Jejunal Diverticulosis with Perforation – A Challenging Differential Diagnosis of Acute Abdomen: Case Report

Abstract

A 56-year-old male presented with dragging upper abdominal pain of one week duration. There was a history of dyspepsia, abdominal discomfort and vomiting after meals for past one week and low grade fever associated with chills and rigors.On examination, the patient was febrile with a temperature of 99 0 F, pulse rate -110/min, blood pressure -130/90 mm Hg. Abdominal examination revealed generalized tenderness with fullness over the right hypochondrium.Laboratory work up revealed Hb-13g/dl, TLC-10,000/cu.mm, DLC -P90 L7 E1 M2, urea -49mg/dl, creatinine -0.5mg/dl. Abdominal radiograph revealed air under the diaphragm. Abdominal CT scan and ultrasound showed multiple diverticuli in the small intestine [Table/ Fig-1] and air under the diaphragm suggesting perforation.Emergency midline laparotomy was performed. Intra-operatively multiple jejunal diverticuli were found on the mesenteric border. They were located between 8 cm to 20 cm from duodeno-jejunal (DJ) flexure. Serosal purulent exudates and multiple inter-loop adhesions were noted. There was purulent material in the peritoneum as well. Proximal jejunal resection with end to end anastomosis was done. The post operative period was uneventful and the patient was discharged on 10 th day after the surgery. One month follow up was uneventful.Gross examination of resected specimen revealed a segment of small bowel, 65 cm in length with eight outpouchings on the serosal aspect along the mesenteric border, of which largest measured 4x3x1 cm with focal areas of exudates on the serosal aspect and adhesions; smallest measured 2x1.5x0.5cm [Table/ Fig-2]. Three ABStRACtMultiple diverticulosis of the jejunum represents a very rare entity. Jejunal diverticula are found to be the rarest of all small bowel diverticula. The disease is usually asymptomatic and often becomes clinically relevant when complicated. This rarity makes it a difficult differential diagnosis. Related complications such as diverticulitis, perforation, and bleeding and/or intestinal obstruction appear in about 10-30% of the patients which increase the morbidity and mortality rates in such individuals. Here, we present a case of jejunal diverticulosis with perforation who presented with symptoms of acute abdominal pain, vomiting and fever along with a brief review of literature.

Jejunal diverticulosis: a rare case of intestinal obstruction

“…Complications of jejunal diverticulosis include obstruction, haemorrhage, diverticulitis and perforation [ 3 ], and occur in 10–30% of the cases. The incidence of each complication is variable and difficult to assess due to the small sample sizes of most studies.…”

“…Small bowel motility disorders with increased intraluminal pressure are considered to be the main aetiological factors for its development [ 2 ]. Although it is often asymptomatic, it can lead to severe complications including perforation, haemorrhage, enterolith formation, diverticulitis and intestinal obstruction [ 3 ].…”

Acute abdomen caused by a large solitary jejunal diverticulum that induced a midgut volvulus. Report of a case

“…They are common in the duodenum and at autopsy series may be present in 10–20% of persons [ 7 ]. Jejunal and ileal diverticuli are much less common occurring in less than 1% of the population [ 8 , 9 ]. Then, in the colon false diverticuli become extremely common.…”

Multiple Small Gut diverticula with ilealperforation: A case report

“…They are diagnostic as well as therapeuticchallenge to surgeons throughout the world. Although it is often asymptomatic, it can leadto severe complications including perforation, DOI: http://dx.doi.org/10.22192/ijcrms.2017.03.04.012 haemorrhage, enterolithformation, diverticulitis and intestinal obstruction 4 .…”