Perforated jejunal diverticulum: CT diagnosis

Acute Ileal Diverticulitis: Computed Tomography and Ultrasound Findings

BACKGROUND

Acute ileal diverticulitis is a rare disease mimicking acute appendicitis. Inaccurate diagnosis with a low prevalence and nonspecific symptoms leads to delayed or improper management.

METHODS

This retrospective study aimed to investigate the characteristic sonographic (US) and computed tomography (CT) findings with clinical features in seventeen patients with acute ileal diverticulitis diagnosed between March 2002 and August 2017.

RESULTS

The most common symptom was abdominal pain (82.3%, 14/17) localized to the right lower quadrant (RLQ) in 14 patients. The characteristic CT findings of acute ileal diverticulitis were ileal wall thickening (100%, 17/17), identification of inflamed diverticulum at the mesenteric side (94.1%, 16/17), and surrounding mesenteric fat infiltration (100%, 17/17). The typical US findings were outpouching diverticular sac connecting to the ileum (100%, 17/17), peridiverticular inflamed fat (100%, 17/17), ileal wall thickening with preserved layering pattern (94.1%, 16/17), and increased color flow to the diverticulum and surrounding inflamed fat on color Doppler imaging (100%, 17/17). The perforation group had a significantly longer hospital stay than non-perforation group (p = 0.002). In conclusion, acute ileal diverticulitis has characteristic CT and US findings that allow radiologists to accurately diagnose the disease.

Perforated jejunal diverticula in a young woman: A case report

INTRODUCTION AND IMPORTANCE

Small bowel diverticulosis is a rare condition. It usually remains asymptomatic and undiscovered, until potentially severe complications such as diverticulitis or even perforation occur. We present an unusual case and discuss the pathophysiology, diagnostics strategies, and possible surgical intervention.

CASE PRESENTATION

A young woman was referred to our emergency department suffering from acute abdominal pain. A computed tomography scan showed signs of small bowel perforation of unknown origin. Exploratory laparotomy revealed multiple perforated jejunal diverticula (JD). The patient underwent segmental resection of the affected jejunum followed by primary anastomosis. Pathological examination confirmed the diagnosis of perforated JD.

CONCLUSIONS

Due to its rarity and variable clinical presentation, it can sometimes be challenging to diagnose this potentially life-threatening condition. If the bowel is suspected from perforation; segmental resection is the treatment of choice, preferably followed by direct restoration of the bowel continuity.

A Rare Presentation of Small Bowel Diverticulosis Causing Chronic Obstruction and Malnutrition: A Case Study with Review of Literature

Small bowel diverticulosis is an uncommon entity. Clinical presentation of small intestinal diverticulosis is variable. A high mortality is associated with complications such as chronic malnutrition, haemorrhage, intestinal obstruction, and perforation. We report a case of a 63-year-old female with multiple small bowel diverticuli spanning from the first part of the duodenum to the proximal ileum presenting with chronic malnutrition and subacute intestinal obstruction. Although exploratory laparotomy was performed, we opted for a totally conservative treatment in order to avoid complications such as short gut syndrome and anastomotic leakage.

Perforation of jejunal diverticulum with ectopic pancreas

Perforation of jejunal diverticulum is a rare complication. Here, we report a case of jejunal diverticulum penetration with surrounding ectopic pancreas. An 83-year-old female patient was admitted to our department with acute onset of severe abdominal pain lasting for half a day. Abdominal computed tomography showed outpouching of the small intestine that contained air/fluid, with multiple surrounding air bubbles in the mesentery of the small intestine. She was diagnosed with penetration of the small intestine, and an emergency laparotomy was indicated. The penetrated jejunal diverticulum was identified ~20-cm distal to the ligament of Treitz. Partial resection of the jejunum was performed, and her postoperative course was uneventful. The pathological findings confirmed diverticulum penetration into the mesentery and severe inflammation at the site, with surrounding ectopic pancreas. Furthermore, the pancreatic ducts were opened through the penetrated diverticulum. This rare case shows that the ectopic pancreas might have caused penetration of jejunal diverticulum owing to the pancreatic duct opening through the diverticulum.

Small bowel diverticulitis: an imaging review of an uncommon entity

In this review, we discuss the clinical and radiologic findings of small bowel diverticulosis, which is infrequently encountered during practice and far less common than colonic diverticulosis. Small bowel diverticulosis can present with a range of emergent symptomatic complications including diverticulitis, perforation, or hemorrhage. Here, we focus on the clinical features, pathogenesis, radiologic findings, and treatment of small bowel diverticulitis. Although not routinely considered in the differential diagnosis of an acute abdomen, prospective radiologic diagnosis of small bowel diverticulitis is important and can lead to conservative treatment thus preventing unnecessary exploratory laparotomy.

Magnetic resonance enterography/enteroclysis in acquired small bowel diverticulitis and small bowel diverticulosis

PURPOSE

Small bowel (SB) diverticulosis is a rare disorder that may entail serious complications, including SB diverticulitis. Both are often missed in imaging. Magnetic resonance enterography/enteroclysis (MRE) is increasingly used to assess SB disease; awareness of the appearance of SB diverticulitis is essential to ensure appropriate management. Our aim was to systematically describe imaging characteristics of SB diverticulosis and diverticulitis in MRE.

METHODS

This retrospective, HIPAA-compliant study identified 186 patients with suspected SB diverticulosis/diverticulitis in medical databases of two tertiary medical centres between 2005 and 2011. Patients with surgically confirmed diagnoses of SB diverticulosis/diverticulitis were included. Two observers analyzed MR images for the presence, location, number, and size of diverticula, wall thickness, and mural and extramural patterns of inflammation.

RESULTS

Seven patients were recruited. MRI analysis showed multiple diverticula in all (100 %). Diverticular size ranged from 0.5 to 6 cm. Prevalence of diverticula was higher in the proximal than the distal SB (jejunum 86 %, ileum 57 %, distal ileum43%). Diverticulitis occurred in 3/7 patients (43 %) showing asymmetric bowel wall thickening and focal mesenteric inflammation.

CONCLUSION

SB diverticulitis demonstrates characteristic MRE imaging features to distinguish this rare disorder from more common diseases. Asymmetric, focal mesenteric and mural inflammation and presence of multiple diverticula are keys to diagnosis.

KEY POINTS

• Small bowel diverticulosis and diverticulitis is rare and often missed in imaging • Acquired small bowel diverticula are variable in size and number • Small bowel diverticulitis demonstrates characteristic features on MR enterography/enteroclysis • A focal or segmental asymmetric small bowel inflammation should prompt the search for diverticula.

Emergency surgery for jejunal diverticulosis: our experience and review of literature

BACKGROUND

Jejunal diverticulosis is a rare entity and is often asymptomatic. However, some of its complications may require acute surgical intervention. This study was performed to evaluate the presentation and outcome of patients who underwent urgent surgery for complicated jejunal diverticulosis.

METHODS

A retrospective review of all patients who underwent emergency surgery for complicated jejunal diverticulosis from November 2005 to December 2008 was performed.

RESULTS

Six cases of complicated jejunal diverticulosis required urgent surgery during the study period. Three patients presented with acute abdomen from perforated jejunal diverticulum. Preoperative computed tomographic (CT) scans were useful in localizing the source of sepsis. One patient died from the subsequent complications. The other three patients presented with massive lower gastrointestinal haemorrhage for which CT angiography was able to localize the source of haemorrhage in two of them. Small bowel resection was then performed and all three were discharged well eventually.

CONCLUSION

Though rare, jejunal diverticulosis can present with several life-threatening complications that mandates immediate surgery. While the surgical procedure may be technically simple, achieving the accurate preoperative diagnosis is often fraught with challenges. CT scan could prove invaluable in the management if the situation permits.

Jejunal diverticulae: reports of two cases with review of literature

INTRODUCTION

Jejunal diverticulosis (JD) is a rare disease of elderly people. Majority of diagnosed individuals are asymptomatic and found incidentally. The disease is clinically significant because of associated potential risk of serious complications. Due to the rarity and variable presentation of this clinical entity, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. Clinical presentations, signs, diagnosis, complications and treatment of JD are discussed through a review of the literature and report of two cases.

METHODS

A literature review was done for analysis of diagnosis, treatment and complications of JD. Two cases of JD diagnosed and treated in our institution are also presented.

CONCLUSION

JD is a rare disease which has variable presentations and thus poses a challenge to our diagnostic skills. Awareness about complications and presentation of the condition is needed for early detection and avoiding unnecessary mortality.

Perforated duodenal diverticulum: clinical and imaging findings in eight patients

BACKGROUND

Duodenal diverticula are common and are usually asymptomatic. We have studied a substantial number of patients who had perforation of a duodenal diverticulum and found these challenging to diagnose with little guidance from prior publications.

METHODS

Retrospective study for the most recent 10-year period of all patients who had a discharge diagnosis of perforated duodenal diverticulum or duodenal diverticulitis and also had relevant imaging studies.

RESULTS

Eight patients had CT evaluation and six had upper GI fluoroscopic evaluation. All presented with acute abdominal pain. Duodenal diverticular perforation was spontaneous in 6 patients, and caused by endoscopy or feeding tube placement in one patient each. The diagnosis was made correctly by imaging in only 2 patients, while retrospective review showed clear evidence of a diverticulum and extraluminal gas in all cases. Clinical management included surgery in five patients and nonoperative management in three. Average duration of hospital stay was 32 days and two patients died.

CONCLUSION

Perforation of a duodenal diverticulum may cause severe illness or death and is difficult to diagnose. Careful attention to CT findings and appropriate use of upper GI studies may allow more confident diagnosis and management.

Small intestinal nonmeckelian diverticulosis

Nonmeckelian jejunoileal diverticula (JID) are rare, but potentially clinically significant lesions. Despite recent advances in modern diagnostic modalities, diagnosis of JID may be problematic. Upper gastrointestinal contrast series with small bowel follow-through examination and mainly enteroclysis are the 2 main diagnostic methods. In selected cases (mainly complicated JID), the physician could use other diagnostic methods, such as ultrasound, computed tomography, endoscopy, intraoperative endoscopy, laparoscopy, radiotagged erythrocyte bleeding scans, and selective mesenteric arteriography. JID may be clinically silent or symptomatic causing chronic pain or malabsorption or other acute complications, such as hemorrhage, inflammation, perforation, etc. Laparotomy remains the gold standard for definite diagnosis of asymptomatic and complicated diverticula. Treatment should be individualized. Surgery could be indicated, mainly in symptomatic diverticula. The extent of resection may be a problem, especially in patients with extensive disease involving large parts of the bowel. In these cases, clinical judgment is required from the part of surgeon to avoid short bowel syndrome.

Jejunal diverticulosis is not always a silent spectator: A report of 4 cases and review of the literature

Jejunal diverticulosis (JD) is a rare clinical entity. The potential complications of this condition are discussed here through a series of cases presented to our centre. A retrospective analysis of four cases, which were diagnosed and treated, was performed. These included two cases of gastrointestinal haemorrhage, one case of perforation and one case of enterolith obstruction. All of these cases were secondary to jejunal diverticulosis and treated surgically. This was accompanied by a literature search to identify the different modalities for diagnosis and treatment of this condition. JD is rare and may lead to a diagnostic delay. Awareness of the wide spectrum of potential complications can prevent this delay.

The clinical significance of acquired jejunoileal diverticula

OBJECTIVE

Because of the relative rarity of acquired jejunoileal diverticulosis, including its symptomatology and complications, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. The purpose of the present study was to draw attention to jejunoileal diverticula and their complications as a site of gastrointestinal symptoms.

METHODS

The records of 10 patients with symptomatic jejunoileal diverticula treated in our departments were reviewed.

RESULTS

The clinical presentation was varying and nonspecific. Jejunoileal diverticula were diagnosed peroperatively in four patients operated on successfully for their acute complications. In one case the diagnosis was considered after a radiotargeted erythrocyte bleeding scan and in five other cases enteroclysis for chronic abdominal complaints demonstrated jejunoileal diverticula. The death of one patient operated on for massive hemorrhage from jejunal diverticula was probably related to delayed diagnosis and treatment.

CONCLUSIONS

Jejunoileal diverticula should not always be dismissed as asymptomatic findings, as they may be the cause of vague, chronic symptomatology and acute complications, including intestinal obstruction, hemorrhage, and perforation. Awareness of the fact that jejunoileal diverticula may cause chronic nonspecific abdominal symptoms and serious acute complications may lead to earlier diagnosis and timely treatment with lower morbidity and mortality.

Jejunal diverticulitis with localized perforation and intramesenteric abscess

We report a rare case of a 69-yr-old white man with jejunal diverticulitis with localized perforation and intramesenteric abscess formation. This entity is often overlooked as a cause of acute abdominal pain in the elderly. Although the clinical diagnosis is difficult, a high index of suspicion should warrant a computed tomography scan or enteroclysis.