3225 A Rare Case of Ruptured Jejunal Diverticulitis

Abstract

INTRODUCTION: Small intestinal diverticula are very rare, and the incidence ranges from 0.06 to 1.3%. Among these, duodenal diverticula are more frequent in 79% of patients followed by 18% in jejunum or ileum and 3% in all segments together. A jejunal diverticulum is usually asymptomatic, but only 10% develop complications. We report a unique case of a 70-year old female who presented with confusion, likely due to sepsis from perforated jejunal diverticulitis, that was successfully managed with initial resuscitation and definitive surgery. CASE DESCRIPTION/METHODS: A 76-year old female presented to the emergency room with confusion and epigastric pain for two days prior to presentation. Vital signs were stable. Physical examination was positive for mild epigastric tenderness. Laboratory results were normal except for leukocytosis of 15000, with left shift. Plain radiograph of the abdomen was negative for obstruction or perforation. Computed Tomography (CT) of the abdomen with oral and intravenous contrast showed the loop of thickened and edematous mid-jejunum and intraperitoneal free air consistent with perforated small bowel diverticulitis with abscess formation (Figure 1). She was initially resuscitated with intravenous fluids and was started on intravenous antibiotics. She underwent diagnostic laparoscopy with small bowel resection, primary anastomosis, drainage of the diverticular abscess. Pathology of resected jejunum was positive for diverticular disease with perforation. She did well postoperatively, tolerated diet, and discharged to home without any complications. DISCUSSION: Jejunal diverticula are usually multiple localized in proximal jejunum, develops as a result of herniation of mucosa, submucosa, serosa through muscular layer of bowel at the point of where vasa recta enter the muscular propria. Jejunal diverticulosis usually asymptomatic, only 10% develop complications. Perforation of jejunal diverticula is a severe complication that occurs in 2-6% of cases. A plain radiograph is the initial testing, but CT or Magnetic Resonance Imaging (MRI) is a gold standard for diagnosis. Acute uncomplicated jejunal diverticulitis is managed with intravenous fluids, bowel rest, and antibiotics. Acute Complicated diverticulitis needs surgical intervention such as laparotomy with segmental small bowel resection with primary anastomosis. Jejunal diverticulitis requires a high degree of clinical suspicion given the low incidence of the condition and increase in mortality after surgery up to 24%.