Enterolith Small-Bowel Obstruction Caused by Jejunal Diverticulosis: Report of a Case

We report the successful surgical treatment of intestinal obstruction caused by enteroliths formed in jejunal diverticula. A 78-year-old man with bowel obstruction of unknown etiology was initially managed conservatively, but suffered recurrence of the obstruction. Thus, we performed a laparotomy, which revealed multiple diverticula in the jejunum, with one enterolith inside a diverticulum and one enterolith in the terminal ileum. There was no abnormal communication between the gallbladder and the intestinal tract, excluding the possibility of a gallstone ileus. The stone in the terminal ileum could not be broken manually, so we performed an enterotomy to remove the stones. Intestinal obstruction caused by enteroliths in small-bowel diverticula is a rare event, which is difficult to diagnose and manage. To our knowledge, only 35 such cases have ever been reported.     

Giant Chylolymphatic Cyst of the Jejunal Mesentry in a Child: Report of a Case

A giant chylolymphatic cyst from the jejunal mesentery in a 4-year-old boy is herein described. The child presented with an acute intestinal obstruction and the etiology of the obstruction was only discovered at surgery, even though preoperative abdominal sonography had hinted at the presence of a mesenteric lesion. An excision of the cyst, along with part of the involved bowel, was performed and was curative. The literature regarding the origin, presentation, complications, and particularly, the diagnosis of this rare lesion is also reviewed. Received: November 5, 2001 / Accepted: July 2, 2002 Reprint requests to: S.K. Ratan, E-13/13, Khirki Extension, Malviya Nagar, New Delhi, PIN 110017, India     

Jejunal diverticulae: reports of two cases with review of literature

Introduction  

Jejunal diverticulosis (JD) is a rare disease of elderly people. Majority of diagnosed individuals are asymptomatic and found incidentally. The disease is clinically significant because of associated potential risk of serious complications. Due to the rarity and variable presentation of this clinical entity, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. Clinical presentations, signs, diagnosis, complications and treatment of JD are discussed through a review of the literature and report of two cases.     

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目的 探讨血管疾病所致急腹症的诊断和治疗。方法 对1997年6月至2002年8月间经治的15例血管源性急腹症的临床资料进行回顾性分析。结果 以中老年病人为多见，常并存心脏、血管疾病。临床表现差异较大，容易漏诊、误诊。平均确诊时间11h，手术治疗11例，非手术治疗4例，死亡2例，致残l例。结论 重视病史的全面采集，坚持正规的体格检查程序，严密观察病情，正确的临床逻辑思维，恰当的辅助检查，是早期诊断和成功治疗该病的关键。     

Appendicitis as a rare cause of mechanical small-bowel obstruction: A literature review of case reports

IntroductionAlthough bowel paralysis accompanying acute appendicitis is well known, mechanical bowel obstruction as a direct consequence of appendicitis remains a rare, but potentially life-threatening, acute abdomen. The aim of our literature review was to find all documented cases of this particular complication and compare them with our own case study.MethodsWe searched the PubMed database for relevant articles published from 1963 to 2015. The study included patients for whom direct links between appendicitis and strangulation of the terminal ileum were found, and for which the disease course had been documented in detail. The study also included our own case report since it met the inclusion criteria. A total of 190 articles were examined with a final yield of 17 case reports from 13 articles.Results17 patients (11 men and 6 women), with a mean age of 48 ± 23.9 years, met the inclusion criteria. The average period between symptom onset and surgery was 3.4 ± 3.7 days. Symptoms of the disease were consistent with small-bowel obstruction. Treatment included simple appendectomy (n = 7), possibly supplemented by segmental resection (n = 5), followed by ileocecal resection (n = 4), and one case that required a right-sided hemicolectomy (n = 1).ConclusionWe found mechanical bowel obstruction directly related to appendiceal inflammation to be extremely rare, and relatively few individual cases involving this potentially life-threatening complication have been documented in the literature. Clinical signs of the disease are variable, non-uniform, and consistent with symptoms of small-bowel obstruction during their progression.     

Multiple Jejunal Diverticulitis with Perforation in a Patient with Systemic Lupus Erythematosus: Report of a Case

A 70-year-old man with systemic lupus erythematosus (SLE) was brought to our Emergency Department after the sudden onset of acute and severe abdominal pain. Physical examination revealed a tender and distended abdomen with guarding and rebound tenderness in the periumbilical region and the left upper quadrant. A plain abdominal X-ray taken with the patient upright showed air fluid levels with dilatation of several loops in the small bowel. As the examination could not rule out bowel ischemia, perforation, or obstruction, an emergency laparotomy was performed, which revealed multiple jejunal diverticulosis, one of which had perforated and adhered to the right colon, causing rotation. The diverticulosis segment was resected and an end-to-end anastomosis was done. The patient had an uneventful postoperative recovery without any complications. This is an unusual cause of peritonitis in a patient with SLE, and we could not find any evidence to suggest involvement of the underlying SLE in the jejunal diverticulosis and diverticulitis in this patient. Nevertheless, the involvement of SLE might be possible and further investigation is warranted.     

Spectrum of disease and outcome of complicated diverticular disease

BACKGROUND: Diverticular disease is a common entity. The presentation, investigations performed, and management are variable. Our objectives were to assess the presentation, extent of disease, and treatment of a cohort of patients with colonic diverticulitis. METHODS: All patients with a diagnosis of diverticulitis over a 9-year period were reviewed. Patients were assessed as to age, sex, presenting symptoms, diagnostic studies, extent of disease, treatment, and outcome. RESULTS: Over a 9-year period (1992 to 2001), 192 patients were admitted with a diagnosis of colonic diverticulitis. The mean age was 61 years (range 28 to 90); 113 of 192 (59%) were female. The mean duration of symptoms prior to presentation was 14 days (range 1 to 270 days). One hundred eighteen of 192 (61%) had a previous documented attack of diverticulitis. Of the investigations performed 128 of 192 (66.7%) had a computed tomography (CT) scan of the abdomen and pelvis, 37 of 192 (20%) underwent a contrast enema, 61 of 192 (32%) underwent colonoscopy and 2 of 192 (1%) underwent a small bowel series. The abnormal findings on the CT scan were as follows: diverticular abscess (16%), diverticulitis (37%), diverticulosis without inflammation (15%), free air (10%) and fistula (1%). The locations of the diverticular abscesses were: pelvic (36%), pericolic sigmoid (36%), and "other," which included interloop (28%). Preoperative abscess drainage occurred in 10 of 192 (5%), which were either percutaneous, 6 of 192 (3%), or transrectal, 4 of 192 (2%). Nine of 192 (6%) presented with a fistula, colovesical fistulae (3%), colocutaneous (1%), enterocolic (1%), or colovaginal (1%). Overall, 73 of 192 (38%) underwent surgery. All patients undergoing surgery had a resection of their colon. The operative findings were localized abscess in 16 of 73 (22%), purulent/feculent peritonitis in 12 of 73 (17%), and phlegmon in 10 of 73 (14%). Sixty-seven of 73 (92%) had a primary resection with anastomosis; 38 of 67 (56%) had a protecting stoma. Five of 73 (7%) patients were found to have an unsuspected carcinoma. Overall, 29 of 192 (15%) developed a complication related to diverticulitis. Morbidity was 15.1%, of which 34% was infection related. Four of 192 patients (2%) died. CONCLUSIONS: In our experience, most patients presented with abdominal pain predominantly in the left lower quadrant. The symptoms were present on average of 14 days, most were female (59%), and most patients had a previous attack of diverticulitis. The commonest investigation performed was a CT scan (66.7%); however, other investigations were performed, for example, barium enemas. The practice of resection and primary anastomosis for acute diverticulitis has an acceptable morbidity and mortality. For high-risk anastomoses, a covering loop ileostomy and not a Hartmann's procedure is preferred. Surgery remains safe for the majority of patients and is associated with resolution of symptoms. We believe that because of the high number of patients in our series who had a previous attack of diverticulitis, therapy should be focused on preventing recurrent and virulent attacks by earlier operative intervention.     

Abdominal Wall Abscess Associated with Perforated Jejunal Diverticulitis: Report of a Case

We report a case of abdominal wall abscess caused by diverticulitis of the jejunum penetrating through the abdominal wall. A 53-year-old Japanese woman visited a local hospital complaining of abdominal pain and a mass in the left lower abdomen. An abdominal computed tomography scan showed a tumor with isodensity in the left lower abdominal wall. Magnetic resonance imaging showed a mass in the abdominal wall with isointensity in the T1-intensified image and high intensity in the T2-intensified images. The mass was heterogeneous inside and protruded partially toward the intraperitoneal cavity. Ultrasound examination showed a heteroechoic mass extending into the intraperitoneal cavity. Laparotomy revealed a tumor in the abdominal wall with a fistulous tract extending to the jejunum. We resected the abdominal wall tumor with partial resection of the small intestine. The resected specimen contained a tumor with a fistulous tract passing through the abdominal wall. Histological examination revealed remarkable infiltration of neutrophils and a bacterial mass in the abdominal wall tumor, with a fistulous tract connected to the area adjacent to the mesenteric border of the jejunum. These findings suggested that diverticulitis of the jejunum had penetrated through the abdominal wall, leading to the formation of an abscess. We report this case to highlight the need for complete gastrointestinal evaluation with gastrointestinal barium studies and imaging analysis to examine extension of intra-abdominal lesions in patients with an unexplained abdominal wall abscess.     

Laparoscopic surgery for complicated diverticular disease: a single-centre experience

Aim The role of laparoscopic surgery in the management of patients with diverticular disease is still not universally accepted. The aim of our study was to evaluate the results of laparoscopic surgery for diverticular disease in a centre with a specialist interest in minimally invasive surgery. Method All diverticular resections carried out between 2006 and 2010 were reviewed. Data recorded included baseline demographics, indication for surgery, operative details, length of hospital stay and complications. Complicated diverticular disease was defined as diverticulitis with associated abscess, phlegmon, fistula, stricture, obstruction, bleeding or perforation. Results One hundred and two patients (58 men) who had surgery for diverticular disease were identified (median age 59 years, range 49–70 years). Sixty‐four patients (64%) had surgery for complicated diverticular disease. The indications were recurrent acute diverticulitis (37%), colovesical fistula (21%), stricture formation (17%) and colonic perforation (16%). Sixty‐nine cases (88%) were completed by elective laparoscopy. Postoperative mortality was 0%. For elective cases there was no difference in morbidity rates between patients with complicated and uncomplicated diverticular disease. The overall anastomotic leakage rate was 1% and the wound infection rate 7%. There was a nonsignificant trend to higher conversion to open surgery in the elective group in complicated (11.4%) compared with uncomplicated patients (5.2%) (P = 0.67). Electively, the rate of stoma formation was higher in the complicated (31.6%) than the uncomplicated group (5.2%) (P < 0.02). Conclusion Laparoscopic surgery for both complicated and uncomplicated diverticular disease is associated with low rates of postoperative morbidity and relatively low conversion rates. Laparoscopic surgery is now the standard of care for complicated and uncomplicated diverticular disease in our institution.     

Recurrent small bowel obstruction secondary to jejunal diverticular enterolith: A case report

BACKGROUNDSmall bowel diverticulosis is an uncommon condition which is usually asymptomatic and is discovered incidentally. One rare complication is enteroliths forming in the diverticula causing bowel obstruction. Only a few cases of such have been described in literature, and recurrence from this aetiology has not been reported previously. This case report outlines the management of a 68-year-old male who presented with recurrent small bowel obstruction secondary to jejunal diverticular enterolith impaction, seven months following a previous episode. CASE SUMMARYA 68-year-old male presented with symptoms of small bowel obstruction. Computed tomography (CT) of the abdomen demonstrated small bowel obstruction from an enterolith formed in one of his extensive jejunal diverticula. He required a laparotomy, an enterotomy proximal to the enterolith, removal of the enterolith, closure of the enterotomy, and resection of a segment of perforated ileum with stapled side-to-side anastomosis. Seven months later, he represented to emergency department with similar symptoms. Another CT scan of his abdomen revealed a recurrent small bowel obstruction secondary to enterolith impaction. He underwent another laparotomy in which it was evident that a large enterolith was impacted at the afferent limb of the previous small bowel anastomosis. A part of the anastomosis was excised to allow removal of the enterolith and the defect was closed with cutting linear stapler. In the following two years, the patient did not have a recurrent episode of enterolith-related bowel obstruction.CONCLUSIONThe pathophysiology underlying enterolith formation is unclear, so it is difficult to predict if or when enteroliths may form and cause bowel obstruction. More research could provide advice to prevent recurrent enterolith formation and its sequelae.     

急性肠系膜缺血所致的急腹症(附22例报告)

目的总结急性肠系膜缺血(AMI)所致急腹症的临床特征并探讨提高疗效的措施。方法回顾性总结22例AMI的临床特点、治疗方法及其预后的关系。结果AMI病人大多属于高龄,常伴有心血管疾病,病情危急多变,缺乏特异表现,其术前误诊率、病死率和致残率分别为72.7%、36.4%和21.4%。结论加强对AMI病理生理的认识,选择合适的影像学检查等以提高早期确诊率,及时给予以手术为主的综合治疗是提高疗效的关键。     

新型冠状病毒肺炎暴发流行中心疫区急腹症诊治经验

目的分析新型冠状病毒肺炎(COVID-19)疫情下在中心疫区开展急腹症诊治的临床效果,总结临床经验。方法回顾性分析2020年1月24日至2020年2月29日华中科技大学同济医学院附属同济医院急诊收治和院内会诊的急腹症病人的临床处置和预后,随访结束时间为2020年3月8日。结果2020年1月24日至2020年2月29日已处置腹痛为主要表现的急腹症病人19例,其中,合并COVID-19病人(确诊及疑似病例)5例。19例病人中,有急诊手术指征并行急诊手术处置的9例,恢复顺利者7例,死亡2例,其中确诊COVID-19病人行急诊手术处置1例,死亡1例;行保守治疗并密切观察病情变化者10例(包括4例COVID-19病人),均恢复良好;随访至今未见密切接触上述COVID-19病人的医护人员出现感染表现。结论COVID-19疫情期间在中心疫区诊治急腹症病人时无论其是否是COVID-19病人都做到仔细检查,严格把握手术指征,术中熟练操作,术后密切监护及观察,同时做好医护人员个人防护。     

Prospective study on the management of patients with complicated diverticular disease

INTRODUCTION: Diverticular disease is a common condition with high morbidity and mortality related to its complications. The aim of this study was to assess the predictive role of acute diverticulitis in the development of further complications from diverticular disease. PATIENTS AND METHODS: Prospective assessment of all patients with complicated diverticular disease over a 1-year period in a large teaching hospital was undertaken. All patients had documented evidence of their diagnosis by radiological, endoscopic or histopathological techniques when feasible. RESULTS: Seventy-seven patients with complicated diverticular disease were identified. There were 53 females and 24 males with a median age of 74 years (range 30-97 years). Complications included: acute diverticulitis (37), fistula (12), perforation (8), bleeding (7), abscess (7) and stricture (6). Only 8 had two or more previous documented episodes of diverticulitis. Twenty-five underwent surgery, 3 died (peritonitis 2, abscess1) and 5 had a complication (anastomotic dehiscence 1, adhesive obstruction 1, incisional hernia 2 and pneumonia 1). Three (5%) of 37 patients with acute diverticulitis had two or more admissions but none underwent surgery or developed further complications. CT was performed during acute admission in 14/37 patients with acute diverticulitis. The majority of patients with fistula (9/12), perforation 7/8, bleeding 6/7 and abscess 5/7 had no previous episode of diverticulitis while most patients with stricture (4/6) had previous documented episodes. CONCLUSION: In our patient population acute diverticulitis is not a good predictor of the development of further complications from diverticular disease as only a minority of patients with perforation, fistula, abscess and bleeding had previous documented episodes of diverticulitis.     

急腹症合并感染性休克的相关因素分析及临床诊治对策

目的：探讨影响急腹症合并感染性休克的相关因素,并予以相对应的措施进行治疗.方法：回顾性分析40例急腹症合并感染性休克的患者,对其发生的相关因素进行分析,并比较治疗后的效果情况.结果：40例患者中有31例抢救成功,9例死亡,存活率为77.5％.患者发生急腹症合并感染性休克的影响因素有：高龄（≥60岁）、多种合并症（≥2种）、慢性疾病史、有创检查和治疗、器官衰竭个数多（＞2个）、全身炎症反应综合征、脏器功能衰竭综合征,低蛋白血症（P＜0.05）.与患者的性别、血培养、住院时间、静脉营养、手术治疗等无关（P＞0.05）,其中年龄、多种合并症、脏器功能衰竭综合征、全身炎症反应综合征是高危险因素.结论：密切注意急腹症合并感染性休克的影响因素,及时早期规范治疗,可提高急腹症合并感染性休克的临床效果,降低死亡发生率.     

肠系膜血管病变引起的急腹症：附17例报告

为了全面认识肠系膜血管病变异致的急腹症的严重性，探讨提高疗效的措施。方法对１７个病例的临床特点，治疗方法和效果进行了分析比较，其中１５例为循环不良引起受累肠管的梗塞，表现为肠梗阻；另２例为血管壁破裂导腹腔内大出血，包括１例少见的肠系膜卒中。结论说明充分认识此疾患，应用恰当的检查技术，早期诊断，及时治疗是提高疗效的关键。     

Jejunal Loop Obstruction by a Gallstone from Hepaticojejunostomy-Induced Acute Cholangitis: Report of a Case

We report a case of jejunal loop obstruction by a large gallstone caused by Roux-en-Y hepaticojejunostomy-induced acute cholangitis. The patient was admitted with sepsis as well as abdominal and back pain. Abdominal computed tomography showed a dilated jejunal loop and an obstructing large mass. After his clinical condition and laboratory values improved, we performed laparotomy, which revealed a dilated jejunal loop with a palpable mass, and a gallstone was removed via enterotomy. After the disimpaction of the stone and control of the infection, his clinical condition and laboratory values continued to improve. Gallstone formation is rare after hepaticojejunostomy and to our knowledge, no other cases of acute cholangitis caused by a stone obstructing the jejunal loop have ever been reported. As with other major complications, early diagnosis and prompt initiation of surgical treatment are important to prevent any deterioration in the patient's general condition. This case report was presented at the poster session of the 18th Congress of The Japanese Society of Hepato-Biliary-Pancreatic Surgery, Osaka, Japan, May 2004.     

Laparoscopic colostomy for acute left colon obstruction caused by diverticular disease in high risk patient: A case report

IntroductionThe colostomy is often necessary in complicated divertcular disease. The laparoscopic colostomy is not widely used for the treatment of complicated diverticular disease. Its use in patients with high operative risk is still on debate. The aim of this case report was to present the benefits of laparoscopic colostomy in patients with high peri-and postoperative risk factors.Presentation of caseWe present a case of 76-year-old female admitted to emergency unit for left colonic obstruction. The patient had a past history of liver cirrhosis HCV-related with a severe malnutrition, hypertrophic cardiomyopathy, diverticular disease, hiatal ernia, previous appendectomy. Patient was classified according to their preoperative risk ASA 3 (classification of the American society of Anestesia-ASA score).Contrast-enhanced abdominal CT revealed a marked thickening in the sigmoid colon and a marked circumferential stenosis in the sigmoid colon in absence of neoplasm, and/or abscess. The laparoscopic procedure is proposed as first intention.DiscussionThe operation time was 50 min, and the hospital stay was 4 days. Post operative complications grade I according to the Clavien Dindo Classification.ConclusionsLaparoscopic colostomy is safe and feasible procedure in experienced hands. It is associated with low morbidity and short stay in hospital and should be considered a good alternative to a laparotomy.     

Jejunal perforation caused by blunt abdominal trauma in a patient with Crohn's disease: Report of a case

We report herein the case of a 23-year-old man with Crohn's disease who was found to have a perforated small bowel following blunt abdominal trauma sustained in a traffic accident. The general findings of diffuse peritonitis were identified by physical examination, and a plain X-ray film showed free air in the abdominal cavity. An emergency laparotomy was performed which revealed three perforated ulcers in the affected intestine. An abrupt increase in intraluminal pressure due to the striking force of the steering wheel to the abdomen was assumed to have been the cause of these perforations.     

Giant Bladder Diverticulum as a Rare Cause of Intestinal Obstruction: Report of a Case

We report a case of intestinal obstruction as an unusual manifestation of bladder diverticulum. To our knowledge, this is the first report of a giant bladder diverticulum causing acute abdomen as a result of mechanical bowel obstruction.