Acute ulcerative jejunal diverticulitis: Case report of an uncommon entity

Surgery for non-Meckel's small-bowel diverticular perforation: two case reports and a literature review

BACKGROUND

Similar to colonic diverticula, small-intestinal diverticula are often asymptomatic, but may cause life-threatening acute complications. Non-Meckel's small-bowel diverticular perforation is rare, and the rate of mortality is high. However, there is currently no consensus regarding its therapeutic management.

CASE PRESENTATION

Case 1: A 73-year-old Japanese man with localized lower abdominal pain was referred to our hospital. Enhanced computed tomography (CT) revealed diverticulitis of the small intestine, which was managed conservatively. Four days after admission, abdominal pain worsened, and repeat CT revealed extraintestinal gas. Emergency surgery was performed for the segmental resection of the perforated jejunum with anastomosis. Case 2: A 73-year-old Japanese woman was transferred to our hospital with small-bowel perforation. CT revealed scattered diverticula in the small intestine and extraintestinal gas around the small-intestinal diverticula. Emergency surgery was performed for the segmental resection of the perforated jejunum with anastomosis.

CONCLUSIONS

Conservative treatment for small-bowel diverticular perforation may be attempted in mild cases; however, surgical intervention should not be delayed. Segmental resection of the affected intestinal tract with an anastomosis is the standard treatment. Residual diverticula should be documented because of the possibility of diverticulosis recurrence.

Complicated jejunal diverticulitis: A case report and review of literature

Jejunal diverticulitis is an uncommon pathology wherein a delay in diagnosis can lead to significant morbidity and mortality. We report a case of such diverticula requiring operative management, after patient failed non-operative management, likely due to advanced jejunal inflammation from a delay in diagnosis and subsequent management.

Complicated jejunal diverticulosis with intestinal perforation and obstruction: delay in hospital visit during confinement due to COVID-19

Diverticulosis of the small bowel is a rare entity. It can cause acute, complications such as diverticulitis, perforation, intestinal bleeding and obstruction. During the pandemic, patients were reluctant to visit hospitals for fear of contracting coronavirus disease 2019. This caused the patients to wait until the extreme deterioration of many acute surgical conditions. An 83-year-old man with multiple comorbidities showed up at the emergency department with generalized abdominal pain of 7 days of evolution. The computed tomography scan revealed a large distention of the small intestine and a small inflammatory abscess. He was transferred to the operating room where a segment of the jejunum affected by multiple diverticula located on the mesenteric side of the intestine and a mesenteric abscess related to a perforated jejunal diverticulum were identified. Complicated jejunal diverticulosis is a difficult entity to diagnose, which can cause significant morbidity and mortality. To avoid this, its timely diagnosis is essential.

Operative Management of Perforated Jejunal Diverticulitis

Small jejunal diverticulitis is very rare, presenting in 0.06% to 1.3% of the population. Many patients remain asymptomatic or have nonspecific symptoms such as malabsorption and abdominal pain, making diagnosis complicated. Up to 6% of patients present with acute perforation. Here, we present such a case involving a 69-year-old female who presented with altered mental status due to sepsis and generalized peritonitis from a perforated jejunal diverticulum that was successfully managed with definitive surgery. We highlight the importance of maintaining a broad differential, early resuscitation, and prompt surgical management in complicated jejunal diverticulitis. Although adjunctive studies such as computed tomography may be helpful in stable patients, definitive surgery was both diagnostic and therapeutic in this case.

Multiple Jejunal Diverticulosis Complicated by Perforation: Case Report and a Brief Literature Review

Background Multiple small-bowel diverticulosis comprises a rare entity with probable underestimated incidence, and that may be the reason why it is sometimes overlooked when managing cases with peritonitis.

Case report In the present paper, we report the case of a 76-year-old male presenting abdominal pain and fever in an acute setting. Computed tomography (CT) scans revealed jejunal thickening and numerous images of saccular addition that were interpreted as jejunoileal diverticulitis. After an initial period of clinical treatment, surgical management was indicated based on a worsening clinical picture and the presence of an extraluminal focus of gas detected in a subsequent CT scan. Through a laparoscopic approach, multiple small-bowel diverticula and a tamponade perforation were found. A segmental intestinal resection was performed, and the patient was discharged after a ten days.

Conclusions Multiple jejunal diverticulosis is a rare condition that should be remembered in the setting of an acute abdomen. As it prevails among older patients, early diagnosis with radiological aid is crucial to establish the most adequate management, including intestinal resection, if necessary.

Abdominal Pain: A Silent and Unlikely Cause

While diverticulosis is a common phenomenon in the large intestine, it is a rare disease found in the small intestine accounting for only 0.06% to 1.3% of cases. Although most cases are asymptomatic, roughly 30% to 40%, it is crucial that it is on the differential of acute abdominal pain as it can be life-threatening and potentially require surgical management. Here, we describe a case of a 61-year-old Hispanic man who was found to have a perforated jejunal diverticula after initially presenting with left upper quadrant abdominal pain.

Jejunal diverticulitis: Things to know to prevent diagnostic mistake

The jejunal diverticula are relatively rare. A female patient was admitted at our emergency department with acute abdominal pain and vomiting. CT-scan of the abdomen showed multiple diverticula in the colon and multiple intra-abdominal fluid collections, also in the left quadrants of the abdomen. Free intraperitoneal extraluminal air was also observed, suggesting bowel perforation. Surgical exploration showed multiple diverticula of the jejunum with a perforated jejunal diverticulum extending approximately 10 cm from ligament of Treitz. Jejunal resection was performed. Jejunal diverticulitis is rare, but it can lead to an acute abdomen increasing mortality especially in elderly patients. Jejunal diverticulitis usually starts with features that mimic colonic diverticulitis. In patients with personal history of colonic diverticulosis and suspected diverticulitis, jejunal or ileal diverticulitis must be excluded occurring with a frequency of 2.3% in patients with known diverticulosis. In absence of pathognomonic colonic diverticulitis CT findings, small intestine acute complicated diverticulitis should be always suspected. In complicated jejunal diverticulitis surgical treatment is mandatory and a laparotomy can be needed for a better management. (www.actabiomedica.it)

Jejunal Diverticulosis Complicated by Diverticulitis and Small Bowel Obstruction

Diverticular disease is common in the Western population and can cause considerable morbidity. The prevalence of colonic diverticulosis reaches 60% by the age of 60 years. Small bowel diverticulosis is much rarer and, when present, most commonly occurs in the duodenum. We herein report an elderly woman with jejunal diverticulosis complicated by diverticulitis and small bowel obstruction, who subsequently underwent small bowel resection and primary anastomosis. As demonstrated by this case, jejunal diverticulitis can cause serious complications and given the possibility of recurrence and serious complications, surgical options should be discussed early in the course of medical care. 

Perforated Jejunal Diverticulitis

Small intestinal diverticula are very rare; their incidence ranges from 0.06 to 1.3%, with a higher prevalence after the 6th decade of life. Among these small intestinal diverticula, duodenal diverticula are more frequent, followed by diverticula of the jejunum and ileum. A jejunal diverticulum is usually asymptomatic; sometimes patients complain of vague chronic symptoms like malabsorption, pain, or nausea that easily lead to misdiagnosis. Complications are rarely reported, only in 10% of patients. We report a unique case of a 70-year-old female who presented with confusion due to sepsis from perforated jejunal diverticulitis, which was successfully managed with initial resuscitation and definitive surgery.

Jejuno-ileal diverticulitis: A disorder not to underestimate

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In the paper a rare case of complete and well documented jejunal diverticulitis complicated with perforation and peritonitis is described.

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Interesting radiological and intraoperative imaging are attached.

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A carefull and recent literature review has been performed in order to discuss diagnosis and management of jejuno-ileal diverticula and our clinical behavior.

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From the discussion emerges that the possibility of the presence of small bowel diverticula must be considered in case of occult bleeding non-indentifiable with gastroscopy or colonoscopy.

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Therapeutic behavior is suggested in case of acute peritonitis due to jejunal diverticula or in case of incidental diagnosis.

Introduction

Jejuno-ileal diverticulitis is an uncommon, acquired clinical entity, with higher prevalence among patients aged between 60 and 70. The condition is usually silent and has been regarded as relatively innocuous. Sometimes patients complain chronic vague symptoms like malabsorption, pain or nausea, that easily lead to misdiagnosis. Acute complications are rare, however, they have been reported and can result in major surgery and high overall mortality.

Case report

We are presenting a case of a 67-year-old patient who presented to our department with abdominal pain and signs of peritonitis. The CT scan displayed an inflammatory mass with a fair amount of free liquid in the abdomen, as well as multiple diverticula at different levels of the intestine. The patient had to underwent immediate surgery, during which a resection of 25 cm jejunum and 80 cm of ileum has been performed.

Conclusion

Jejuno-ileal diverticula are a very uncommon finding that can present formidable challenges in diagnosis and treatment. The course can be completely asymptomatic, however, in rare cases, the condition can lead to severe complications that often require surgery. Multi detector CT (MDCT) with intravenous contrast should always be the modality of choice for investigating a suspect of small bowel diverticula. There are no specific guidelines respect the management of jejuno-ileal diverticulitis, nevertheless, in the acute setting, bowel resection is the treatment of choice.

As well as setting out the rarity of this case, our work intends to review the current literature regarding the epidemiology, natural history, diagnosis and management of jejuno-ileal diverticula

Rare Coexistance of Ileal Diverticulosis, Crohn's Disease and Small Bowel Adenocarcinoma: Report of a Case

BACKGROUND/AIM

Adenocarcinoma is one of the most common malignant tumors of the small intestine complicating Crohn's disease. However, the coexistence of both conditions with diverticulosis of small bowel in young age makes this coincidence rare and clinical diagnosis very difficult.

CASE REPORT

We report a case of a woman admitted to our Department with acute abdominal pain and fever. The surgical and histological investigation, revealed a rare coexistence that has never been mentioned in the published medical literature.

CONCLUSION

Ileal diverticulosis is not frequent and often asymptomatic as well as adenocarcinoma of the small bowel. In this case, those diseases along with Crohn's disease led the patient to acute symptoms.

A rare presentation of an acute abdomen: an ileal diverticular perforation

Background

This case report highlights the value of prompt intervention of diagnostic laparoscopy in a patient suspects of having an acute abdomen due to an intestinal perforation, where there is a limitation of performing Contrast Enhanced Computed Tomography of abdomen. A previously healthy young adult presenting with an acute abdomen due to a spontaneous ileal perforation, without any associated risk factors is a rare clinical entity in a developing country. Therefore, entertaining an early diagnosis will possibly prevent a fatal consequence.

Case presentation

A male patient, 29 years old, recently diagnosed as a young hypertensive without any associated factors, currently on antihypertensive treatment, was admitted to our hospital presenting with an acute severe abdominal pain. During initial assessment, the patient was febrile (101 °F), ill looking, tachycardic (pulse rate 121 bpm) with rapid shallow breathing. Abdominal examination reviled diffuse guarding and rigidity, more severe on right iliac fossa. Following history and clinical examination probable clinical diagnosis was made as an acute appendicitis with perforation. However, ultrasonography was found to have normal appendix. Contrast Enhanced Computed Tomography was not performed as a subsequent investigation because of the impairment of renal functions of this patient. Though, non-contrast CT would have been ascertained more diagnostic yield, given the critically ill status of this patient we decided to perform urgent diagnostic laparoscopy. It reviled pus in several abdominal cavities and dense adhesions. Therefore, the procedure was converted to a laparotomy and found to have an ileal perforation with diffuse peritoneal contamination. Diseased ileal segment was resected and anastomosed. Followed by peritoneal lavage.

Conclusion

Ileal perforation due to diverticular disease in a healthy young adult is rare. This case report highlights the importance of considering this clinical entity as a differential diagnosis, the value of early diagnostic laparoscopy, especially in clinical settings with limitations to CT scan, since late diagnosis can give rise to fatal outcome.

Perforation of jejunal diverticulum with ectopic pancreas

Perforation of jejunal diverticulum is a rare complication. Here, we report a case of jejunal diverticulum penetration with surrounding ectopic pancreas. An 83-year-old female patient was admitted to our department with acute onset of severe abdominal pain lasting for half a day. Abdominal computed tomography showed outpouching of the small intestine that contained air/fluid, with multiple surrounding air bubbles in the mesentery of the small intestine. She was diagnosed with penetration of the small intestine, and an emergency laparotomy was indicated. The penetrated jejunal diverticulum was identified ~20-cm distal to the ligament of Treitz. Partial resection of the jejunum was performed, and her postoperative course was uneventful. The pathological findings confirmed diverticulum penetration into the mesentery and severe inflammation at the site, with surrounding ectopic pancreas. Furthermore, the pancreatic ducts were opened through the penetrated diverticulum. This rare case shows that the ectopic pancreas might have caused penetration of jejunal diverticulum owing to the pancreatic duct opening through the diverticulum.

Flare-Up Diverticulitis in the Terminal Ileum in Short Interval after Conservative Therapy: Report of a Case

Diverticulitis in the terminal ileum is uncommon. Past reports suggested that conservative therapy may be feasible to treat terminal ileum diverticulitis without perforation; however, there is no consensus on the therapeutic strategy for small bowel diverticulitis. We present a 37-year-old man who was referred to our hospital for sudden onset of abdominal pain and nausea. He was diagnosed with diverticulitis in the terminal ileum by computed tomography (CT). Tazobactam/piperacillin hydrate (18 g/day) was administered. The antibiotic treatment was maintained for 7 days, and the symptoms disappeared after the treatment. Thirty-eight days after antibiotic therapy, he noticed severe abdominal pain again. He was diagnosed with diverticulitis in terminal ileum which was flare-up of inflammation. He was given antibiotic therapy again. Nine days after antibiotic therapy, laparoscopy assisted right hemicolectomy and resection of 20 cm of terminal ileum were performed. Histopathology report confirmed multiple ileal diverticulitis. He was discharged from our hospital 12 days after the surgery. Colonoscopy was performed two months after the surgery and it revealed no finding suggesting inflammatory bowel disease. Surgical treatment should be taken into account as a potential treatment option to manage the diverticulitis in the terminal ileum even though it is not perforated.

Obscure Gastrointestinal Bleeding Due to a Small Intestinal Gastrointestinal Stromal Tumor in a Young Adult

The source of most cases of gastrointestinal bleeding is the upper gastrointestinal tract. Since bleeding from the small intestine is very rare and difficult to diagnose, time is required to identify the source. Among small intestine bleeds, vascular abnormalities account for 70-80%, followed by small intestine tumors that account for 5-10%. The reported peak age of the onset of small intestinal tumors is about 50 years. Furthermore, rare small bowel tumors account for only 1-2% of all gastrointestinal tumors. We describe a 29-year-old man who presented with obscure anemia due to gastrointestinal bleeding and underwent laparotomy. Surgical findings revealed a well-circumscribed lesion measuring 45 × 40 mm in the jejunum that initially appeared similar to diverticulosis with an abscess. However, the postoperative pathological diagnosis was a gastrointestinal stromal tumor with extramural growth.

One of the Rare Causes of Acute Abdomen Leading to Subileus: Jejunal Diverticulitis

BACKGROUND

Jejunal diverticulitis is one of the rare causes of acute abdomen generally seen in the elderly. Jejunal diverticulosis was defined as the herniation of the mucosa and the submucosa from the inside of the muscular layer of the bowel wall on the mesenteric side of the intestine.

CASE REPORT

We presented the intraoperative and pathological findings of a 69-year-old male patient who had presented with complaints about abdominal pain, nausea, and vomiting and been operated upon due to subileus and peritonitis induced by large-sized jejunal diverticulitis, along with his computed tomography (CT) findings.

CONCLUSION

Jejunal diverticulitis is uncommon and may be a disease which might be difficult to diagnose when it develops on the basis of the large-sized diverticula resembling intestinal ansae. To the best of our knowledge, the computed tomography and intraoperative findings of a case in which partial resection is applied to the jejunum due to subileus have not been previously presented in the literature.

Jejunal Diverticulosis Presented with Acute Abdomen and Diverticulitis Complication: A Case Report

Background

Jejunal diverticulosis is a rare, usually asymptomatic disease. Its incidence increases with age. If symptomatic, diverticulosis may cause life-threatening acute complications such as diverticulitis, perforation, intestinal hemorrhage and obstruction. In this report, we aimed to present a 67-year-old male patient with jejunal diverticulitis accompanying with abdominal pain and vomiting.

Case Report

A 67-year-old male patient complaining of epigastric pain for a week and nausea and fever for a day presented to our emergency department. Ultrasonographic examination in our clinic revealed diverticulum-like images with thickened walls adjacent to the small intestine loops, and increase in the echogenicity of the surrounding mesenteric fat tissue. Contrast-enhanced abdominal computed tomography showed multiple diverticula, thickened walls with showing contrast enhancement and adjacent jejunum in the left middle quadrant, increased density of the surrounding mesenteric fat tissue, and mesenteric lymph nodes. The patient was hospitalized by general surgery department with the diagnosis of jejunal diverticulitis. Conservative intravenous fluid administration and antibiotic therapy were initiated. Clinical symptoms regressed and the patient was discharged from hospital after 2 weeks.

Conclusions

In cases of diverticulitis it should be kept in mind that in patients with advanced age and pain in the left quadrant of the abdomen, diverticular disease causing mortality and morbidity does not always originate from the colon but might also originate from the jejunum.

A Retrospective, Unicentric Evaluation of Complicated Diverticulosis Jejuni: Symptoms, Treatment, and Postoperative Course

Background

In contrast to the diverticulosis of the colon, jejunal diverticulosis is a rare condition. The incidence is 0.06–5% in large autopsy series. Complicated diverticulosis jejuni (CDJ) often presents with unspecific symptoms. Therefore, diagnosis is often a challenging process and due to the clinical rarity generally valid recommendation of perioperative management does not exist.

Patients and methods

We considered only patients who were operated in our center between April 2007 and August 2014. Patients were identified by data bank search via International Statistical Classification of Diseases and Related Health Problems diagnosis code K57.10. Data were manually screened, and patients with Meckel’s and duodenal diverticula were excluded from this study. Eleven consecutive patients with CDJ were finally included in this study. We analyzed symptoms, diagnostic procedures, surgical treatment, and postoperative morbidity and mortality.

Results

The median age of our patients was 76 years (range: 34–87). CDJ presented most frequently as intestinal bleeding or as diverticulitis. Clinical symptoms were unspecific abdominal pain, hematemesis or melena, ileus, nausea, and emesis as well as patients with acute abdomen. Esophagogastroduodenoscopies confirmed CDJ in two of the three patients. An abdominal computed tomography scan only helped to diagnose CDJ in two of the 10 patients. Eight (72.7%) patients received an open segmental resection with primary anastomosis. In three (27.3%) cases, a reoperation was necessary. Overall morbidity rate was 45.5%, and perioperative mortality was 9.1%.

Conclusion

Due to the acute character of the disease, patients with CDJ are seriously ill. To diagnose patients with CDJ remains challenging as diagnostic investigations are usually not helpful in confirming the diagnosis. Still, diagnosis of CDJ is most frequently confirmed intraoperatively.

Jejuno-ileal diverticulitis: Etiopathogenicity, diagnosis and management

INTRODUCTION

Although diverticular disease of the duodenum and colon is frequent, the jejuno-ileal diverticulosis (JOD) is an uncommon entity. The perforation of the small bowel diverticula can be fatal due to the delay in diagnosis.

PRESENTATION OF CASE

We report the case of a 79-year-old man presenting with generalized abdominal pain and altered bowel habits. Physical examination revealed a severe diffuse abdominal pain. A CT scan of the abdomen and pelvis with oral contrast showed thickening of the distal jejunal loop and thickening and infiltration of the mesenteric fat and the presence of free air in the mesentery suggesting a possible perforation adjacent to the diverticula. A midline laparotomy was performed. The jejunal diverticula were found along the mesenteric border. Forty centimeters of the jejunum were resected. Histopathology report confirmed the presence of multiple jejunual diverticula, and one of them was perforated. The patient tolerated the procedure and the postoperative period was uncomplicated.

DISCUSSION

The prevalence of small intestinal diverticula ranges from 0.06% to 1.3%. The etiopathogenesis of JOD is unclear, although the current hypothesis focuses on abnormalities in the smooth muscle or myenteric plexus, on intestinal dyskinesis and on high intraluminal pressures. Diagnosis is often difficult and delayed because clinical symptoms are not specific and mainly imaging studies performs the diagnosis.

CONCLUSION

Because of the relative rarity of acquired jejuno-ileal diverticulosis, the perforation of small bowel diverticulitis poses technical dilemmas.

Jejunal diverticulitis ascending to the duodenum as a rare cause of acute abdomen

We present the case of a 73 year-old Caucasian male with acute abdominal pain, peritonism and vomiting. Due to the severity of symptoms a CT examination of the abdomen was performed. The scans revealed multiple jejunal diverticula, wall thickening of the duodenum and jejunum, and free peritoneal fluid. No clear signs of mesenteric infarction, free abdominal air or abscess formation were seen. An additional exploratory laparotomy was conducted to confirm the CT findings and rule out the need for resection of small bowel. Since the results were matching, conservative therapy was scheduled and the patient recovered well. Jejunal diverticulitis is a rare cause of acute abdomen, however has to be considered as a differential diagnosis to more common entities. It usually stays localized, while in our case the inflammation ascended to the duodenum. CT is the modality of choice to diagnose and rule out potentially life threatening complications.

Giant and multiple jejunal diverticula presenting as peritonitis a significant challenging disorder

Jejunal diverticula are an uncommon acquired disease that is usually silent and asymptomatic. When symptomatic, they present with chronic nonspecific symptoms like pain, nausea, malnutrition and sometimes with acute presentation like gastrointestinal hemorrhage, peritonitis and obstruction. The majority of complications seen as an acute abdomen similar to appendicitis, cholecystitis or colonic diverticulitis but they also may appear with atypical symptoms. We are presenting a 63-year-old male reported in emergency with painful abdomen and diagnosed as having peritonitis. On laparotomy, we incidentally found giant and multiple jejunal diverticula along with ileal perforation. Nothing was done to the jejunal diverticula, as these were multiple and non-obstructive. In the follow-up of 16 months, the patient was doing well. Jejuno-ileal diverticulosis is a rare condition that continues to present formidable challenges in diagnosis and treatment.

Perforated midgut diverticulitis: Revisited

AIM: To study and provide data on the evolution of medical procedures and outcomes of patients suffering from perforated midgut diverticulitis.

METHODS: Three data sources were used: the Medline and Google search engines were searched for case reports on one or more patients treated for perforated midgut diverticulitis (Meckel’s diverticulitis excluded) that were published after 1995. The inclusion criterion was sufficient individual patient data in the article. Both indexed and non-indexed journals were used. Patients treated for perforated midgut diverticulitis at Vestfold Hospital were included in this group. Data on symptoms, laboratory and radiology results, treatment modalities, surgical access, procedures, complications and outcomes were collected. The Norwegian patient registry was searched to find patients operated upon for midgut diverticulitis from 1999 to 2007. The data collected were age, sex, mode of access, surgical procedure performed and number of patients per year. Historical controls were retrieved from an article published in 1995 containing pertinent individual patient data. Statistical analysis was done with SPSS software.

RESULTS: Group I: 106 patients (48 men) were found. Mean age was 72.2 ± 13.1 years (mean ± SD). Age or sex had no impact on outcomes (P = 0.057 and P = 0.771, respectively). Preoperative assessment was plain radiography in 53.3% or computed tomography (CT) in 76.1%. Correct diagnosis was made in 77.1% with CT, 5.6% without (P = 0.001). Duration of symptoms before hospitalization was 3.6 d (range: 1-35 d), but longer duration was not associated with poor outcome (P = 0.748). Eighty-six point eight percent of patients underwent surgery, 92.4% of these through open access where 90.1% had bowel resection. Complications occurred in 19.2% of patients and 16.3% underwent reoperation. Distance from perforation to Treitz ligament was 41.7 ± 28.1 cm. At surgery, no peritonitis was found in 29.7% of patients, local peritonitis in 47.5%, and diffuse peritonitis in 22.8%. Peritonitis grade correlated with the reoperation rate (r = 0.43). Conservatively treated patients had similar hospital length of stay as operated patients (10.6 ± 8.3 d vs 10.7 ± 7.9 d, respectively). Age correlated with hospital stay (r = 0.46). No difference in outcomes for operated or nonoperated patients was found (P = 0.814). Group II: 113 patients (57 men). Mean age 67.6 ± 16.4 years (range: 21-96 years). Mean age for men was 61.3 ± 16.2 years, and 74.7 ± 12.5 years for women (P = 0.001). Number of procedures per year was 11.2 ± 0.9, and bowel resection was performed in 82.3% of patients. Group III: 47 patients (21 men). Patient age was 65.4 ± 14.4 years. Mean age for men was 61.5 ± 17.3 years and 65.3 ± 14.4 years for women. Duration of symptoms before hospitalization was 6.9 d (range: 1-180 d). No patients had a preoperative diagnosis, 97.9% of patients underwent surgery, and 78.3% had multiple diverticula. Bowel resection was performed in 67.4% of patients, and suture closure in 32.6%. Mortality was 23.4%. There was no difference in length of history or its impact on survival between Groups I and III (P = 0.241 and P = 0.198, respectively). Resection was more often performed in Group I (P = 0.01). Mortality was higher in Group III (P = 0.002).

CONCLUSION: In cases with contained perforation, conservative treatment gives satisfactory results, laparoscopy with lavage and drainage can be attempted and continued with a conservative course.

Laparoscopic diagnosis and management of an acute jejunal diverticulitis

Jejunal diverticulitis is a rare clinical entity with a high degree of clinical variability and nonspecific radiographic findings, making it a diagnostic challenge. Definitive diagnosis is typically not made until surgery is undertaken, most commonly by laparotomy. We present a case of laparoscopic diagnosis and management of an elderly man with an acute jejunal diverticulitis. The use of a laparoscopic approach provided for an effective therapy without any perioperative morbidity. Clear visualization of the extent of the disease allowed us to avoid intestinal resections. Laparoscopic washout and postoperative bowel rest and intravenous antibiotics seem to be sufficient for acute nonperforated jejunal diverticulitis. Despite his advanced age, our management allowed for a speedy and uneventful recovery in our patient. As a result, we advocate that diagnostic laparoscopy should be considered in most cases of suspected acute jejunal diverticulitis. In addition to facilitating a correct diagnosis, laparoscopic exploration and washout may provide effective management of the acute attack while obviating the need for major abdominal explorations and resections.

Complicated jejunal diverticulitis: a challenging diagnosis and difficult therapy

BACKGROUND/AIM

In contrast to diverticulosis of the colon, jejunal diverticulosis is a rare entity that often becomes clinically relevant only after exacerbations occur. The variety of symptoms and low incidence make this disease a difficult differential diagnosis.

PATIENTS AND METHODS

Data from all patients who were treated in our surgical department for complicated jejunal diverticulitis, that is, gastrointestinal hemorrhage or a diverticula perforation were collected prospectively over a 6-year period (January 2004 to January 2010) and analyzed retrospectively.

RESULTS

The median age among the 9 patients was 82 years (range: 54-87). Except for 2 cases (elective operation for a status postjejunal peridiverticulitis and a re-perforation of a diverticula in a patient s/p segment resection with free perforation), the diagnosis could only be confirmed with an exploratory laparotomy. Perforation was observed in 5 patients, one of which was a retroperitoneal perforation. The retroperitoneal perforation was associated with transanal hemorrhage. Hemodynamically relevant transanal hemorrhage requiring transfusion were the reason for an exploratory laparotomy in 2 further cases. In one patient, the hemorrhage was the result of a systemic vasculitis with resultant gastrointestinal involvement. A singular jejunal diverticulum caused an adhesive ileus in one patient. The extent of jejunal diverticulosis varied between a singular diverticulum to complete jejunal involvement. A tangential, transverse excision of the diverticulum was carried out in 3 patients. The indication for segment resection was made in the case of a perforation with associated peritonitis (n=4) as well as the presence of 5 or more diverticula (n=2). Histological analysis revealed chronic pandiverticulitis in all patients. Median operating time amounted to 142 minutes (range: 65-210) and the median in-hospital stay was 12 days (range: 5-45). Lethality was 0%. Major complications included secondary wound closure after s/p repeated lavage and bilateral pleural effusions in one case. Signs of malabsorption as the result of a short bowel syndrome were not observed. Minor complications included protracted intestinal atony in 2 cases and pneumonia in one case. Median follow-up was 6 months (range: 1-18).

CONCLUSION

Complicated jejunal diverticulitis often remains elusive preoperatively due to its unspecific clinical presentation. A definitive diagnosis can often only be made intraoperatively. The resection of all diverticula and/or the complete diverticula-laden segment is the goal in chronic cases. The operative approach chosen (tangential, transverse excision vs segment resection) should be based on the extent of the jejunal diverticulosis as well as the intraoperative findings.

Jejunal Diverticular Perforation due to Enterolith

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life-threatening and require early surgical treatment. Small bowel perforation secondary to jejunal diverticulitis by enteroliths is rare. The aim of this study was to report a case of small intestinal perforation caused by a large jejunal enterolith. An 86-year-old woman was admitted with signs of diffuse peritonitis. After initial fluid recovery the patient underwent emergency laparotomy. The surgery showed that she had small bowel diverticular disease, mainly localized in the proximal jejunum. The peritonitis was due to intestinal perforation caused by an enterolith 12 cm in length, localized inside one of these diverticula. The intestinal segment containing the perforated diverticulum with the enterolith was removed and an end-to-end anastomosis was done to reconstruct the intestinal transit. The patient recovered well and was discharged from hospital on the 5th postoperative day. There were no signs of abdominal pain 1 year after the surgical procedure. Although jejunal diverticular disease with its complications, such as formation of enteroliths, is difficult to suspect in patients with peritonitis, it should be considered as a possible source of abdominal infection in the elderly patient when more common diagnoses have been excluded.

Multiple giant diverticula of the jejunum causing intestinal obstruction: report of a case and review of the literature

Multiple diverticulosis of jejunum represents an uncommon pathology of the small bowel. The disease is usually asymptomatic and must be taken into consideration in cases of unexplained malabsorption, anemia, chronic abdominal pain or discomfort. Related complications such as diverticulitis, perforation, bleeding or intestinal obstruction appear in 10-30% of the patients increasing morbidity and mortality rates. We herein report a case of a 55 year-old man presented at the emergency department with acute abdominal pain, vomiting and fever. Preoperative radiological examination followed by laparotomy revealed multiple giant jejunal diverticula causing intestinal obstruction. We also review the literature for this uncommon disease.

Application of laparoscopy in the management of obscure gastrointestinal bleeding

Gastrointestinal (GI) bleeding is considered obscure when it persists or recurs after negative endoscopy. Small bowel lesions account for approximately 1-fourth of cases of obscure GI bleeding. These lack specific clinical symtoms and signs, and tend to be inaccessible to routine examinations. The management of patients with intermittent obscure GI bleeding poses both diagnostic and therapeutic challenges. The aim of this study was to report the importance of laparoscopy in diagnosing and treating small bowel lesions responsible for obscure bleeding in 5 patients with subacute presentations. Data were collected from 2 hospitals' in-patient records and a prospective database. All patients underwent laparoscopic exploration. After the identification of the diseased segments, laparoscopy-assisted segmental resection of the small bowel and enteroentorostomy were carried out in all cases. This approach enabled a successful minimally invasive treatment of the obscure GI bleeding. The overall procedure was safe and our results were satisfactory.