Perforated jejunal diverticulum: a case report

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Jejunal diverticulosis is a rare condition with an incidence rate of 0.1–1.5%.1 Jejunal diverticulae (JD) can be asymptomatic and easily overlooked. These are pseudodiverticulae as they only contain mucosa and submucosa. JD occur at the mesenteric border of the small bowel with a higher incidence in males.2 An association with Raynaud's phenomenon and systemic sclerosis has been published.2 Complications such as diverticulitis, bleeding, mechanical bowel obstruction and perforation occur in 6–10% of cases.3 In the elderly patient population, JD has a high morbidity and mortality rate. Typically, endoscopic procedures such as double‐balloon endoscopy and capsule endoscopy may be used in its diagnosis but these have little role in the emergency setting. In cases of a perforated JD with localized peritonitis in a stable patient, non‐surgical management with intravenous antibiotics and a computed tomography (CT)‐guided drainage of any collection has been proven to be a suitable alternative to surgery.4
An 88‐year‐old man presented to the emergency department with a 12‐h history of left‐sided abdominal pain. He had associated nausea with a normal bowel movement that morning. He had an endoluminal repair of an abdominal aortic aneurysm several years ago and had undergone a total knee replacement just 2 weeks prior to this presentation and denied taking any non‐steroidal anti‐inflammatory medications. He denied any other surgical history and was known to have diverticular disease of the colon, diagnosed on colonoscopy 2 years prior. A mild elevation in his white cell count and C‐reactive protein was seen. Physical examination revealed localized peritonitis to the left side of the abdomen. A plain erect chest and abdominal X‐ray showed faecal loading within the colon with free gas under the right hemi‐diaphragm. Vital signs were stable and the patient remained afebrile. A CT scan of his abdomen (Fig. 1) showed a thickened loop of small bowel adherent to the descending colon with free gas under the diaphragm. There seemed to be a perforation in the proximal jejunum showing signs of inflammation. The patient underwent a laparotomy, which showed multiple diverticulae located at the jejunum on the mesenteric border with a 1‐cm perforation (Fig. 2). He underwent a segmental resection of this perforation with a primary anastomosis. He recovered well post‐operatively and was discharged home on day 4.
JD are the least commonly occurring type of small bowel diverticulosis. JD are most commonly seen in the proximal jejunum (75%) followed by the distal jejunum (20%) and the ileum (5%).3 These pseudodiverticulae are of the pulsion type and occur because of a combination of increased small bowel intraluminal pressure and bowel wall weakness.5 It is an acquired condition seen in the elderly population, where the clinical diagnosis may be difficult as the patient can present with non‐specific symptoms such as chronic abdominal pain or bloating. Bacterial overgrowth in the JD because of faecal stasis can result in diarrhoea and malabsorption in up to 10% of the cases.6 A rare case of a large faecolith originating from a jejunal diverticulum leading to small bowel obstruction has also been recently published.7 Any patient with known JD presenting with localized peritonitis should evoke a high suspicion of a perforation of the JD. Laparotomy or laparoscopy may be used to manage the perforation. Stable patients with a perforated JD with localized peritonitis have been shown to benefit from conservative management only. This is achieved with a CT‐guided drainage of the abscess cavity along with intravenous antibiotics, without need for any further surgical intervention. These patients may have an earlier recovery as compared with the patient undergoing a laparotomy and/or small bowel resection.
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