Small Bowel Diverticulosis: A Possible Rare Complication of Roux-en-Y Gastric Bypass

Abstract

Introduction: Small bowel diverticulosis is a rare finding usually encountered incidentally or after development of symptomatic complications. Jejunoileal diverticulosis represents only 20% of all small bowel diverticulosis, diagnosed via endoscopy or small bowel follow through study. It appears as yet unreported as a complication of Roux-en-Y gastric bypass. We present a patient with Roux-en-Y found to have jejunal diverticula potentially representing a rare late complication of the procedure. Case: A 49-year-old female with history of Roux-en-Y 10 years prior presented with 3 days of worsening exertional dyspnea and one day of dark stools. Labs revealed a hemoglobin of 6.2 from baseline of 11 and rectal exam revealed melenic stool. She reported recent NSAID use 3-4 times daily for the previous 2 weeks. Subsequent upper endoscopy (EGD) revealed a nonbleeding anastomotic ulcer, as well as numerous diverticula throughout the jejunum. All biopsies were normal. Proton pump inhibitor therapy was started with no further bleeding on follow-up. Review of the patient's Roux-en-Y operative report revealed no mention of small bowel diverticula or mucosal irregularity. An EGD and colonoscopy prior to the bypass were normal. Discussion: Jejunal diverticulosis has an estimated incidence of 0.2-7% and coexists with colonic diverticulosis in up to 75% of patients, suggesting similar pathogenesis. It has been associated with disorders of intestinal dyskinesia, connective tissue disease such as systemic sclerosis, systemic myopathies and visceral neuropathies. Diverticula can result in numerous complications including pseudoobstruction, bacterial overgrowth, malabsorption, gastrointestinal bleeding, diverticulitis, fistulization and perforation. While the Roux-en- Y procedure has numerous well-known complications which also include forms of obstruction, malabsorption, ulceration, and perforation, report of jejunal diverticulosis is not among them. In this patient with normal intestinal mucosa, no colonic diverticula, no family history of diverticulosis and no evidence of intestinal irregularity at time of surgery, it is believed that the Rouxen-Y surgery likely contributed to the development of this condition. Whether by excessive dumping into the early duodenum, or if pseudoobstruction or adhesions caused a predilection for intestinal wall defects, the temporal relationship of these conditions are strongly suggestive of a causal relationship.Figure 1Figure 2