Weight loss and anemia caused by bacterial overgrowth in a large jejunal diverticulum

Abstract

Small bowel diverticulae are relatively uncommon except in the elderly (1–5%), localized to the jejunum (80%), and have few significant complications (10%). We report a case of an elderly male with prolonged diarrhea, severe weight loss (40 lbs.) and anemia secondary to bacterial overgrowth in a large jejunal diverticulum with a prompt response to antibiotics. An 86 year-old male had a 20 year history of three to four, watery, urgent bowel movements per day accompanied by occasional nocturnal fecal incontinence. In the last four years he experienced more than 40 pounds weight loss with early satiety. He denied any abdominal pain, fevers, night sweats, joint pains or travel. His past medical history was significant for benign prostatic hypertrophy, gastroesophageal reflux disease and glaucoma but denied any abdominal surgeries. His medications included Diphenoxylate/ Atropine for the diarrhea, lansoprazole, and multivitamins. Family history was non contributory. Physical examination was unremarkable. Initial diagnostic evaluation included negative stool studies for clostridium difficile, bacterial pathogens or parasites. Laboratory bloodwork revealed a macrocytic anemia and low serum carotene, but was otherwise normal. Endoscopic evaluation revealed atrophic gastritis and pan-diverticulosis on colonoscopy. Enteroscopy revealed a giant proximal jejunal diverticulum, 8–10 cm in length. Biopsies of the diverticulum revealed focal, active cryptitis with partial villous blunting and focal increased intraepithelial lymphocytes. Sterile saline aspiration of the diverticulum revealed 9106 lactose fermenting gram-negative bacilli. A barium small bowel follow through confirmed the large jejunal diverticulum. Hydrogen breath testing revealed an increase in excreted hydrogen from 7 PPM to 107 PPM at 1 hour after 25 grams of oral lactose. The patient was initiated on antibiotic therapy with metronidazole 500 mg three times a day for 6 weeks. On completion of this therapy the patient's diarrhea completely resolved. He gained weight and remained asymptomatic on 6 month follow up. We are presenting this case as an illustration of how a large jejunal diverticulum can result in clinically significant diarrhea, weight loss and anemia secondary to bacterial overgrowth. Review of the literature does not reveal any such cases of a single large diverticulum associated with such significant symptomatology from bacterial overgrowth in the diverticulum.