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A Perforated Jejunal Diverticulum

Posted Nov 03 2010 12:00am

 

Jaimini Cegla, Puja Chudasama, Tushar Agarwal and Shahid Chaudhary

Department of Surgery, The Hillingdon Hospital, Pield Heath Road, Uxbridge, Middlesex,

UB8 3NN, UK

Case report
A 65-year-old lady presented with a 5-day history of watery diarrhea with
no mucous or blood, anorexia and right-sided abdominal pain. She denied recent travel or eating
anything unusual. Her past medical history included an appendectomy, reversal of a retrograde
uterus, angina, Sjogren’s syndrome and irritable bowel syndrome causing intermittent abdominal
pain over the previous 4 years. The gastroenterologists had investigated her for her bowel
symptoms and a barium enema was found to be normal. Interestingly, her mother died of
‘‘a ruptured intestine’’ at the age of 62 and her sister was known to have diverticulosis.
On examination, she was clinically dehydrated, but she was stable and apyrexicial. She was
tender in both iliac fossae, the right worse than the left with rebound tenderness. Bowel sounds
were present.

She was reviewed a few hours later and the abdomen was found to be soft with tenderness
in the left iliac fossa and some voluntary guarding. There was no rigidity and bowel sounds
were present. The main differential diagnosis was diverticulitis and intravenous broad-spectrum
antibiotics were commenced.

The next morning there was some localised peritonism in the left iliac fossa and the impression
was still a case of diverticulitis. The computed tomography (CT) scan of the abdomen
revealed a modest amount of free fluid in the abdominal cavity, with some free air in the
retroperitoneum in front of the third and fourth parts of the duodenum. A small bowel
perforation was seen within a thickened loop. The sigmoid colon and the rest of the large bowel
appeared normal.

She proceeded to emergency laparotomy, which revealed multiple jejunal diverticula, one of
which had perforated leading to an abscess involving the mesentery of that section.
The rest of the gastrointestinal tract appeared normal including the large bowel, which did not
show any evidence of diverticular disease. A segmental resection of the jejunum was carried out.
She made a non-eventful post-operative recovery and was discharged home later that week.

Discussion
This case illustrates the diagnostic dilemma of jejunal diverticular perforation. Jejunal diverticula
have a prevalence of approximately 1% in the general population. Radiologically, barium studies have picked up
diverticula in the jejunum in 0.1–0.4% of the population. The incidence has been found to be
higher in men (58%) than women (42%).

The most common part of the small bowel to be affected by diverticula was the proximal
jejunum (75%), followed by the distal (20%) and then the ileum (5%). Seventy seven percent of
cases demonstrated multiple as opposed to solitary diverticula. Acquired diverticula tend to
involve the mucosa, submucosa and serosa. In contrast to true congenital Meckelian diverticula,
these acquired diverticula originate from the mesenteric border of the bowel where the
arteries enter through the bowel wall. They can be anything from a few millimetres in size to
up to 10cm.

Complications of jejunal diverticula occur in 6–10% of cases. These include diverticulitis,
haemorrhage, mechanical obstruction and perforation. Perforation of jejunal diverticula is
a rare complication. The largest case series to date that has been reported in the literature is
of 13 patients between 1971 and 1994.  The time frame between clinical presentation and diagnosis seems to be the biggest determinant of prognosis.

Clinically, this diagnosis may easily be confused with other causes of an acute abdomen such as
sigmoid diverticulitis, appendicitis, perforated peptic ulcer or ischaemic bowel.

Teaching point
One needs to maintain a high degree of suspicion if the patient is already known to have jejunal
diverticulosis. However, it is true that the patient will be treated on the merits of clinical signs and
a decision to perform a laparotomy is based on clinical signs, irrespective of the underlying
etiology. The literature also illustrates that radiological help must be used early to make the diagnosis. CT will yield
the definitive diagnosis and must be considered early in the management of these patients.

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