p\u003e\n\u003cp\u003eAll authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e*These authors contributed equally to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003ecknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to all those who contributed to the successful completion of this study. We are particularly indebted to the medical staff at The First People's Hospital of Yunnan Province for their steadfast support and assistance throughout the research process. We also extend our heartfelt thanks to the patients and their families for their utmost trust and willingness to share their experiences and data, providing invaluable contribution to the advancement of pediatric gastrointestinal diseases.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBoyd R. 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Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical-Review[J].ENDOSCOPY.2022,54(6):591\u0026ndash;622\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1055/a-1811-7025\u003c/span\u003e\u003cspan address=\"10.1055/a-1811-7025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endoscopic submucosal dissection (ESD), duodenal diverticulum, pancreatitis","lastPublishedDoi":"10.21203/rs.3.rs-8156506/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8156506/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA 10-year-old boy presented with recurrent abdominal pain and vomiting for Over a 20-month period. He had previously been diagnosed with recurrent acute pancreatitis at local hospitals and treated conservatively, but the symptoms continued to recur. Upon admission to our hospital, recurrent acute pancreatitis was confirmed. Endoscopic ultrasonography revealed a large diverticulum in the descending part of the duodenum. After resolution of the pancreatitis, the patient underwent duodenal diverticulum reconstruction via a submucosal tunnel combined with endoscopic submucosal dissection (ESD) under endoscopic guidance. The procedure was well tolerated, and the patient recovered uneventfully.\u003c/p\u003e","manuscriptTitle":"Endoscopic Submucosal Dissection for Pediatric Intraluminal Duodenal Diverticulum Presenting with Acute Pancreatitis: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-12 13:28:54","doi":"10.21203/rs.3.rs-8156506/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-05T06:10:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T15:41:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-21T19:53:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319735833921090457256946722441635964817","date":"2026-02-21T19:17:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"77325206775649058204874002547809200057","date":"2026-02-10T04:46:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113042332091018041004144400318920195627","date":"2026-01-19T16:14:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-09T09:20:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-09T09:19:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-09T04:59:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-09T04:32:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-12-09T04:27:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a73ed989-967a-4541-9e94-229202f107ed","owner":[],"postedDate":"December 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T03:23:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-12 13:28:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8156506","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8156506","identity":"rs-8156506","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}