An Unusual Cause of Abnormal Liver Enzymes, Leukocytosis, and Right Upper Quadrant Abdominal Pain

Abstract

n 84-year-old man with history of atrial fibrillaAtion on warfarin, coronary artery disease, and chronic kidney disease presented to our institution with abdominal pain, nausea, and jaundice of 1-week duration. During the preceding few months, he had postprandial right upper quadrant abdominal pain that became constant the week of his presentation. On admission, the patient was afebrile, heart rate was 68 beats per minute, and he was hypotensive with blood pressure of 90/40 mm Hg. He was alert and oriented and had jaundice and scleral icterus. His abdomen was mildly distended, with tenderness to palpation over the right upper quadrant and epigastric area without rebound or guarding. The remainder of his physical examination was unremarkable. Blood work revealed white blood cell count of 18.6 10/L (3.8–10.6), hemoglobin 9.2 g/dL (12.9–16.9), serum creatinine 6.1 mg/dL (0.5–1.4), total bilirubin 9.6 mg/dL (0.3–1.5), direct bilirubin 8.2 mg/dL (0.1–0.5), aspartate aminotransferase 59 IU/L (15–41), alanine aminotransferase 51 IU/L (17–63), alkaline phosphatase 801 IU/L (38–126), and international normalized ratio >16. A noncontrast computed tomography (CT) scan was unremarkable with the exception of cholelithiasis. Because of concern for ascending cholangitis, the patient underwent endoscopic retrograde cholangiopancreatography, which failed to demonstrate biliary dilation or filling defects in the biliary tree. The patient’s abnormal liver enzymes were attributed to cholestasis of sepsis, the etiology of which was unclear. During the next 48 hours, his liver enzymes remained elevated, and despite aggressive fluid hydration and empiric antibiotics for anaerobic and gram-negative rod coverage, the patient clinically deteriorated. Pressor support was initiated for hypotension, and the patient had worsening of his abdominal pain, for which a repeat abdominal CT scan with oral contrast was performed (Figure A, arrow indicates extravasated oral contrast at the mid-jejunum with associated extraluminal free air). Repeat CT scan demonstrated multiple jejunal, distal ileal and sigmoid diverticula. There was infiltration of the jejunal mesentery, presence of jejunal mesenteric gas, and extraluminal contrast suggestive of jejunal diverticulitis complicated by perforation. The patient was emergently taken to the operating room for exploratory laparotomy. Intraoperatively, the patient was found to have bile peritonitis and a small perforation in the midjejunum approximately 40 cm distal to the ligament of Treitz. The patient underwent resection of 8 cm of involved jejunum with end-to-end jejunojejunal anastomosis. The patient’s postoperative course was complicated by respiratory failure, which led to his death 6 days later. Small bowel diverticulosis is a rare condition with a prevalence of 0.06%–1.3% compared with 50%–70% for colonic diverticulosis. Up to 80% of small bowel diverticular disease occurs in the jejunum. Jejunal diverticulosis is an acquired disorder, resulting from herniation of mucosa and submucosa through the muscularis along weak points at the mesenteric border where the vasa recta vessels penetrate the bowel wall. Proposed risk factors include conditions associated with increased intraluminal pressure, such as obesity and constipation, as well as motility disorders, including progressive systemic