Perforated Jejunal Diverticulum Research Articles

Recurrent Small Bowel Obstruction and Perforation as a Complication of EFEMP1-Associated Systemic Venous Amyloidosis

Abstract Introduction/Objective Amyloidogenic protein EGF-containing fibulin-like extracellular matrix protein 1 (EFEMP1) is a newly described age-related systemic venous amyloidosis. EFEMP1 venous deposition has recently been reported in postmortem gastrointestinal specimens in which the deceased presented with gastrointestinal bleeding. Methods/Case Report We report a case of a 53-year-old female with long-standing seronegative spondylitis, and multiple recurrent small bowel obstructions and perforations status post surgical interventions who presented with 3 days of generalized abdominal pain, 10/10 in severity with nausea, emesis and absence of bowel movement. Abdominal CT scan confirmed closed loop obstruction in the left hemi-abdomen. An emergent partial duodenectomy was performed with extensive lysis of adhesion which revealed a perforated jejunal diverticulum with abscess formation. Microscopic examination demonstrated the presence of eosinophilic, amorphous, acellular material in the venules of the duodenum wall. Congo red stain demonstrating the presence of amyloid deposits and the specimen was sent for amyloid typing. Liquid chromatography tandem mass spectrometry demonstrated a peptide profile consisting of serum amyloid P, apolipoprotein A4, apolipoprotein E, and abundant peptides associated with EFEMP1/FBLN3 consistent with a recently described age-related venous amyloidosis derived from EFEMP1 protein. Results (if a Case Study enter NA) N/A. Conclusion EFEMP1-associated systemic venous amyloidosis has a predilection for females with a median age of 75 years and almost exclusively occurs in the gastrointestinal tract. We report this case for its novelty, unique clinical presentation and to emphasize awareness of this entity as we learn more about its etiology, presentation, management, and prognostication.

S3493 Two Cases of Perforated Jejunal Diverticulum With Severe COVID-19

Introduction: Jejunoileal diverticulitis is very rare with a high mortality rate of 21-40%. The rates of small bowel diverticulitis with perforation associated with COVID are unknown. Here, we present cases of complicated jejunal diverticulitis with perforation in two patients with severe COVID infection. Case Description/Methods: The first patient is a 69-year-old man who presented to our Emergency Department with shortness of breath, cough, and diarrhea. He was diagnosed with severe COVID-19 despite being vaccinated. He was started on methylprednisolone and remdesivir. 13 days into admission, the patient developed pneumomediastinum. Computed Tomography Abdomen/Pelvis (CT A/P) for further evaluation showed pneumoperitoneum and perforated jejunal diverticulitis. Given the severity of COVID pneumonia requiring high-flow oxygen, continued use of corticosteroids (methylprednisolone 40mg BID), and risk of surgical complications with COVID, conservative management with antibiotics and bowel rest was pursued. The patient developed an abscess in the mesentery and pelvis for which a drain was placed percutaneously by Interventional Radiology. He unfortunately developed progression of the perforation and passed away from septic shock. The second patient is a 57-year-old male with hypertension, deep vein thrombosis who presented with worsening shortness of breath, cough, fever. He was diagnosed with severe COVID (unvaccinated) and started on baracitinib, remdesivir, methylprednisolone. Ten days into admission he developed severe abdominal pain, nausea, vomiting, and worsening leukocytosis. CT A/P showed new abscess involving the left upper quadrant with a contained jejunal perforation. The patient was initially managed with bowel rest, antibiotics and pain control. However, he developed worsening leukocytosis and pain with peritonitis on exam. He was taken emergently to the operating room and had proximal perforated jejunum resection and lysis of adhesions. He ultimately had small bowel re-anastomosis. He continued to improve clinically and was discharged home. (Figure) Discussion: It is unclear if the complication of perforated diverticulum in these cases is due to the underlying inflammatory response due to COVID, steroid-induced disruption of intestinal mucosal barrier or incidental diverticulitis with evolution to complicated perforation. However, each case reminds us how important it is to take abdominal complaints in COVID seriously as jejunoileal diverticulitis has a high mortality rate.Figure 1.: Left panel- Patient 1 CT Abdomen/Pelvis transverse view showing jejunal perforation with surrounding inflammation (arrow). Right panel- Patient 2 CT Abdomen/Pelvis transverse view showing thickened loops of jejunum with interloop abscess (arrow).

Perforated jejunal diverticulum

Introduction: intestinal diverticula are infrequent, with most common location in duodenum. Only a few patients develop symptoms, intestinal perforation beign the most associated with a deadly outcome. 8-30% of patients with suspicion of perforated jejunal diverticulum receive urgent surgical management, which consists in intestinal resection and termino-terminal anastomosis. Case report: 101-year-old female patient who shows at the emergency room with an acute abdomen. An abdominal CT scan was performed, which showed free abdominal fluid and pneumoperitoneum. Exploratory laparotomy was planned and performed, and showed evidence of multiple jejunal diverticulums, one of which presented with perforation. We performed resection and anastomosis of 90 cm of the affected jejunum. Conclusion: despite being an infrequent pathology, in patients who present with acute abdomen, the most accurate management remains surgery.

Perforated jejunal diverticulum as an unsual cause of acute abdomen: A case report.

Introduction and importanceJejunal divertica is a rare entity with an often clinically silent course. However, it may be associated to life-threatening complications such as perforation. Therefore it should be considered in every case of acute abdomen.Case presentationA 60-year-old female presented with a generalized abdominal pain associated with vomiting evolving for 24 h. Physical examination found an irreducible and tender hernia in the umbilical region with abdominal guarding. Laboratory test results showed a biological inflammatory syndrome. The primary diagnosis of strangulated umbilical hernia was suspected and the patient underwent an emergency laparotomy. Intra-operative examination revealed mutiple jejunal diverticula, with a perforation in one diverticulum leading to generalized peritonitis. A bowel resection and peritoneal lavage were performed with good outcome.Clinical discussionJejunal diverticula is a challenging condition with various non-specific clinical presentations. Jejunal perforation is its most feared complication. Deceitful abdominal examination among elderly patients and lack of specific signs may lead to diagnostic delay responsible for high mortality rate and poor prognosis. Adjunctive imaging modalities may be needed to help establish a prompt diagnosis and dictate management strategy. Treatment of perforated jejunal diverticulum is based on limited bowel resection associated to primary anastomosis.ConclusionJejunal diverticulitis should be kept in mind as a differential diagnosis in every case of acute abdomen. High index of clinical suspicion and eventual further radiological examinations are required to avoid misdaignosis and save patients' lives.

Situs Inversus Associated with Perforated Small Intestine Diverticulum - Case Report

Situs Inversus (SI) is a rare congenital anomaly that affects 1:10,000 to 1:20,000 people. It is characterized by the mirror image of the abdominal and thoracic viscera. Situs Inversus Incompletus (SII) is an abdominal heterotaxis associated with levocardia. It is a much rarer condition and accounts for 1 in 2,000,000 of the general population. Small bowel diverticulum is a rare condition, in which most patients are asymptomatic. In this report, we present a patient with IBS with an acute abdomen due to a perforated jejunal diverticulum, treated at the Hospital de Base of São José do Rio Preto, Brazil.

Strangulated Femoral Hernia With Perforated Jejunal Pseudodiverticula : a Case Report

Introduction: Sixty percent of femoral hernias are characterized by incarceration and strangulation. Jejunal pseudo diverticulum are rare and usually asymptomatic. It may cause chronic obstruction of small bowel and can lead to an acute perforation.Case presentation: An 85 – year – old woman presenting with 1 week history of generalized abdominal pain, with episodes of vomiting, fever, and history of 6 months of reponible femoral hernia and 2 weeks strangulated of femoral hernia. An abdominal X-ray displayed multiple dilated loops of the small bowel, coil spring sign and intra peritoneal free air. This patient underwent a laparotomy and hernioraphy, which identified single perforated jejunal pseudo diverticulum 50 cm from ligamentum of treitz orally from strangulated of ileal on femoral hernia site, and associated fecal contamination. The management for this case was perforation repaired with diverticulectomy, simple closure, and extensive washout of intraperitoneal cavity. The non tension femoral hernia repair was performed with monofilament, macroporous MESH.Conclusion: chronic intestinal obstruction caused by femoral hernia in the elderly can lead a performed of intestinal pseudo diverticulum and lead to significant morbidity and mortality. This could be suspected in those presenting with cramping abdominal pain and altered bowel habits.Keywords: hernia, femoral, strangulated, pseudo diverticulum, perforated, management

Perforated Jejunal Diverticulum ? A Rare Acute Abdomen Presentation

Perforated Jejunal Diverticulum ? A Rare Acute Abdomen Presentation

Perforated Jejunal Diverticulum Treated by Exteriorization in An Adult Patient with Alcoholic Psychosis: A Case Report

We herein describe a surgical case of perforated jejunal diverticulum in an adult patient with alcoholic psychosis and dementia. A 70-year-old Japanese male presented with vomiting and abdominal pain in a mental hospital. He had undergone a distal gastrectomy, the details of which are unclear. He entered the internal medicine ward of our hospital and was diagnosed with bowel obstruction and conservatively treated with a long tube. At the 4th hospital day, he suffered from severe abdominal pain with muscular defense. Computed tomography revealed a dilated small intestine and intra-abdominal free air and ascites. After laparotomy, a perforated jejunal diverticulum was identified at 30 cm along the anal side from the ligament of Treitz. Adhesiolysis and exteriorization of the perforated jejunal diverticulum using a tube were performed, as the status of the patient was too serious to tolerate resection of the small intestine including the perforated lesion. The patient eventually recovered and left the hospital on Day 37 after the operation. This report presents a rare surgical case of perforated jejunal diverticulum due to small bowel obstruction in an adult patient with alcoholic psychosis and dementia.

Efficacy of Early Laparoscopic Surgery in Acute Abdomen Secondary to Perforated Jejunal Diverticulitis

A 39-year-old man with abdominal pain, fever and general poor state. Physical examination showed fever, Tachycardia, Left basal hypoventilation and acute surgical abdomen. A Abdominal X-Ray showed accumulation of calcifications in mesogastric. The laboratory test showed leukocytosis and the abdominal CT-Scan showed the cause of the acute surgical abdomen. The laparoscopic surgery was recommended and performed. A 12-inch angle of Treitz was found perforated diverticulum which was covered with omentum. Forty inches of jejunum including the perforated diverticulum were resected. The patient was discharged from the hospital on the sixth postoperative day. The pathological evaluation revealed a perforated jejunal diverticulum and diverticulosis yeyunal.

Perforated jejunal diverticulum: a rare case of acute abdomen

Jejunal pseudo-diverticulosis is a rare acquired herniation of the mucosa and submucosa through weakened areas of the muscularis mucosa of the mesenteric aspect of the bowel. They are asymptomatic in the majority of cases; however, they can present with a wide spectrum of non-specific symptoms such as chronic abdominal discomfort, postprandial flatulence, diarrhoea, malabsorption and steattorhoea. In up to 15% of cases, more serious acute complications may arise such as the development of intestinal obstruction, haemorrhage or as in our case, localized peritonitis secondary to perforation. Perforation carries an overall mortality rate of up to 40% and exploratory laparotomy followed by copious lavage with segmental resection and primary anastomosis remains the mainstay of managing such sequalae of jejunal pseudo-diverticulosis. Our case report highlights the importance of maintaining a high clinical suspicion of a perforated jejunal diverticulum in an elderly patient presenting with an acute abdomen.

Perforated Jejunal Diverticulum in A Nonsteroidal Anti-Inflammatory Drug User: A Case Report and Review of the Literature

Perforated Jejunal Diverticulum in A Nonsteroidal Anti-Inflammatory Drug User: A Case Report and Review of the Literature

Perforated Jejunal Diverticulum - an Unusual Presentation

Jejunal diverticula are rare and usually asymptomatic. Acute complications may include haemorrhage, diverticulitis, obstruction, abscess formation and perforation. Here we report a case of 61 years lady who presented with generalized abdominal pain, vomiting and fever. There were features of acute peritonitis on examination. Exploratory laparotomy revealed a perforated jejunal diverticulum. Resection of the jejunal segment containing the perforated diverticulum and primary anastomosis was done. Histopathological examination revealed jejunal diverticulum with pinhole perforation. DOI: http://dx.doi.org/10.3126/jpahs.v1i1.13016 Journal of Patan Academy of Health Sciences. 2014 Jun;1(1):43-45

Perforated Jejunal Diverticulum: A Rare Cause of Acute Abdomen in Elderly Patient

Jejunal diverticula are rare, acquired lesions seen in elderly patients. Most of the cases are asymptomatic, and are generally detected incidentally. Symptoms, if present, include nonspecific chronic abdominal pain and malabsorption. They may be associated with complications like hemorrhage, diverticulitis, obstruction or perforation. Diverticular perforation is rare, occurring only in around 5-6% of all patients. We present a rare case of 76 year old male with acute abdomen associated with jejunal diverticular perforation and review the literature on this complication.

Perforation of Jejunum Diverticula: Report of Two Cases

Perforation of jejunal diverticulum is quite uncommon. Clinically this diagnosis may be easily confused with other causes of an acute abdomen. We present two cases with acute abdomen caused by perforation of jejunal diverticulum. These two patients are diagnosed and treated at different phases of the entity. Choice of surgical procedure was different in these patients. Physicians should increase the awareness of perforated jejunal diverticulum in patients with acute abdomen.

A Rare Case of Jejunal Diverticula Presenting as Small Bowel Perforation and GI Bleeding

Introduction: Jejunal diverticulosis is rare and asymptomatic in most patients with a prevalence of 0.26 %. Complications are rare and include perforation, inflammation, bacterial overgrowth, and hemorrhage. Jejunal diverticula complicated by perforation and bleeding has never been reported in the same patient to the best of our knowledge, and we are reporting one such case. Case Report: A 62-year-old female with multiple medical problems was transferred to our hospital due to acute abdomen with septic shock and ascites. CTAP showed ascites with free air with pneumatosis of small bowel. She was taken for emergent surgery, which showed small bowel perforation due to diverticulum extending into the mesentery. Fifteen cm of small bowel was resected and side to side anastomosis was performed. The patient did well for 15 days post-op. On the 16th post-op day, we were consulted for rectal bleeding and anemia during hemodialysis, and hemoglobin dropped from 8 to 5.8. She underwent emergent enteroscopy, which showed multiple diverticula in the duodenum and jejunum with signs of recent bleed from the diverticula. The anastomotic site was inspected, and was ruled out to be the bleeding source. Discussion: Jejunal diverticulosis is uncommon and is rarely symptomatic. Its incidence increases with age, usually presenting in the seventh decade of life, and is more common in men. It usually occurs along the mesenteric border of the jejunum, and a majority of patients present with bleeding present with shock. It is speculated to be due to larger diameter of the Jejunal arteries. Surgery is the treatment of choice, with resection of the affected portion of small bowel, which reduces the mortality from 80% in non-surgical management to 14% with surgery. Though endoscopic treatment offers an alternative way to avoid surgery, the risk of re-bleeding is high. There is a significant lapse of time before diagnosis in patients with perforated jejunal diverticulum, since it occurs along the mesenteric border, which results in early containment of the perforation. In conclusion, jejunal diverticulosis, though rare, can cause life-threatening bleeding and should be considered a possible etiology in massive upper GI bleeding when traditional endoscopy up to second part of duodenum does not reveal a source.

腹腔鏡補助下手術を行った空腸憩室穿孔による汎発性腹膜炎の1例

症例は77歳，男性．2013年5月上旬に下腹部痛があり，翌日に当院救急外来を受診した．来院時状態は安定しており，臍部から下腹部に圧痛・反跳痛を認めたが，筋性防御はなかった．胃十二指腸潰瘍の既往はなかった．CTでは少量のfree airが上腹部から臍下部まで広範囲に認められたが，穿孔部位の特定は困難であった．部位不明ながら上部消化管穿孔を疑い腹腔鏡下に検索したところ，Treitz靱帯から約20cmの上部空腸に憩室穿孔を認めたため，空腸部分切除および腹腔内洗浄ドレナージを行った．病理組織所見では仮性憩室の穿孔であった．消化管穿孔の原因部位が特定できない場合には，腹腔鏡下に検索を行い原因に合わせて術式を選択することも有用であり，選択枝の一つと考えられる．また，空腸憩室穿孔はまれであり術前診断が困難であるが，消化管穿孔の原因の一つとして念頭に置く必要がある．

Non-surgical management of recurrent perforation of a jejunal diverticulum following previous segmental bowel resection: a case report

IntroductionPerforations of jejunal diverticula are uncommon and repeated symptomatic perforations have been reported only twice before in the literature. This is the first case report of recurrent perforation of a jejunal diverticulum to be successfully managed non-operatively.Case presentationWe report a recurrent perforation of a jejunal diverticulum in an 87-year-old Caucasian man who presented with a 1-week history of epigastric pain. The diagnosis of a perforated jejunal diverticulum was made from the appearances of the abdominal computed tomography scan together with the presence of jejunal diverticula noted at the time of a previous laparotomy for the first perforation of a jejunal diverticulum.ConclusionWhilst this case report by itself does not add to the knowledge we already have of jejunal diverticula, it is one report of a rare condition and more reports are required in the future to establish the recurrence rate of jejunal diverticula perforation and how perforated jejunal diverticula are best managed.

Perforation of Jejunal Diverticula in Steroids and Nonsteroidal Anti‐Inflammatory Drug Abusers: A Case Series

Jejunal diverticula are rare lesions, and when complications arise, they pose diagnostic difficulties. Perforation is a common complication resulting in an acute abdomen, although preoperative diagnosis is usually not possible. The "gold standard" for management for patients with complications is surgery. We present a series of patients with perforated jejunal diverticula who were on prolonged treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids for Chikungunya fever. There were a total of six patients, all of them presenting with perforative peritonitis, with or without shock. Plain abdominal radiogram and ultrasonogram confirmed this, although the exact site of the perforation was not diagnosed preoperatively. All patients underwent exploratory laparotomy and perforated jejunal diverticulum was found. Resection and anastomosis was performed in all cases. The mean operating time was 113.5 minutes, and the blood loss was not significant. Postoperative course was uneventful except wound infection in two patients. There was no mortality. Prolonged NSAID and steroid use are known to cause ulceration/perforation of the upper digestive tract and colonic diverticula. This seems to be the most likely cause for the perforation of jejunal diverticula in our series of patients. This view is supported by the absence of inflammation and infiltration of neutrophils on histopathological examination of the diverticula.

Jejunal perforation in gallstone ileus – a case series

IntroductionGallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, and only a handful of cases have been reported. We present two cases of perforation of the jejunum in gallstone ileus, and remarkably in one case, the gallstone ileus caused perforation of a jejunal diverticulum and is to the best of our knowledge the first such case to be described.Case presentationsCase 1A 69 year old man presented with two days of vomiting and central abdominal pain. He underwent laparotomy for small bowel obstruction and was found to have a gallstone obstructing the mid-ileum. There was a 2 mm perforation in the anti-mesenteric border of the dilated proximal jejunum. The gallstone was removed and the perforated segment of jejunum was resected.Case 2A 68 year old man presented with a four day history of vomiting and central abdominal pain. Chest and abdominal radiography were unremarkable however a subsequent CT scan of the abdomen showed aerobilia. At laparotomy his distal ileum was found to be obstructed by an impacted gallstone and there was a perforated diverticulum on the mesenteric surface of the mid-jejunum. An enterolithotomy and resection of the perforated small bowel was performed.ConclusionGallstone ileus remains a diagnostic challenge despite advances in imaging techniques, and pre-operative diagnosis is often delayed. Partly due to the elderly population it affects, gallstone ileus continues to have both high morbidity and mortality rates. On reviewing the literature, the most appropriate surgical intervention remains unclear.Jejunal perforation in gallstone ileus is extremely rare. The cases described illustrate two quite different causes of perforation complicating gallstone ileus. In the first case, perforation was probably due to pressure necrosis caused by the gallstone. The second case was complicated by the presence of a perforated jejunal diverticulum, which was likely to have been secondary to the increased intra-luminal pressure proximal to the obstructing gallstone.These cases should raise awareness of the complications associated with both gallstone ileus, and small bowel diverticula.

A CASE OF PERFORATED JEJUNAL DIVERTICULUM WITH RECKLINGHAUSEN DISEASE

We experienced a case of perforated jejunal diverticulum with Recklinghausen disease. The case involved a 51 year old man who had been diagnosed as having Recklinghausen disease at the age of 23. He received a neurosurgical operation for his brain tumors on December 17, 1996. The postoperative course was uneventful, but he had sudden onset of abdominal pain on January 8, 1997. His abdomen was elastic hard. Tenderness and defence were recognized. Abdominal X-ray film showed no significant remarks, but abdominal CT showed free air on upper abdomen. With the diagnosis of panperitonitis, the patient was op-erated on at same day. Intraoperative findings showed a jejunal diverticulum packed with food residue and its perforated point. A partial resection of the jejunum and dranage were performed with the diagnosis of pan-peritonitis due to perforated jejunal diverticulum. The pathological findings demonstrated that the cause of the jejunal diverticulum was a neurofibroma associated with Recklinghausen disease.