Perforated Jejunal Diverticulitis

MAY 25, 2007

Parviz Goshtasby, MD
Chief Surgical Resident
Department of Surgery

Vasudevan
Tiruchelvam, MD

General Surgery
Attending
Department of Surgery

Thomas Nicholson,
MD

General Surgery
Attending
Department of Surgery
York Hospital
York, PA

Jejunal diverticula are rare and usually occur in the elderly. The condition is difficult to diagnose because patients generally present with symptoms that mimic other diseases. It is important for clinicians to have a heightened awareness of jejunal diverticulitis because perforation and other complications can occur if it is not recognized promptly in symptomatic patients. The authors report a case of jejunal diverticulitis that was initially treated with medical management but eventually required surgical intervention. The perforation was observed during the operation. The authors also review the literature and discuss the presentation, diagnosis, and optimal management of this disease.

Although diverticular disease is a common pathology of the colon, diverticulosis of the small bowel and its complications are relatively rare. As a result, the diagnosis is often missed, which can be disastrous. We describe an interesting case of perforated jejunal diverticulitis. Our patient was successfully treated and had a favorable outcome. We also review the literature regarding this rare condition.

Case report
A 69-year-old woman presented to the emergency department with a 36-hour history of left-sided abdominal pain without nausea or vomiting. On physical examination, she had a temperature of 101?F, pulse of 120 beats per minute, blood pressure of 100/60 mm Hg, respiratory rate of 20 breaths per minute, and an oxygen saturation of 95% on room air. The patient's abdomen was soft and nondistended, but a small mass and tenderness were elicited on deep palpation in the left mid-abdomen. There were no peritoneal signs and only minimal bowel sounds on auscultation. The patient's medical history was noncontributory.





Laboratory studies were significant for an elevated white blood cell (WBC) count of 16,500/mm3. Computed tomography (CT) scans of the abdomen revealed a 5-cm, complex, inflammatory mass in the left upper quadrant adjacent to a loop of small bowel, indicating diverticulitis (Figure 1). The patient was clinically stable and was admitted to the hospital for intravenous antibiotics, including levofloxacin and metronidazole, and fluid resuscitation.

The patient remained febrile, and an upper gastrointestinal series with small bowel follow-through with barium revealed several small duodenal diverticula (Figure 2). There was a tract of contrast arising from the proximal jejunum leading to a mottled collection of debris and gas in the left upper quadrant. Based on these findings, a diagnosis of jejunal diverticulitis with abscess was made.

The patient was taken to the operating room on hospital day 6 once her fever had resolved and her WBC count returned to normal. A midline exploratory laparotomy revealed several small duodenal diverticula and a large diverticulum arising on the mesenteric border of the proximal jejunum (Figure 3). There was a small perforation with a collection of pus near the base of the diverticulum. The bowel proximal and distal to the diverticular mass was carefully mobilized and resected using a gastrointestinal anastomosis stapling device. A window was placed in the transverse mesocolon and the proximal jejunum was anastomosed to the second portion of the duodenum in a retrocolic side-to-side fashion. The abdomen was irrigated and a Jackson-Pratt drain was left near the anastomosis.

Pathology revealed a 5-cm segment of small bowel with a 5.5 x 4.5 x 4.0-cm diverticulum arising from a 2-cm mesenteric defect along the bowel wall. The diverticular wall consisted only of mucosa, 0.3 to 0.4 cm in thickness. There was no sign of malignancy.

The patient did well postoperatively and was discharged to home on postoperative day 6 tolerating a regular diet. The patient was doing well at 1-year follow-up.

Discussion
Jejunal diverticulosis was first reported in 1807 by Sir Astley Paston Cooper. Autopsy studies reveal an incidence between 1.3% and 4.6%, whereas radiologic studies show an incidence between 0.02% and 2.3%.1 Over 80% of jejunal diverticula occur in patients 70 years and older. Jejunal diverticula make up only 8% of all small bowel diverticula2 and are associated with diverticula of other areas, with colonic involvement observed in up to 50% of cases.3

Jejunal diverticula are thought to be due to an acquired disease process. These pulsion-type false diverticula occur along the mesenteric border of the intestine, where blood vessels pierce the muscularis layer of the bowel wall, causing weak areas to develop. These weak areas lead to herniation of mucosa, submucosa, and serosa while excluding the muscularis layer. Diverticula may be difficult to identify during laparotomy because they may be hidden by mesenteric fat. Most jejunal diverticula are asymptomatic; however, a number of acute complications may occasionally be present.

Surgical management of small bowel diverticulosis was first described in 1906 by Gordinier and Sampson.4 Jejunal diverticulitis occurs with a frequency of 2.3% in patients with known diverticulosis.2 The etiology is thought to be secondary to luminal obstruction leading to bacterial stasis and a localized inflammatory reaction. Diverticulitis may be further complicated by perforation with peritonitis, mechanical obstruction, or fistulization. A case of manifestation as an abdominal wall abscess has also been reported.5 A preoperative diagnosis of jejunal diverticulitis is rarely made because this condition's presentation is similar to that of other acute abdominal pathologies, including perforated ulcer, appendicitis, pancreatitis, and acute cholecystitis.

Perforation of jejunal diverticula is uncommon, which may be related to the low intraluminal pressures within the small bowel. Instigating factors for perforation were shown to be related to a necrotizing inflammatory reaction in 82% of cases, followed by blunt trauma (12%) and foreign body impaction (6%).6 Cocaine sniffing has also been noted as a risk factor.7 Perforation often occurs into the mesenteric leaves of the jejunum, leading to a mesenteric abscess. Although the perforation may be contained within the mesentery, preventing leakage into the peritoneal cavity and resultant peritonitis, it also leads to a delay in diagnosis because the classical physical examination findings of an acute abdomen are absent, which may prove disastrous when frail or elderly patients are involved.

A review of reported cases showed jejunal diverticula occur equally in both sexes and that patients have an average age of 62 years on presentation.8 The overall mortality was 24% with survival not influenced by sex, age, or extent of operation; however, a longer duration of symptoms marked a poorer outcome. Of patients with perforation, 83% had multiple diverticula.

Jejunal diverticulosis often presents a diagnostic dilemma. Enteroclysis is thought to be the best diagnostic tool for visualizing this disease because the positive pressure that results from instillation of barium and insufflation causes the diverticula in the bowel lumen to become prominent.2 Standard upper gastrointes-tinal contrast studies may also be helpful, showing contrast-filled outpouchings characteristic of diverticulosis. Thickened mucosal folds may indicate diverticulitis whereas free extravasation of contrast indicates perforation. CT scanning is helpful in showing acute inflammatory changes, such as mesenteric stranding and abscess or free air around the diverticular site. Plain upright radiographs of the abdomen may demonstrate air-fluid levels in the diverticula. Laboratory studies tend to be nonspecific, but an elevated WBC count with bandemia can support the diagnosis of diverticulitis or perforation.

Management of jejunal diverticula depends on a patient's symptoms. It is generally recommended that asymptomatic diverticula found incidentally during laparotomy for other reasons should be left alone.8 Surgical resection is the standard of care for symptomatic patients with complicated diverticula.9 Surgery is required in approximately 8.5% of all patients with jejunal diverticula,10 although it increases to 40% in patients with symptoms or complications.11 Localization of the diverticula may be difficult during laparotomy because they are frequently hidden between the mesenteric leaves. Techniques to facilitate exposure include jejunal insufflation of air using manual compression and intraoperative endoscopy.

Resection of the surrounding small bowel with primary anastomosis is recommended for complicated diverticula. Some studies support a laparoscopic approach to exploration and small bowel resection.12 Extensive resection of multiple diverticula may lead to short bowel syndrome; thus, resection should be limited only to the diseased segment. Attempts to resect all portions of the bowel containing diverticula also do not guarantee that other portions of the bowel will remain free of diverticula.13 Simple diverticulectomy with oversew is not recommended because it has been linked to postoperative leakage, sepsis, and death.2

The mortality rate of complicated jejunal disease has ranged between 21% and 30% over the past 30 years8; however, some reviews indicate a mortality rate between 0% and 5%.14,15 These reviews may reflect improvements in intensive care management and antimicrobial treatment. Morbidity and mortality are mostly related to the obscurity of the diagnosis as well as the advanced age and significant comorbidities of most patients presenting with complications. Clinicians should have a high index of suspicion for this disease because early operative intervention is imperative.

Conclusion
Jejunal diverticular disease is a rare clinical entity that is difficult to diagnose. Although conservative medical management may be attempted for stable patients, surgical resection of involved bowel segments is the standard of care for patients with recurrent symptoms who have undergone unsuccessful medical management or have complications. It is imperative for general surgeons to be familiar with this entity so that they can act quickly and contribute to a successful clinical outcome for their patients.

Acknowledgments
We wish to thank Ms. Sue Shultz, Director of Library Services, Philip A. Hoover MD Library, York Hospital, for her editorial assistance; and Dr. Thomas Scott, Director of the General Surgical Residency Program, York Hospital, for reviewing the contents of this article.

References
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10. Rodriguez HE, Ziauddin MF, Quiros ED, et al. Jejunal diverticulosis and gastrointestinal bleeding. J Clin Gastroenterol. 2001;33(5): 412-414.

11. Maull KI, Nicholson BW, Mendez-Picon G. Jejunoileal diverticulosis. South Med J. 1981;74(7):792-795.

12. Cross MJ, Snyder SK. Laparoscopic-directed small bowel resection for jejunal diverticulitis with perforation. J Laparoendosc Surg. 1993;3(1):47-49.

13. Brown JE, Vallette R, Brown JE Jr. Recurrent jejunal diverticulosis. South Med J. 1985;78(3):352-353.

14. Tsiotos GG, Farnell MB, Ilstrup DM. Nonmeckelian jejunal or ileal diverticulosis: an analysis of 112 cases. Surgery. 1994;116(4): 726-732.

15. Akhrass R, Yaffe MB, Fischer C, et al. Small-bowel diverticulosis: perceptions and reality. J Am Coll Surg. 1997;184(4): 383-388.



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