Saudi Journal of Gastroenterology

CASE REPORT
Year
: 2002  |  Volume : 8  |  Issue : 2  |  Page : 62--63

Perforation of jejunal diverticulum


Asal Y Izzidien Al-Samarrai 
 Department of Surgery, Consultant Surgeon, Prince Charles Hospital, United Kingdom

Correspondence Address:
Asal Y Izzidien Al-Samarrai
Department of Surgery, Prince Charles Hospital, Merthyr Tydfil CF 47 9DT, Cardiff
United Kingdom




How to cite this article:
Al-Samarrai A. Perforation of jejunal diverticulum.Saudi J Gastroenterol 2002;8:62-63


How to cite this URL:
Al-Samarrai A. Perforation of jejunal diverticulum. Saudi J Gastroenterol [serial online] 2002 [cited 2021 Jan 26 ];8:62-63
Available from: https://www.saudijgastro.com/text.asp?2002/8/2/62/33374


Full Text

 Introduction



Due to the rarity of acquired jejunoileal diverticulitis, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality [1] . The incidence of jejunoileal Diverticulum is between 1.1 % and 2.3%, based on findings at autopsy (when the intestine is insufflated with air) or during major abdominal surgical procedures. They may be single but are usually multiple and are confined to the jejunum in 80-90% of cases. Acute complications are estimated to occur in 5-10% of cases of small bowel diverticulosis [2] . A 78 years male, who presented with a provisional diagnosis of peritonitis and was found to have a perforation of a Jejunal diverticulum is reported.

 Case Report



A 78-year male, presented with a sudden onset of severe, continuous, central abdominal pain, which increased with movement and coughing. He had a past history of chronic obstructive airway disease, congestive cardiac failure, wedge resection of left lung and he was on steroids for eleven years. On examination he was febrile (temp 38.9 C), dehydrated and tachycardic (pulse rate 120/min.), Abdominal examination revealed generalised tenderness with guarding and rigidity. His white cells count, urea and electrolyte and serum amylase were normal. Chest radiograph showed no air under the diaphragm.

Laparoscopy through a supra-umbilical incision showed a bile stained free fluid in the pelvis. Oesophagus, stomach, duodenum and gallbladder looked normal. It was not possible to identify the site of perforation, hence a laparotomy was done. Multiple jejunal diverticulae were found along the mesenteric border, 30cm from the duodeno-jejunal flexure. [Figure 1],[Figure 2].

The mesentery and lymph node adjacent to the most proximal diverticulum were inflamed. Diverticulosis of the jejunum was noted with pus oozing from underneath the lymph node. The diverticulum was explored but no perforation could be seen. A swab was taken for bacteriological examination, a biopsy was carried out and the site oversewn.

The patient was initially admitted to the intensive care unit and transferred to the ward when stable. He was discharged home after eight days and followed up in the out patient clinic. The histological study revealed portions of jejunal mucosa with thin muscularis mucosa. Surrounding fibro-connective tissue showed acute fibrinopurulent exudates extending from mucosa to serosa, consistent with perforation.

 Discussion



Clinically, patients with jejunal diverticulae may remain asymptomatic but they can present with abdominal pain, flatulence, borborygmi or malabsorption syndrome [3] . They may present as an acute abdomen due to diverticulitis or perforation following inflammation, foreign body, amyloid disease or malignancy such as lympho sarcoma, MEN-I or fibrous histiocytoma. Because of the relative rarity, the diagnosis of jejunoileal diverticulosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. Jejunoileal diverticulae should not always be dismissed in asymptomatic patients, as they may cause vague, chronic symptomatology and acute complications, including intestinal obstruction, haemorrhage, and perforation [1] . Acute jejunal diverticular perforation must be considered in the differential diagnosis of an acute abdominal process. A few patients with a localised collection have been managed conservatively with antibiotics and CT guided aspiration [4] .

Complicated small-bowel diverticulae cause abdominal pain, gastrointestinal haemorrhage, small bowel obstruction, and peritonitis. The present patient had an occult perforation of a small-bowel diverticulum and there were diverticulae throughout the whole small bowel [5] . Jejunal diverticular perforation is an uncommon cause of acute abdominal pain in the elderly [6] . From 1971 to 1994 Koger et al have reported 13 patients (nine men and four women) with a mean age of 68 years. All patients have experienced sudden onset of abdominal pain, nausea and vomiting, and leukocytosis. Three patients have had localised peritonitis and underwent immediate laparotomy. The remaining ten patients have had abdominal tenderness without peritoneal signs. All have experienced worsening signs and symptoms and underwent exploratory laparotomy and resection of the involved jejunal segment within 13 hours to eight days after admission [6] .

 Conclusion



Jejunal diverticular perforation is an uncommon and thus frequently overlooked cause of acute abdomen in elderly patients and it must be considered in the differential diagnosis.

References

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2Roses DF, Gouge TH. Scher KS, et al. Perforated diverticula of the jejunum and ileum. Am J Surg 1976; 132: 649-52 .
3Mortensen N, C V Mann, RCG, Russell and N S Williams. The Small and Large Intestine.. (ED) Baily & Love Short Practise of Surgery 22nd Edition Chapman & Hill Medical 1992; 786
4Novak JS, Barkan JS. Nonsurgical management of acute jejunal diverticulitis: a review. American journal of Gastroenterology 1997: 92: 1929-31.
5Klee FE, Osswald BR. Wysocki S. Severe abdominal pain and thrombocytopenia--typical symptoms of occult jejunal diverticulum perforation? Journal of Gastroenterology 1997; 32: 246-50.
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