Two Cases of Jejunal Diverticulitis: A Rare Cause of Abdominal Pain

Abstract

Purpose: Although colonic diverticulitis represents a relatively common condition, we present a rare condition of jejunal diverticulitis in two patients with a constellation of symptoms of periumbilical abdominal pain, fever, and nausea. Methods: Clinical Vignette. Results: A 58 year old male presented with a 9 year history of intermittent periumbilical abdominal pain, associated with nausea and subjective fevers. The patient was empirically treated with a short course of oral Flagyl® by his primary care physician with partial resolution of his pain. However, when the antibiotic was discontinued, the pain returned as “the worst ever”. His nausea also recurred with signs of dehydration, requiring hospital admission for IV fluids. On exam, the patient demonstrated a fever of 100.9 F and his abdomen was mildly tender to deep palpation in the periumbilical region. Laboratory analyses demonstrated normal values, except for a leukocytosis of 12.8 K. The patient underwent a barium swallow examination with a small bowel follow-through, which demonstrated numerous jejunal diverticula (Figure 1a). CT scan demonstrated an inflammatory process in the small bowel consistent with a diagnosis of jejunal diverticulitis (Figure 1b). Our second case of jejunal diverticulitis involves a 76 year old woman with identical signs and symptoms of periumbilical abdominal pain, nausea, fever and a leukocytosis of 13.6K. The diagnosis of jejunal diverticulitis was made by CT scan, which demonstrated a 2 cm jejunal diverticulum associated with peridiverticular inflammation, bowel wall thickening and pockets of extraluminal gas adjacent the diverticulum, suggesting a perforation. In both cases, the patients were treated with a 10 day course of an oral fluoroquinolone and Flagyl® with complete resolution of their symptoms.Figure 1Conclusion: Small bowel diverticula are uncommon findings with a prevalence of <1% on several autopsy studies. We present two cases of jejunal diverticulitis, which represents a rare cause of abdominal pain, as <5% of small bowel diverticula will present with diverticulitis. The diagnosis is difficult to make on the basis of clinical presentation alone and is typically made by radiographic imaging, most commonly CT scan. However, by recognizing the collection of signs and symptoms of periumbilical abdominal pain, nausea, fever and leukocytosis as the typical presentation of small bowel diverticulitis, the diagnosis can be facilitated despite the rarity of this condition.