SCIENTIFIC
Perforated Jejunal Diverticulitis : A Rare Cause of Abdominal Pain
AUTHORS : Yuki Nakao 1
Errington Thompson 1 Jared Mattingly 2 Rebecca Wolfer 1
1
Department of General Surgery , Marshall University Joan C . Edwards School of Medicine
2
Marshall University Joan C . Edwards School of Medicine
CASE PRESENTATION
An 80-year-old male presented to the emergency department with a one-day history of sudden onset of diffuse abdominal discomfort and localized left upper quadrant pain associated with vomiting . His physical examination showed a heart rate of 78 beats / minute , regular rhythm , blood pressure of 125 / 77 mmHg , a respiratory rate of 18 breaths / minute , a temperature of 38.3 ℃, and oxygen saturation of 97 % on room air . His abdominal examination was significant for localized tenderness of the left upper quadrant with rebound and guarding .
Results of laboratory testing included hemoglobin of 13.8 g / dL , white blood cell count of 10.5x10 9 / L , serum creatinine level of 1.37 mg / dL , and base deficit of -5 mmol / L . Other laboratory data such as platelet count , blood glucose level , and liver function tests were within normal limits . Electrocardiogram showed normal sinus rhythm with no ST changes . Abdominal and pelvic computed tomography ( CT ) imaging was performed , which showed pneumoperitoneum with stranding of fat in the left mid-abdomen about the transverse colon and contiguous with the jejunum . A large jejunal diverticulum with mild jejunal mural thickening and diverticular distention were noted ( Figure 1 ). Sigmoid colonic diverticula were also noted .
ABSTRACT
The patient underwent exploratory laparotomy , which revealed a moderate amount of turbid fluid in the left abdomen stemming from a perforation in the proximal jejunum along with an inflamed diverticulum ( Figure 2 ). A bulging diverticulum measuring 2.7 cm x 2.5 cm x 1.7 cm with a 0.3 cm perforation site was resected . Several diverticula were found throughout the sigmoid colon , and the colon was soft without evidence of active diverticulitis or perforation . The specimen was dissected open to show enteral contents and a fecalith in the diverticulum . No masses or nodules were identified grossly . Microscopic examination revealed diverticulum with transmural inflammation , necrosis , and perforation and associated acute and chronic serositis . Margins appeared viable , with no dysplasia or malignancy observed ( Figure 3 ). Additionally , multiple diverticula were discovered within the jejunum . A short segment ( 10 cm ) small bowel resection with side-to-side stapled anastomosis was performed . The remaining diverticula were left untouched except around the perforated site . The patient had no postoperative complications . He was able to tolerate a regular diet and was discharged home on post operative day seven .
DISCUSSION
Small intestinal diverticula are rare , accounting for 0.07-3.2 % of all gastrointestinal diverticula . 1 Diverticula of the small intestine can be classified as acquired or congenital , including Meckel ’ s diverticulum . Acquired diverticula are usually pseudodiverticula and are more common on the mesenteric side , with 87 % of diverticula within 100 cm of the Treitz ligament
Cases of small intestinal diverticulosis are rare and mostly asymptomatic . Occasionally , a small bowel diverticulum may perforate . We describe the case of an 80-year-old male who presented with abdominal pain and signs of localized peritonitis . The ultimate diagnosis was confirmed to be perforated jejunum diverticula . Perforation of the jejunal diverticulum should be considered as part of the differential diagnosis of acute abdomen in elderly patients , and appropriate treatment options , ranging from early surgery to conservative measures , should be tailored to the patient ’ s presenting condition and their overall physiology .
in the jejunum . 2 Additionally , it has been reported that 30-61 % of patients with jejunal diverticulosis also present with colonic diverticulosis . 3
A PubMed search for the years 2012-2022 using the keywords diverticulitis , small intestine , and perforation revealed 29 cases of jejunal diverticular perforation , including our case ( Table 1 ). Males accounted for 17 / 29 ( 58.6 %) of cases , and the mean age was 66.1 ± 16 ( mean ± SD ). All 29 patients presented with abdominal pain as the main complaint , and of those described , peritoneal irritation signs were generalized in 7 / 25 ( 28 %) and localized in 7 / 25 ( 28 %). No surgery-related complications were reported in surgical cases . It is not possible to discern if there were truly no complications or if this reflects the abbreviated nature of case reports . Conservative treatment with antimicrobial agents was chosen in five patients , all of whom had negative peritoneal irritation signs . 4-8 Indications for conservative / nonoperative treatment were not consistently reported , though reasons may include patients ’ other comorbid conditions or overall severity of illness . The majority of patients , 26 / 27 patients ( 96.3 %), were discharged from the hospital with a mean hospital stay of 9.3 ± 8.4 ( mean ± SD ) days . The mortality rate was 3.7 % ( 1 / 27 ). The other two patients ’ outcomes were not described .
Although there are various descriptions about the potential pathogenesis of small intestinal diverticula , it is believed that the mucosa passes through the muscular layer of the small bowel wall . This mechanism
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