Jejunal diverticulosis found in a patient with long-standing pneumoperitoneum and pseudo-obstruction on imaging: a case report

Abstract

Small bowel diverticulosis is a rare finding within the general population and jejunal diverticulosis, specifically, is even rarer. Clinical manifestations can range from post-prandial pain, constipation and malabsorption to serious complications, such as gastro-intestinal hemorrhage, perforation and acute intestinal obstruction. Here we describe the case of an 81-year-old gentleman who presented with a three-year history of abdominal pain and weight loss. Despite unremarkable physical examination and laboratory tests, persistent pneumoperitoneum and dilated loops of small bowel were found on imaging. Having been given a diagnosis of small bowel bacterial overgrowth, the patient underwent capsule endoscopy study for further evaluation of his small bowel. The capsule did not reach the colon and the patient never noted passing the capsule in his stool so, six months post-procedure, a computed tomography (CT) scan seemed to reveal the retained capsule. Subsequent exploratory laparotomy revealed 200 cm of atonic, dilated jejunum with impressive diverticula along the anti-mesenteric border. This case report is an example of an unusual set of presenting signs and symptoms of jejunal diverticulosis, including persistent pneumoperitoneum, pseudo-obstruction and small bowel bacterial overgrowth. A literature review has revealed that these signs have been present in other cases of jejunal diverticulosis, although the etiology and pathophysiology is not clearly understood.

Jejunal pseudodiverticulosis. Three cases report

“…Jejunal pseudodiverticulosis is an uncommon entity (incidence between 0.06-1.5%) (1,2), and is more frequent in males (53%) between the 6 th and 7 th decades of life (2,3).…”

“…This herniation is secondary to a hyper-pressure in the intestinal lumen (1,2,4). The pseudodiverticula size is variable, their typical location is in the proximal jejunum (1,2) and they can coexist with other pseudodiverticula in the gastrointestinal tract (2,3). Pseudodiverticula are usually asymptomatic and an incidental finding.…”

“…Nevertheless, they can cause non-specific abdominal discomfort, dyspepsia and malabsorption. Less frequently, they display an acute onset with perforation, obstruction or bleeding (1)(2)(3)(4)(5).…”

“…Conservative management should be performed in the absence of complications (3). Surgical management should be offered in complicated cases; intestinal resection and primary anastomosis is the treatment of choice.…”

A 74-year-old woman with malabsorption and intestinal pseudo-obstruction

“…The interrupted transport of the endoscopic capsule occurred most likely due to a temporary capture of the capsule in one of the diverticula, as no specific stenosis was revealed in the MRI-Sellink. According to the scientific literature small intestine diverticula are often linked to pseudo-obstruction manifestations with disrupted intestinal transport [2]. Abdominal computed tomography scan is the diagnostic tool of choice even if it is not possible to identify all small bowel diverticula.…”