matosis in the abdomen . Specific findings of diverticular perforation in the small intestine include arrowhead-like shaped outpouching of the small bowel , in which air leaking outside the intestinal tract into an area that is draped with omentum or mesentery . 11 , 12 However , these findings are not always present . In the current case , the so-called arrowhead-like shape was not seen , but the presence of pneumatosis reinforced the diagnosis of perforated jejunal diverticulum .
Treatment of perforation of small bowel diverticula should start with stabilizing the patient and obtaining a CT scan of the abdomen and pelvis with intravenous contrast . 13 Routine laboratory studies should be obtained and broad-spectrum antibiotics initiated . If the patient is considered to be an acceptable surgical risk , the patient should be taken to the operating room . Surgical risk should be evaluated and clearly documented in the chart by the attending surgeon . Once in the operating room , the attending surgeon should perform a resection limited to the perforated small bowel . A primary anastomosis should be performed using the approach with which the surgeon is most comfortable , whether open or laparoscopic . Standard postoperative management should be employed . Patients should be encouraged to ambulate . Nasogastric tubes should be removed early in the patient ’ s postoperative course . Limiting the use of narcotics should promote bowel motility . 14 Intravenous acetaminophen has been shown to be beneficial in relieving postoperative pain and it does not seem to promote postoperative delirium . Many hospitals are limiting intravenous acetaminophen secondary to cost constraints . Acetaminophen can be given per rectum with the same pain-relieving benefits . 15 One should avoid using intravenous ketorolac . Caution should be exercised in the use of non-steroidal anti-inflammatories in elderly patients due to the high incidence of nephrotoxicity . 16 Additionally , ketorolac has been implicated in slower healing in surgical cases involving the large bowel , as well as with a higher incidence of anastomotic leaks . 17 Having the patients chew gum every six to eight hours promotes intestinal motility . 18 Beginning a clear liquid diet as soon as the patient ’ s nausea and vomiting has resolved promotes early re-
A perforation ( indicated by the arrow ) in the proximal jejunum with an inflamed diverticulum .
covery . Broad-spectrum antibiotics should be tailored to the intraoperative culture results and should not be continued any longer than four days postoperatively . 19 All of these measures decrease length of stay , decrease the patient ’ s discomfort , and improve the patient outcomes . Conservative treatment with antimicrobial agents can be effective in selected patients . 5-9
CONCLUSION
FIGURE 2 : Gross View of Perforated Diverticula in the Jejunum
A perforation ( indicated by the arrow ) in the proximal jejunum with an inflamed diverticulum .
FIGURE 3 : Histology of the Diverticulum with Transmural Inflammation , Necrosis , and Perforation
Jejunal diverticula are a rare condition . They can present as perforated peritonitis . Perforation of a jejunal diverticulum should be considered as part of the differential for acute abdominal pain in relatively elderly patients . Physicians must order a thoughtful , expedited work-up and then , when indicated , take these patients to the operating room for definitive therapy , though for select patients , conservative therapy with antibiotics may be effective .
REFERENCES
1 . Longo WE , Vernava AM 3rd . Clinical implications of jejunoileal diverticular disease . Dis Colon Rectum . 1992 Apr ; 35 ( 4 ): 381-8 . doi : 10.1007 / BF02048119 .
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