Jejunal diverticulosis: a potentially dangerous entity

Although jejunal diverticulosis is a rare entity and usually asymptomatic, it may cause chronic symptoms and acute complications. Because of the rarity of the entity, diagnosis is often delayed, resulting in unnecessary morbidity and mortality. The purpose of this study was to draw attention to jejunal diverticula and their complications. The medical records of 8 consecutive patients with complications due to small-bowel diverticula treated at our department during the past 4 years were reviewed. All diverticula were located in the jejunum. Seven patients had acute complications, 3 patients had an intra-abdominal abscess, 2 had free perforation with diffuse peritonitis, 1 had a bowel occlusion and 1 patient had concomitant bleeding and occlusion. One patient presented with chronic symptoms. A preoperative diagnosis of jejunal diverticula, before explorative laparotomy, was not reached in any of the 7 patients with acute symptoms. In the patient with chronic symptoms, multiple jejunal diverticula complicated by a jejuno-colic fistula and foreign body were found at laparotomy. On patient died of multiorgan failure. Small-bowel diverticulosis is a rare entity, but it should not be regarded as a clinically insignificant finding. It may be difficult to make a preoperative diagnosis. Patients with incidentally detected proximal jejunal diverticula, at imaging studies or at laparotomy, warrant close observation and awareness that the diverticula may cause serious complications.     

Complicated Jejunal Diverticulitis: A Challenging Diagnosis and Difficult Therapy

Background/Aim:

In contrast to diverticulosis of the colon, jejunal diverticulosis is a rare entity that often becomes clinically relevant only after exacerbations occur. The variety of symptoms and low incidence make this disease a difficult differential diagnosis.

Patients and Methods:

Data from all patients who were treated in our surgical department for complicated jejunal diverticulitis, that is, gastrointestinal hemorrhage or a diverticula perforation were collected prospectively over a 6-year period (January 2004 to January 2010) and analyzed retrospectively.

Results:

The median age among the 9 patients was 82 years (range: 54–87). Except for 2 cases (elective operation for a status postjejunal peridiverticulitis and a re-perforation of a diverticula in a patient s/p segment resection with free perforation), the diagnosis could only be confirmed with an exploratory laparotomy. Perforation was observed in 5 patients, one of which was a retroperitoneal perforation. The retroperitoneal perforation was associated with transanal hemorrhage. Hemodynamically relevant transanal hemorrhage requiring transfusion were the reason for an exploratory laparotomy in 2 further cases. In one patient, the hemorrhage was the result of a systemic vasculitis with resultant gastrointestinal involvement. A singular jejunal diverticulum caused an adhesive ileus in one patient. The extent of jejunal diverticulosis varied between a singular diverticulum to complete jejunal involvement. A tangential, transverse excision of the diverticulum was carried out in 3 patients. The indication for segment resection was made in the case of a perforation with associated peritonitis (n=4) as well as the presence of 5 or more diverticula (n=2). Histological analysis revealed chronic pandiverticulitis in all patients. Median operating time amounted to 142 minutes (range: 65–210) and the median in-hospital stay was 12 days (range: 5–45). Lethality was 0%. Major complications included secondary wound closure after s/p repeated lavage and bilateral pleural effusions in one case. Signs of malabsorption as the result of a short bowel syndrome were not observed. Minor complications included protracted intestinal atony in 2 cases and pneumonia in one case. Median follow-up was 6 months (range: 1–18).

Conclusion:

Complicated jejunal diverticulitis often remains elusive preoperatively due to its unspecific clinical presentation. A definitive diagnosis can often only be made intraoperatively. The resection of all diverticula and/or the complete diverticula-laden segment is the goal in chronic cases. The operative approach chosen (tangential, transverse excision vs segment resection) should be based on the extent of the jejunal diverticulosis as well as the intraoperative findings.     

Midgut volvulus due to jejunal diverticula: A case report

Jejunal diverticulosis is uncommon and often asymptomatic. It can produce significant complications, and some complications are potentially life threatening and require early surgical treatment, such as obstruction, hemorrhage and perforation. There is no consensus on the management of this disease. Only a few cases of jejunal diverticulosis with midgut volvulus have been reported. We herein report a case of 57-year-old woman with jejunal diverticulosis causing small bowel volvulus who complained of intermittent upper abdominal pin-prick for 5 years that eventually progressed to a complete obstruction. The computed tomography scans revealed a mesenteric vessel "whirlpool" and laparotomy showed midgut volvulus secondary to jejunal diverticula. This case highlights jejunal diverticulosis causing small bowel volvulus as an uncommon mechanism of small bowel obstruction, which should be included in the differential diagnosis of small bowel obstruction.     

The clinical significance of acquired jejunoileal diverticula

Objective: Because of the relative rarity of acquired jejunoileal diverticulosis, including its symptomatology and complications, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. The purpose of the present study was to draw attention to jejunoileal diverticula and their complications as a site of gastrointestinal symptoms.
Methods: The records of 10 patients with symptomatic jejunoileal diverticula treated in our departments were reviewed.
Results: The clinical presentation was varying and nonspecific. Jejunoileal diverticula were diagnosed peroperatively in four patients operated on successfully for their acute complications. In one case the diagnosis was considered after a radiotargeted erythrocyte bleeding scan and in five other cases enteroclysis for chronic abdominal complaints demonstrated jejunoileal diverticula. The death of one patient operated on for massive hemorrhage from jejunal diverticula was probably related to delayed diagnosis and treatment.
Conclusion: Jejunoileal diverticula should not always be dismissed as asymptomatic findings, as they may be the cause of vague, chronic symptomatology and acute complications, including intestinal obstruction, hemorrhage, and perforation. Awareness of the fact that jejunoileal diverticula may cause chronic nonspecific abdominal symptoms and serious acute complications may lead to earlier diagnosis and timely treatment with lower morbidity and mortality.     

Multiple giant diverticula of the foregut causing upper gastrointestinal obstruction

Small bowel diverticulosis represents an uncommon disorder （except for Meckel diverticulum） often misdiagnosed since it causes non-specific gastrointestinal symptoms. Most of times the diagnosis is carried out in case of related complications, such as diverticulitis, hemorrhage, perforation or obstruction. intestinal obstruction can be caused by inflammatory stenosis due to repeated episodes of diverticulitis, volvulus, intussusception or jejunal stones. Herein we report a case of multiple jejunal diverticula causing chronic gastrointestinal obstruction.     

Irritable Bowel Syndrome and Symptomatic Diverticular Disease—Different Diseases?

The influence of colonic diverticula on symptomatology and prognosis was investigated in 69 patients with irritable bowel syndrome. Roentgenograms at the time of diagnosis were blindly correlated to patient complaints and to result of follow-up 5 to 7 yr after the irritable bowel syndrome had been diagnosed. Patient complaints were not related to the presence or extent of diverticulosis. Half the patients had unchanged or aggravated symptoms at follow-up irrespective of diverticulosis. Accordingly, the presence of colonic diverticula did not change the natural history of the irritable bowel syndrome.     

Intestinal motility in small bowel diverticulosis: a case report and review of the literature

Small bowel diverticulosis is a rare disease that is usually associated with recurrent pseudo-obstruction, bacterial overgrowth, and malabsorption. The more severe complications include hemorrhage and perforation. There is evidence to suggest that this entity is a result of small bowel motor dysfunction. For this reason, it has been associated with disorders in which a myopathic or neuropathic process is involved, such as scleroderma. The majority of patients with jejunal diverticulosis do not require surgery and can be managed medically. We report a case of jejunal diverticulosis in a 63-year-old gentleman who presented with symptoms of pseudo-obstruction. Ambulatory duodenojejunal manometry revealed several abnormalities suggestive of small bowel motor dysfunction. Enteroclysis, however, did not find evidence of mechanical obstruction, and the patient had marked improvement with cisapride and antibiotics.     

Complicated small-bowel diverticulosis： A case report and review of the literature

While jejunoileal diverticula are rare and often asymptomatic, they may lead to chronic non-specific or acute symptoms. The large majority of complications present with an acute abdomen similar to appendicitis, cholecystitis or colonic diverticulitis but they also may appear with atypical symptoms. As a result, diagnosis of complicated jejunoileal diverticulosis can be quite difficult, and may solely depend on the result of surgical exploration. In the absence of contra-indications, diagnostic laparoscopy has the benefit of thorough examination of the abdominal contents and helps to reach an absolute diagnosis. Surgical resection of the involved small-bowel segment with primary anastomosis is the preferred treatment in patients with symptomatic complicated jejunoileal diverticular disease. An atypical presentation of complicated jejunal diverticulitis in conjunction with sigmoid diverticulitis diagnosed with laparoscopy and treated with surgical resection is presented.     

Small bowel diverticulosis: An overlooked entity

Opinion statement Small bowel diverticulosis (SBD) is a rare entity. Most cases of diverticulosis are asymptomatic. SBD is often discovered incidentally during contrast studies and endoscopy. When patients report chronic gastrointestinal symptoms such as abdominal pain, bloating, flatulence, and anemia, SBD is often an overlooked diagnosis. Patients requiring treatment for SBD are those with complications such as malabsorption, hemorrhage, obstruction, and acute inflammation with abscess or rarely perforation. Malabsorption can be managed with broad-spectrum antibiotics and vitamin supplementation. Hemorrhage is treated conservatively with resuscitation efforts, but recurrent bleeding requires surgery. Enteroliths causing obstruction in the duodenum can be relieved by endoscopy, that is, by manipulation, but jejunoileal obstruction requires a resection. Pseudoobstruction may be managed with prokinetics such as metoclopramide, erythromycin, and the 5-hydroxytryptamine 4 agonist tegaserod. Uncomplicated cases of SBD are treated with bowel rest and antibiotics. However, perforation or abscess formation not amenable to percutaneous drainage mandates surgical resection. Any patient with a triad of anemia, abdominal pain, and an abdominal radiograph with dilated loops of small bowel merits SBD in the differential diagnosis.     

Diverticular complications of renal failure

Ten patients with chronic renal failure presented with complications of colonic diverticula. Five had acute diverticulitis, 4 perforated diverticula, and 1 lower gastrointestinal hemorrhage. Symptoms were less severe than expected. In 3 the diagnosis was first suspected when free intra-abdominal air was detected. Seven patients had laparotomy, 5 emergently. Radiologists should be aware of the potential for diverticular complication in patients with renal failure, even with minimal or absent symptoms. Suspicion of colonic pathology either clinically or radiographically should be evaluated promptly so that aggressive therapy can begin.     

Jejunal Diverticulitis

A case of perforated jejunal diverticulitis in a 44-yr-old man is described and the literature is reviewed. Jejunal diverticulosis occurs in 0.07% to 2% of the population. Enteroclysis is the best diagnostic test. Diverticulitis with perforation is rare and is associated with high mortality. Treatment is surgical resection of the involved segment. Other complications are bacterial overgrowth, obstruction, and acute hemorrhage. Several theories to explain the physiopathogenesis of the diverticula formation may relate to manometric or histological abnormalities of the small bowel.     

JEJUNAL DIVERTICULITIS MANIFFSTING WITH ABDOMINAL WALL ABSCESS

Jejunal diverticulosis is generally considered to be an innocuous condition, but serious complications can arise and lead to acute or chronic syndromes. In this report, we describe a case of jejunal diverticulitis presenting with an abdominal wall abscess. To our knowledge, this is (he first documented case of jejunal diverticulitis complicated by fistula formation leading to the development of an abdominal wall abscess. Because jejunal diverticula generally localize at the mcsenteric border and their perforation tends to result in intra-abdominal abscess formation, we speculate that the abdominal wall absciss described in our case here was due to adhesions of jejunal loops to the abdominal wall secondary to previous abdominal surgeries.     

Malabsorption in jejunal diverticulosis treated with resection of the diverticula

Patients with jejunal diverticula usually are asymptomatic unless bacterial overgrowth within the diverticula is sufficient to cause vitamin B12 deficiency, by direct uptake of the vitamin by the bacteria, or malabsorption resulting from bacterial deconjugation of bile salts and impaired lipid digestion. The administration of broad-spectrum antibiotics usually constitutes effective treatment that suppresses bacterial flora, with surgery reserved for complications such as hemorrhage, perforation, and abscess formation, and acute or chronic intestinal obstruction. Our patient had many diverticula, and two courses of antibiotics failed to provide prolonged relief of symptoms. After surgical exploration to exclude the presence of partial intestinal obstruction or infiltrating disease of the terminal ileum, the segment of jejunum bearing diverticula was resected. Since operation the patient has remained asymptomatic, which suggests that in certain patients, even with many diverticula, surgical exploration and excision of the diverticula may be curative.     

Intestinal motility in patients with small bowel diverticulosis

It has been demonstrated that motility disorders may be responsible for esophageal and colon diverticulosis. Recently anatomic alterations of both small bowel muscular layers and myenteric plexus have been described in patients with small bowel diverticulosis. Such pathological features could be responsible for motility disorders and small bowel diverticulosis formation. The aim of this work was to study the small bowel motility in patients with small bowel diverticulosis. Ten patients (mean age: 69.2 +/- 6 years mean +/- SEM) with more than 3 diverticula in the jejunum or the ileum (excepting duodenal diverticulum) were studied. After an overnight fast, a 4 lumen probe (side holes 10 cm apart) was used to record duodeno-jejunal motility for 4 hours. Esophageal manometry was also performed in 8 patients. The mean number of phase 3 of the migrating motor complex (mean +/- SEM) during 4 hours was significantly lower in patients with small bowel diverticulosis (0.15 +/- 0.05/hours; mean +/- SEM) than in 10 normal volunteers (0.52 +/- 0.07/hours; mean +/- SEM) (P less than 0.01); 5 patients had zero phase 3 during the 4 hours of recording; one patient displayed intestinal hypomotility associated with aberrant phase 3 like activity; 4 patients showed simultaneous minute-rhythm during more than 80 percent of the phase 2 of the migrating motor complex. Esophageal manometry was also disturbed in 6 patients (low amplitude contractions less than 30 cm H2O in the distal esophagus). Bacterial overgrowth was investigated in 8 patients by means of a glucose breath-test and was found in 6 cases. In conclusion, duodeno jejunal motility is altered in patients with small bowel diverticulosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Recent Advances in Diverticular Disease

Diverticular disease is common and accounts for substantial health care utilization in the USA. Recent publications in the areas of diverticulosis and diverticular disease have highlighted several notable advances that are now changing practice. Despite colonic diverticula being common, only 1–4 % of individuals with colonic diverticula will develop diverticulitis. After a first occurrence of acute diverticulitis, the risk of recurrence is 20 % at 5 years. Complications most commonly occur with the first occurrence of acute diverticulitis and not with recurrent episodes. After an episode of diverticulitis, many patients continue to experience chronic gastrointestinal symptoms. Prophylactic surgery is an option to reduce the risk of recurrence and its negative impact on quality of life. Importantly, the rationale for surgery is no longer to prevent complications because this risk is low. The review concludes with practical recommendations for patients with diverticulosis and diverticular disease.     

Complicated colonic diverticulosis: surgical perspective from an Indian Centre.

INTRODUCTION: Colonic diverticulosis was previously uncommon in India but its incidence seems to have increased recently. Patients with the disease in developing countries are also underdiagnosed and are therefore more likely to present with complications needing operation. However there is a paucity of surgical data on the condition. METHOD: Between August 1996 and February 2005 we operated on 32 patients (28 males, 4 females mean age 60 years) with colonic diverticulosis and analysed their characteristics from a prospective database. We here with describe our experience. RESULTS: Operations for diverticular disease constituted 3% of all the colorectal operations we performed. The diverticula were in the sigmoid colon in 28 (88%) and also in the descending colon in 4 (12%). Twenty-four patients were symptomatic. Twenty-two patients were diagnosed before surgery, 8 at operation and the rest from resected specimens. Emergency operations were performed in 23 and elective procedures in 9 patients. Ten patients were operated on for perforation and abscess, 8 for obstruction, 8 for colovesical fistula, 3 for peritonitis and 3 for haemorrhage. Emergency procedures were performed in 2 stages (resection plus a proximal diversion) in 20; unless done for bleeding in a stable patient where a primary anastomosis was done. One patient who had had an emergency procedure died of sepsis and ketoacidosis in the post-operative period. The 8 patients with colovesical fistulae were all males, had only sigmoid involvement and had had symptoms for a longer duration than the 24 without fistulae. CONCLUSIONS: Although operations for colonic diverticulosis still form a small proportion of the total number of colorectal operations, the diagnosis is often delayed till complications ensue and thus patients usually require emergency procedures. Males with long standing symptoms and sigmoid diverticula may develop colovesical fistulae.     

Management of surgical complications of small-bowel diverticulosis

INTRODUCTION: Diagnosis of complications of small bowel diverticulosis is difficult in the emergency setting and often delays surgical management. The aim of this study was to report our experience with seven patients presenting with a surgical complication of small-bowel diverticulosis. PATIENTS AND METHODS: From January 1, 1995 to June 30, 2001, 7 patients presenting with a complication of small-bowel diverticulosis were included in this retrospective study. The mean age of the patients was 73.1 years. Complications were bleeding in 4 cases and diverticulitis with perforation and abscess formation in 3 cases. RESULTS: The time between complication onset and its management was 20.6 days. Among paraclinical examinations small-bowel barium opacification showed diverticulosis in 4 cases. Other investigations such as endoscopy or CT-Scan imaging studies were used to eliminate other causes of acute abdomen. Patients were operated on in all cases and a segmental small bowel resection was performed in all cases while in one patient, a diversion stomy was performed. One patient died following septic peritonitis treatment. CONCLUSION: Small-bowel diverticulosis is unfrequent. In cases of gastrointestinal haemorrhage or occlusion, diagnosis is performed by eliminating other more frequent causes. If emergency surgery is not required, barium opacification seems to be the most sensitive examination.     

Acute ulcerative jejunal diverticulitis： Case report of an uncommon entity

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Its reported incidence varies from 0.05% to 6%. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life threatening and require early surgical treatment. We report a case of an 88-year-old man investigated for acute abdominal pain with a high biological inflammatory syndrome. Inflammation of multiple giant jejunal diverticulum was discovered at abdominal computed tomography （CT）. As a result of the clinical and biological signs of early peritonitis, an emergency surgical exploration was performed. The first jejunal loop showed clear signs of jejunal diverticulitis. Primary segmental jejunum resection with end-toend anastomosis was performed. Histopathology report confirmed an ulcerative jejunal diverticulitis with imminent perforation and acute local peritonitis. The patient made an excellent rapid postoperative recovery. Jejunal diverticulum is rare but may cause serious complications. It should be considered a possible etiology of acute abdomen, especially in elderly patients with unusual symptomatology. Abdominal CT is the diagnostic tool of choice. The best treatment is emergency surgical management.     

Jejunal diverticulosis and gastrointestinal bleeding

Occult gastrointestinal bleeding frequently frustrates clinicians' attempts to locate the source. Foci of hemorrhage within the small bowel are often found only at laparotomy and can be attributed to Meckel's diverticula, carcinomas, or less frequently, pulsion-type diverticula. We report our experience with two patients whose jejunal diverticula resulted in recurrent episodes of massive gastrointestinal hemorrhage.     

Enterolith ileus complicating jejunal diverticulosis.

Small intestinal obstruction caused by enteroliths originating in jejunal diverticula is rare. We present our experience with three elderly female patients who were successfully treated for this condition. The diagnosis, in all three cases, was made on laparotomy. Two patients underwent enterolithotomy while the third, who had a acutely inflamed jejunal diverticulum, had a jejunal resection.