Small Bowel Diverticula Research Articles

Perforation peritonitis secondary to jejunal diverticulosis

Small bowel diverticula are rare presentations and jejunal diverticula are even more rare. Due to their asymptomatic nature, they are diagnosed at a very late stage leading to poor prognosis. Jejunal Diverticulosis is a rare diagnosis which presents at later stages with mild symptoms as in our case. Prognosis is poor due late presentation and high mortality. Timely management is important to reduce mortality. Here is a case report highlighting the presentation, the diagnostic workup and management of a patient with perforated Jejunal Diverticulosis.

Meckel’s diverticulum with varied clinicopathological presentations: A case series at a rural tertiary care center

Meckel’s diverticulum (MD), first documented by Wilhelm Fabricius Hildanus in 1598 as a small bowel diverticulum and later detailed by Johann Friedrich Meckel in 1809, is a remnant of the vitellointestinal duct connecting the fetal gut with the yolk sac. It is a true diverticulum, comprising of all the layers of the bowel wall. The commonly cited “rule of 2s” regarding the diverticulum is: Occurs in 2% of the population, has a 2:1 male-to-female ratio, usually discovered by 2 years of age, located 2 feet from the ileocecal valve, and commonly 2 cm in diameter and 2 inches long. Most Meckel diverticula are benign and are incidentally discovered during autopsy, laparotomy, or barium studies. Vitellointestinal duct lining cell being pluripotent, heterotopic tissues such as gastric, pancreatic followed by others might be found. Common clinical presentation in symptomatic cases is gastrointestinal hemorrhages followed by intestinal obstruction, diverticulitis, cystic abdominal mass, patent umbilical fistula, and neoplasm. Clinical signs and symptoms are non-specific simulating other abdominal emergencies and routine radiology is unable to detect the anomaly in rural peripheral centers. Hence, prompt surgical intervention may be needed in emergency cases. Diverticulectomy or ileal segment resection with end-to-end anastomosis is done. Due to the difficulty of diagnosing a pathologic MD pre-operatively, many surgeons recommend prophylactic diverticulectomy in those found incidentally.

Perforated Jejunal Diverticulitis: A Rare Cause of Abdominal Pain

Cases of small intestinal diverticulosis are rare and mostly asymptomatic. Occasionally, a small bowel diverticulum may perforate. We describe the case of an 80-year-old male who presented with abdominal pain and signs of localized peritonitis. The ultimate diagnosis was confirmed to be perforated jejunum diverticula. Perforation of the jejunal diverticulum should be considered as part of the differential diagnosis of acute abdomen in elderly patients, and appropriate treatment options, ranging from early surgery to conservative measures, should be tailored to the patient's presenting condition and their overall physiology.

S1840 Intestinal Obstruction Secondary to Small Bowel Diverticula: A Review of Literature on Clinical Presentation and Optimal Management

S1840 Intestinal Obstruction Secondary to Small Bowel Diverticula: A Review of Literature on Clinical Presentation and Optimal Management

267 Perforated Meckels diverticulitis; a cautionary tale highlighting the importance of accurate vetting information in the selection and interpretation of radiological investigations

Abstract Background Failure of the vitelline duct involution process during the 7th week of gestation gives rise to the most common congenital anomaly of the GI tract; Meckel’s diverticulum. Clinical presentation is extremely variable. We present an unusual case of a perforated Meckel’s diverticulitis and a cautionary tale highlighting the importance of accurate clinical information when requesting radiological investigations. Case report An 18 year old gentleman presented acutely with 24 hours of rectal pain and associated fever. There were no urinary or penile symptoms. Examination revealed lower abdominal tenderness. Rectal and prostatic examination were normal. Abdominal ultrasound revealed a dilated appendix with surrounding free fluid. Diagnostic laparoscopy revealed pus in the right iliac fossa with a submerged and mildly injected appendix. A separate cause was sought – a perforated small bowel diverticulum was found in a 600mL pelvic collection. The procedure was converted to a Laparotomy with small bowel resection and side-side anastomosis plus appendicectomy and washout. Post-operative histology revealed a perforated Meckel’s diverticulitis. Discussion This unusual case highlights the importance of using the correct radiological investigation at the correct time for the correct clinical query. Clinical information supplied to radiologists, particularly ultrasonographer's, drastically alters the extent of examination and interpretation of imaging. Conclusion Providing accurate clinical information to Radiologists is key for accurate interpretation of imaging. Inaccurate information impacts the ability to arrive at the correct diagnosis, give the correct treatment and, in a surgical setting, complete the correct consent process for the patient.

Analysis of two cases of small bowel diverticulum misdiagnosisand its comorbidities: A report of two cases

To discuss and analyze the diagnosis and treatment methods of small bowel diverticulum to improve the level of diagnosis and treatment. The clinical data of two patients with small bowel diverticulum found by intraoperative exploration in our hospital were analyzed, and the preoperative and postoperative diagnoses were compared, as well as the causes and treatment methods of misdiagnosis. The two patients could not be clearly diagnosed before surgery, but they were clearly diagnosed during surgical exploration, and they were discharged after surgical treatment. Small intestinal diverticulum has no specific clinical manifestations; preoperatively, it is not easy to diagnose and is often diagnosed in autopsies or other operations. Patients with acute abdomen and gastrointestinal bleeding, such as small intestinal bleeding and acute appendicitis, should be vigilant for small bowel diverticula to avoid delaying the condition and causing serious consequences.

A Rare Case of Sigmoid Intussusception due to Sigmoid Diverticula in a Patient with Concomitant Extensive Small Bowel Diverticula

Small intestinal diverticula is a rare occurrence, and their surgical management remains controversial due to the lack of a recognized classification system. Complications such as perforation and obstruction are treated surgically. Their etiology remains nebulous but theories such as damage to the Auerbach’s nerve plexus have been advanced as a possible cause. The concomitant presence of a sigmoid intussusception due to diverticular disease in the same patient is truly a rare occurrence. The vast majority of colonic intussusception is due to malignancy and a benign etiology remains elusive. The reported cases of benign causes include a lipoma and benign lymphadenopathy. We believe this to be the first such case report of a colonic diverticulum causing an intussusception. Despite an exploratory laparotomy of less than sixty minutes, the patient demised in the intensive care unit following an occipital lobe stroke. We believe this case of sigmoid intussusception with concomitant small intestinal diverticula to be the first such case report of its kind in English-language scientific publications.

Analysis of Two Cases of Small Bowel Diverticulum Misdiagnosis and its Comorbidities: Report of Two Challenging Cases

To discuss and analyze the diagnosis and treatment methods of small bowel diverticulum to improve the level of diagnosis and treatment. Methods: The clinical data of two patients with small bowel diverticulum found by intraoperative exploration in our hospital were analyzed, and the preoperative and postoperative diagnoses were compared, as well as the causes and treatment methods of misdiagnosis. Results: The two patients could not be clearly diagnosed before surgery, but they were clearly diagnosed during surgical exploration, and they were discharged after surgical treatment. Conclusion: Small intestinal diverticulum has no specific clinical manifestations; preoperatively, it is not easy to diagnose and is often diagnosed in autopsies or other operations. Patients with acute abdomen and gastrointestinal bleeding, such as small intestinal bleeding and acute appendicitis, should be vigilant for small bowel diverticula to avoid delaying the condition and causing serious consequences.

Bowel Perforation Due to Complicated Jejunal Diverticulitis: A Rare Case Report and Literature Review

Small bowel diverticulosis is a rare and acquired disease usually diagnosed as an incidental radiological finding. We report the case of a 65-year-old man admitted to our Emergency Department with abdominal pain and fever. The CT-scan showed multiple jejunal diverticular eversions and oedema of the surrounding tissues. At urgent laparotomy the radiological finding was confirmed with microperforation of one diverticula. Bowel resection was performed and histology revealed erosive inflammation with ischemic mucosa. Small bowel diverticula do not require any treatment if asymptomatic, nevertheless cases like this could be life-threatening. Urgent surgical procedure must be the treatment of choice in these patients.

Enterolith from Small Bowel Diverticulum as an Uncommon Cause of Acute Small Bowel Obstruction and Literature Review

Enterolith from Small Bowel Diverticulum as an Uncommon Cause of Acute Small Bowel Obstruction and Literature Review

S3369 Small Bowel Diverticulitis: A Unique Urinary Presentation

Introduction: Small bowel diverticula (SBD) are rare and often discovered incidentally. Although usually asymptomatic, complications such as diverticulitis, obstruction, abscess, and perforation can occur. Given the rarity of SBD, no established treatment guideline exists. We present a case of a healthy patient with urinary symptoms who was found to have SBD. Case Description/Methods: A healthy 54-year-old female presented to her PCP with sharp suprapubic abdominal pain with dysuria and gross hematuria. Physical examination demonstrated suprapubic tenderness upon palpation. A urinalysis and urine culture were unremarkable. However, there was concern for urinary tract infection (UTI) and patient was started on Cephalexin 500mg BID for 14 days. Two days later, patient presented to the ER with worsening symptoms. She now had associated nausea and vomiting with fever. She exhibited guarding and rebound tenderness on physical examination. A CMP was unremarkable with normal LFTs. She had a WBC count of 11.8 K/mm3. Given worsening suprapubic pain, a CT abdomen and pelvis with contrast was obtained which showed severe acute small bowel diverticulitis involving a 6 cm long distal ileal loop adjacent to the bladder. Surgery services were consulted for intervention and recommended inpatient observation and initiation of IV antibiotics. The patient refused and wished to go home. She was discharged with Ciprofloxacin 500mg BID and Metronidazole 500mg TID for 14 days. The patient was scheduled to follow up with GI clinic. A repeat CT abdomen and pelvis with contrast showed near complete resolution of the inflammatory features of small bowel diverticulitis. Patient reported retuning to her baseline health. (Figure) Discussion: Most patients with SBD are asymptomatic. However, symptoms may reflect local inflammation as seen in our patient who presented with suprapubic pain, dysuria, and gross hematuria. No established treatment guidelines exist for SBD and thus colonic diverticulitis management is used as a guide. Asymptomatic patients do not require treatment. For patients with uncomplicated SBD, management includes diet adjustment and antibiotics. For complicated SBD, as evidenced by perforation on imaging or hemodynamic instability, surgical management is often required.Figure 1.: (top): CT abd and pelvis w/contrast showing large small bowel diverticulitis measuring 2.1 cm. (bottom): CT abd and pelvis w/contrast showing marked improvement of the small bowel diverticulitis with near complete resolution of inflammatory changes and wall thickening.

S2561 Terminal Ileal Diverticular Bleed: A Case Report and Review on Current Approaches for Intervention

Introduction: Colonic Diverticula are one of the most common findings in colonoscopies and are a common cause of lower GI bleed. They are most commonly seen in the large bowel - with 64% in the sigmoid colon, 8% in the descending colon or splenic flexure, 7% in the transverse colon, and 20% in the ascending colon or hepatic flexure. Small bowel diverticula are rare but they carry a risk of serious complications. This case report describes a 66 years old Male who presented to the emergency department with an acute lower GI bleed and was found to have a bleeding terminal ileum diverticulum, which was stopped with endoscopic intervention. Case Description/Methods: A 66 years old Male presented to the Hospital with an Acute Lower GI bleed with hemodynamic instability, for which a decision was made to obtain a CT Angiogram, that showed active bleeding into a diverticulum of the terminal ileum from a distal branch of the superior mesenteric artery. Colonoscopy was performed, and terminal ileum intubation showed a single small bleeding diverticulum. For Hemostasis, hemostatic clips were successfully placed, and there was no bleeding at the end of the procedure. The patient recovered uneventfully and had no further gastrointestinal bleeding. Discussion: Diverticulosis refers to the presence of small outpouchings that develop in the wall of the gastrointestinal tract. It is thought to be caused by abnormal intermittent high pressure in the colon due to muscle spasms or straining with stool at weak spots in the colon wall in the large intestine. An acquired diverticulum in the small intestine is a rare condition and may be a serious cause of lower GI bleed due to the technical difficulty with endoscopic intervention given its unusual anatomic location. Historically, approaches like changing the patient's position, attaching a transparent hood at the distal end have been tried. Hemostasis is usually achieved by injection, hemoclip, coagulation, thrombin spray, or combination. In the diverticula that are unable to be accessed by endoscopic intervention, other options include therapeutic angiography and embolization of the bleeding vessel or surgical treatment consisting of resection of the intestinal segment containing the diverticula. Thus, clinicians must be vigilant that although colonoscopy can define the cause in most patients with lower gastrointestinal bleeding, no bleeding site is identified in 10 %– 20 % of cases. In such cases, an important cause may be an incomplete workup that overlooked the ileocecal region.Figure 1.: Active Hemorrhage into a Diverticulum of the Terminal Ileum

S3435 Jejunal Diverticula: A Lesser Known Cause for Massive Lower GI Bleeding

Introduction: Small bowel diverticula are rare. We describe a case of Jejunal diverticula that caused massive lower GI bleeding requiring surgical intervention. Case Description/Methods: A 77 year old male presented to our ER with sudden onset bright red blood per rectum. The patient first noticed 2 days ago that his stool was dark red followed by red streaking on toilet paper. A few hours later he developed rectal urgency followed by another large bloody bowel movement along with associated diaphoresis, LLQ cramping and presyncope. Past medical history included GERD, BPH, Hypertension and Polycythemia Vera. He had never undergone an EGD and his last screening colonoscopy was normal 5 years ago. Labwork revealed acute anemia with Hb of 7.7 g/dL (baseline 13) and one unit of RBCs was therefore transfused. Emergent EGD and colonoscopy were performed and these were unremarkable apart from sigmoid diverticulosis. The following day massive rectal bleeding recurred and this time a radionuclide bleeding scan was obtained which was positive for active bleeding in small bowel lumen at the LUQ. Interventional Radiology did not feel the area was approachable for embolization. 6 additional units of RBCs were given due to persistent bleeding. General Surgery was called and the patient was taken to OR for exploratory laparotomy with small bowel resection. Diffuse proximal Jejunal diverticulosis was found to be actively bleeding with blood traveling all the way to distal colon. 60 cm of Jejunum was transected 30 cm from the ligament of Treitz. The patient had an unremarkable postoperative recovery with no further episodes of bleeding and stable Hemoglobin on serial CBCs. Discussion: Diverticulosis involving the small bowel, especially the Jejunum, is rare. These lesions have a higher incidence in the elderly and are acquired as a result of increased intraluminal pressure. They are thin and friable due to lack of muscularis layer. Concurrent colonic diverticulosis is common. Traditionally considered to be asymptomatic and incidental findings on imaging or surgical exploration, Jejunal diverticula can uncommonly cause lower GI bleeding. Traditional endoscopy is unhelpful given the lack of accessibility of the small bowel. CT Angiography and Nuclear Medicine bleeding scans may be beneficial to localize bleeding. Hemorrhage is usually brisk, requiring massive blood transfusion to maintain hemodynamics. Unstable patients should undergo emergent laparotomy so that resection of the involved segment can be performed.

S3389 Chronic Diarrhea Caused by Duodenal Diverticulum

Introduction: Diverticula are bulging sacs that can occur in any part of the gastrointestinal tract. While mostly seen in the large intestine, 9–23% of small bowel diverticula are found incidentally via endoscopy. Small intestinal bacterial overgrowth (SIBO) is characterized by an abnormally increased bacterial burden in the small intestine with symptoms including abdominal distension and pain, bloating, and diarrhea. Small intestinal diverticulosis is a known risk factor for SIBO. Small bowel aspirates and culture is considered gold standard for diagnosing SIBO, while aspirates from diverticula is not routine practice for diagnosis. We present a case of SIBO diagnosed by aspirates from a large duodenal diverticulum (DD). Case Description/Methods: A 62-year-old female with chronic diarrhea, hepatic steatosis without cirrhosis, GERD, and diverticulosis presented to the gastroenterology clinic for continued complaints of diarrhea and bloating. The patient noted 4-5 bowel movements per day. Vital signs, physical exam, and previous workup including stool culture, Clostridium difficile study, colonoscopy with biopsies, fecal calprotectin and elastase, abdominal imaging, and celiac serologies were unremarkable. Patient tried pancrelipase with no noticeable difference in diarrhea. An esophagoduodenoscopy (EGD) performed showed multiple fundic gland polyps in the stomach and a large 40 mm diverticula in the 3rd portion of the duodenum. Duodenal and gastric biopsies obtained ruled out celiac disease, pathogens, and Helicobacter pylori. Aspiration of duodenal diverticular fluid was significant for >100,000 colony forming units per mL (CFU/mL) Escherichia coli, Enterococcus faecium, and Streptococcus mitis. Disaccharidases (lactase, sucrase, maltase, palatinase, glucoamylase) were within normal limits. Patient was initiated on rifaximin 550mg TID for 14 days with improvement of her chronic symptoms. (Figure) Discussion: While most DD are asymptomatic, small, and require no treatment, intervention is necessary if the patient develops SIBO, bowel obstruction, diverticulitis, bleeding, or perforation. SIBO can be diagnosed via small bowel aspirates showing >1000 CFU/mL. Large DD can lead to SIBO by creating a protected environment for bacterial species. Treatment of diarrhea due to SIBO and large DDs are treated with antibiotic therapy, like our patient who was prescribed rifaximin and noted improvement of symptoms. It is important to understand that while DD are uncommon, large diverticulum can lead to chronic diarrhea and SIBO.Figure 1.: [A] EGD findings with a large duodenal diverticulum in the upper left corner; [B] Process of aspirating duodenal diverticulum fluid.

Small bowel diverticula in elderly patients: a case report and review article

BackgroundSmall intestine diverticula are rare findings that were mostly reported in the elderly population as asymptomatic findings. However, they can also present with a wide range of symptoms (bloating, early satiety, chronic abdominal discomfort, and diarrhea/steatorrhea) or complications (gastrointestinal bleeding, small bowel obstruction, acute diverticulitis, or perforation) which in turn warrant medical treatment or urgent surgical intervention.Case presentationThis is a case report of an 84-year-old female who presented with an acute surgical abdomen. An exploratory laparotomy revealed complicated small bowel diverticula with a jejunal diverticulum perforation, for which a diverticulectomy was performed.ConclusionsThroughout this paper, we are aiming to outweigh the consideration of the possibility of complicated small bowel diverticula as a differential in the evaluation of any acute abdomen, especially in the elderly, which warrants emergency surgical management.

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.

Multiple Jejunal Diverticulosis Complicated by Perforation: Case Report and a Brief Literature Review

Abstract Background Multiple small-bowel diverticulosis comprises a rare entity with probable underestimated incidence, and that may be the reason why it is sometimes overlooked when managing cases with peritonitis. Case report In the present paper, we report the case of a 76-year-old male presenting abdominal pain and fever in an acute setting. Computed tomography (CT) scans revealed jejunal thickening and numerous images of saccular addition that were interpreted as jejunoileal diverticulitis. After an initial period of clinical treatment, surgical management was indicated based on a worsening clinical picture and the presence of an extraluminal focus of gas detected in a subsequent CT scan. Through a laparoscopic approach, multiple small-bowel diverticula and a tamponade perforation were found. A segmental intestinal resection was performed, and the patient was discharged after a ten days. Conclusions Multiple jejunal diverticulosis is a rare condition that should be remembered in the setting of an acute abdomen. As it prevails among older patients, early diagnosis with radiological aid is crucial to establish the most adequate management, including intestinal resection, if necessary.

Jejunal diverticular disease complicated with spontaneous perforation: A rare case of acute abdomen and literature review

Introduction: The jejunal diverticular disease is an uncommon clinical pathology. In general, these diverticula are an incidentaloma found on imaging exams that can be seen in elective surgeries for other purposes. In a minority of cases it causes symptoms which result from serious complications such as perforation. Case report: A 56-year-old male patient, previously healthy and without comorbidities, was admitted to the emergency department due to abdominal pain which had started 24 hours ago, without improvement. On examination, the patient was in pain and in Mohammedan prayer's position in bed and had a distended abdomen with signs of peritoneal irritation. An abdominal tomography showed massive distension of intestinal loops and free fluid in the peritoneal cavity. He underwent exploratory laparotomy which showed multiple diverticula in the jejunum and one of them was perforated. Segmental enterectomy with primary anastomosis was performed. Conclusion: Complicated jejunal diverticular disease should be ranked among the differential diagnoses in acute perforating abdomen. Segmental jejunal resection is the treatment of choice. Keywords: small bowel diverticulum; jejuno-ileal diverticula; diverticulitis; perforation; acute abdomen; surgery.

EP.TU.542Enterolith ileus secondary to small bowel diverticulum: a rare cause of small bowel obstruction

Abstract Small intestinal diverticula are rare and possibly acquired secondary to bowel dyskinesia, abnormal peristalsis or high intraluminal pressures. Enterolith formation within these diverticula and intra-luminal bowel obstruction from them are a less encountered complication. A seventy-five year old man, with no history of abdominal surgery, presented with 10 days of colicky right iliac fossa pain and recurrent episodes of bilious vomiting. He initially reported diarrhoea but complained of eventual absolute constipation for last 5 days. Physical examination revealed distended abdomen with right-sided tenderness and no mass or faeces were noted on rectal examination. Biochemistry indicated raised inflammatory markers and an acute kidney injury. Abdominal CT scan revealed a 3.5 cm calculus in the distal ileum causing obstruction initially flagged as gallstone ileus. No gallstones or pneumobilia were identified although some intrahepatic duct dilatation was noted. An emergency laparotomy was conducted, where the radiological findings were reinforced and the calculus was extracted via enterotomy. There were no abnormal communications between gallbladder and intestinal tract suggestive of passage of gallstone to ileum. The small bowel traced from duodenojejunal flexure to terminal ileum did not reveal any further calculi or diverticula. FTIR spectrum analysis of the extracted specimen indicated similarities to enterolith. Retrospective analysis of radiological images revealed a possible duodenal diverticulum. The case highlights the diagnostic conundrum and therapeutic challenges of small bowel diverticular enterolith.

Acute Abdomen caused by Perforated Jejunal Diverticulitis

Jejunal diverticulum accounts for only 25% of small bowel diverticula, and approximately 7% of these will present as complicated jejunal diverticulitis or perforation. Here, we described a case of jejunal diverticular perforation presented as acute abdominal peritonitis. The computed tomography of the abdomen suggested small bowel perforation and therefore, emergency surgical exploration was performed. Intraoperatively, multiple jejunal diverticulae were found with one forming a localised diverticular abscess. Segmental resection of the diseased segment with primary anastomosis was performed. The patient made an uneventful post-operative recovery. Although complicated jejunal diverticulitis is rare, emergency surgery is often warranted if perforation occurs. Computed tomography is valuable in the diagnosis and preoperative planning especially in an emergency surgical conundrum when there is equivocal clinical peritonitis or perforation.