Massive bleeding from multiple jejunal diverticula associated with an angiodysplasia: report of a case

Arteriovenous malformations within jejunal diverticulosis: case report and literature review

Background

Jejunal diverticula are the rarest of all small bowel diverticula. Most patients with jejunal diverticula are asymptomatic. Major complications include diverticulitis, gastrointestinal hemorrhage, intestinal obstruction and perforation. The hemorrhage has been attributed to diverticulitis with ulceration, diverticulosis associated with trauma and irritation disorder. However, only six cases reported the arteriovenous malformations within jejunal diverticulosis to be the cause of hemorrhage.

Case presentation

We present a case of arteriovenous malformations within jejunal diverticulosis in a 68-year-old male presented with lower gastrointestinal bleeding. After admission and stabilization, upper and lower endoscopies were performed without demonstrating the bleeding site. They only revealed clotted and red blood throughout the colon. Technetium-labeled red blood cell bleeding scan, endoscopic capsule, and selective angiography were performed to localize the site of bleeding without significant findings. As the clinical status of the patient deteriorated, exploratory laparotomy was performed urgently. Extensive jejunal saccular pouches were found 10 cm distal to duodenojejunal junction extending 1.6 m distally. Segmental resection was performed with side to side primary anastomosis. Microscopic examination of the specimen revealed many diverticula. He was followed up 2 years after that without complications.

Conclusion

We report yet the seventh case jejunal diverticulosis with the presence of angiodysplasia, in hope of expanding the knowledge of a rare occurrence and increasing the demand for further research about the etiology, clinical impact and treatment of such anomalies coexistence. This case also highlights the importance of considering the diagnosis of AVMs within jejunal diverticulosis in the presence of uncontrollable blood loss in the pre- or intra- operatively diagnosed jejunal diverticulosis and the urgent need for surgical intervention. In addition, the diagnostic tests should be performed close to the bleeding episode.

A Retrospective, Unicentric Evaluation of Complicated Diverticulosis Jejuni: Symptoms, Treatment, and Postoperative Course

Background

In contrast to the diverticulosis of the colon, jejunal diverticulosis is a rare condition. The incidence is 0.06–5% in large autopsy series. Complicated diverticulosis jejuni (CDJ) often presents with unspecific symptoms. Therefore, diagnosis is often a challenging process and due to the clinical rarity generally valid recommendation of perioperative management does not exist.

Patients and methods

We considered only patients who were operated in our center between April 2007 and August 2014. Patients were identified by data bank search via International Statistical Classification of Diseases and Related Health Problems diagnosis code K57.10. Data were manually screened, and patients with Meckel’s and duodenal diverticula were excluded from this study. Eleven consecutive patients with CDJ were finally included in this study. We analyzed symptoms, diagnostic procedures, surgical treatment, and postoperative morbidity and mortality.

Results

The median age of our patients was 76 years (range: 34–87). CDJ presented most frequently as intestinal bleeding or as diverticulitis. Clinical symptoms were unspecific abdominal pain, hematemesis or melena, ileus, nausea, and emesis as well as patients with acute abdomen. Esophagogastroduodenoscopies confirmed CDJ in two of the three patients. An abdominal computed tomography scan only helped to diagnose CDJ in two of the 10 patients. Eight (72.7%) patients received an open segmental resection with primary anastomosis. In three (27.3%) cases, a reoperation was necessary. Overall morbidity rate was 45.5%, and perioperative mortality was 9.1%.

Conclusion

Due to the acute character of the disease, patients with CDJ are seriously ill. To diagnose patients with CDJ remains challenging as diagnostic investigations are usually not helpful in confirming the diagnosis. Still, diagnosis of CDJ is most frequently confirmed intraoperatively.

Diagnosis and management of jejunoileal diverticular hemorrhage: a decade of experience

OBJECTIVE

The aim of this study was to evaluate the clinical features and management of jejunoileal diverticular hemorrhage at Changhua Christian Hospital over the past decade.

METHODS

A retrospective study on the clinical features, treatment and outcomes of the patients with jejunoileal diverticular hemorrhage diagnosed from January 2000 to December 2010 was conducted.

RESULTS

Twenty-eight patients (male to female ratio 15:13) were enrolled in the study with a mean age of 73.9 years. Symptoms consisted of bloody stool (46.4%), tarry stool (82.1%), coffee ground vomitus (7.1%) and shock (39.3%). The mean duration of hospital stay was 13.5 days and the mean blood transfusion volume was 13.5 units. Eight patients (28.6%) underwent surgical resection, 9 (32.1%) received endoscopic therapy and 11 (39.3%) were administered conservative therapy. Five patients (17.9%) had recurrent bleeding during the follow-up. Two patients (7.1%) died eventually.

CONCLUSIONS

The management of jejunoileal diverticular hemorrhage has mainly been nonsurgical at our institution over the past decade. The decreased requirement of surgical intervention might be attributed to the improvement of diagnostic and treatment procedures during this period.

Small bowel emergency surgery: literature's review

Emergency surgery of the small bowel represents a challenge for the surgeon, in the third millennium as well. There is a wide number of pathologies which involve the small bowel. The present review, by analyzing the recent and past literature, resumes the more commons. The aim of the present review is to provide the main indications to face the principal pathologies an emergency surgeon has to face with during his daily activity.

The clinical significance of jejunal diverticular disease diagnosed by double-balloon enteroscopy for obscure gastrointestinal bleeding

BACKGROUND

Jejunal diverticular disease is a rare cause of gastrointestinal bleeding. The reported incidence of this disease is low in the studies of double-balloon enteroscopy.

AIM

The aim of this study was to evaluate the clinical features and management of jejunal diverticular disease, diagnosed by double-balloon enteroscopy, at our institution.

METHOD

This was a retrospective study of patients with jejunal diverticular disease conducted from April 2004 to September 2009 at Changhua Christian Hospital. We evaluated the clinical significance of jejunal diverticular disease and the outcome of endoscopic treatment for jejunal diverticular bleeding.

RESULTS

From April 2004 to September 2009, a total of 55 patients underwent double-balloon enteroscopy due to obscure gastrointestinal bleeding. Fifteen of these patients were diagnosed with jejunal diverticular disease (8 men and 7 women, mean age 71 years). Four patients were found to have a single diverticulum. Gastrointestinal bleeding was attributed to jejunal diverticular disease in 12 patients. Six patients received endoscopic treatment in order to achieve hemostasis. One patient received emergency surgery due to uncontrolled bleeding.

CONCLUSIONS

To our knowledge, this is the first study reporting the clinical significance of jejunal diverticular disease diagnosed by double-balloon enteroscopy. We found that obscure GI bleeding was attributed significantly to jejunal diverticular disease.

Successful double balloon enteroscopy treatment for bleeding jejunal diverticulum: a case report and review of the literature

In this article, we report a case study of a 54-year old man who presented with massive gastrointestinal bleeding. Esophagogastroduodenoscopy and colonoscopy had been performed in another hospital, but the location of the bleeding could not be identified, and the patient was transferred to our hospital. An initial abdominal computed tomography scan showed only a large blood clot in the small bowel and colon, with duodenojejunal diverticulosis. Emergent angiography was performed due to persistent active bleeding. Active bleeding from the jejunum was found, and the patient received a double balloon enteroscopy, which disclosed active bleeding in one of the jejunal diverticula. Two hemoclips were applied to treat the Dieulafoy's lesion within the diverticulum. The patient had no bleeding during the month following treatment. Bleeding of the jejunal diverticulum is a rare clinical condition, and only a few cases have been reported in the literature with successful endoscopic treatment. A short review of the current methods of diagnosis and treatment of this rare disorder is provided.

ArterioVenous Malformation within Jejunal Diverticulum: an unusual cause of massive gastrointestinal bleeding

Massive gastrointestinal (GI) bleeding can occur with multiple jejunal diverticulosis. However, significant bleeding in the setting of few diverticulae is very unusual and rare. We report a case of massive gastrointestinal bleeding from an arteriovenous malformation (AVM) within a jejunal diverticulum to underscore the significance of such coexisting pathologies. Mesenteric angiogram was chosen to help identify the source of bleeding and to offer an intervention. Despite endovascular coiling, emergent intestinal resection of the bleeding jejunal segment was warranted to ensure definitive treatment. However several reports have shown jejunal diverticulosis as a rare cause of massive GI bleeding. The coexistence of jejunal diverticulum and AVM is rare and massive bleeding from an acquired Dieulafoy-like AVM within a diverticulum has never previously been described. Awareness of Dieulafoy-like AVM within jejunoileal diverticulosis is useful in preventing delay in treatment.

Massive bleeding from a ruptured artery in jejunal diverticulosis without pre-existing mucosal inflammation or ulceration

A case of massive bleeding from a ruptured artery in jejunal diverticulosis without pre-existing mucosal inflammation or ulceration is presented. A 75-year-old bed-ridden man had massive gastrointestinal bleeding and deteriorated to a state of shock rapidly. Panendoscopy, selective abdominal angiography, and radionuclide scanning were performed, but none of these studies revealed the exact bleeding point. Emergent operation revealed a segment of jejunal diverticulosis with bleeding, and it was resected. Pathologic examination revealed tortuous veins in the submucosa of diverticula and a ruptured artery with evidence of active bleeding in a large diverticulum. No pre-existing mucosal inflammation or ulceration was seen. The bleeding cause is thought to be acquired false diverticular wall tearing of a submucosal artery by bowel distension or unknown moving content.

Acquired Jejunoileal Diverticulosis and Its Complications: A Review of the Literature

Jejunoileal diverticulosis is a rare entity. Jejunoileal diverticulosis is not a disease that surgeons see often in clinical practice; however, it should remain on the differential diagnosis for any patient with an acute abdomen or gastrointestinal bleeding of unknown origin. It can present with a wide range of clinical scenarios and when patients experience chronic symptoms such as bloating, abdominal pain, nausea, bacterial overgrowth, or malabsorption, medical therapy is successful in most patients. However, when patients present with acute symptoms of bleeding, inflammation, perforation, or obstruction, surgical resection and primary anastomosis is often the treatment of choice. If patients are asymptomatic, they are better left alone, even when discovered incidentally in the operating room. In closing, the possibility of a patient having jejunal diverticular disease should be suspected whenever the symptoms of obscure abdominal pain, anemia, dilated jejunal loops on abdominal radiographs, a history of colonic diverticuli, and a history of acute appendicitis.

Colonic angiodysplasia and true diverticula: is there an association?

AIMS

To investigate the pathology of colectomy specimens, from patients presenting with lower gastrointestinal haemorrhage, who had undergone preoperative mesenteric angiography. The angiography diagnoses ranged from active bleeding of unknown aetiology to angiodysplasia.

METHODS AND RESULTS

The macroscopic and microscopic pathology of 11 colectomy specimens was studied. All the specimens contained blood on receipt with no obvious macroscopic source of haemorrhage identified. In all cases the large bowel demonstrated diverticula with an unusual topography. These were wide-mouthed, up to 20 mm across and exhibited a partly scattered distribution across the bowel; in two cases the diverticula contained blood clot. Histology demonstrated true diverticula invested by all muscle layers, exhibiting thick-walled vessels, within the submucosa and within the muscularis propria fibres, resembling the vascular elements identified in congenital vascular malformations. The two cases that contained blood clot revealed the thick-walled vessels to have ruptured into the diverticular lumen. Histology from the background colon between the diverticula demonstrated vascular lesions fulfilling the histological criteria for angiodysplasia; these features were also represented in the true-type diverticula. Most cases showed right-sided angiodysplasia and right-sided true diverticula. However, left-sided angiodysplastic lesions were also seen in association with left-sided true-type diverticula.

CONCLUSIONS

We have identified the dual pathologies of angiodysplasia and multiple true-type diverticula, and suggest a topographical relationship between these two lesions. Furthermore, we propose that the thick-walled vessels within the true diverticula are congenitally abnormal, and raise the possibility that these vessels exert local haemodynamic effects, that effectively predispose the colon to acquired angiodysplastic phenomena.

Jejunal diverticulosis and gastrointestinal bleeding

Occult gastrointestinal bleeding frequently frustrates clinicians' attempts to locate the source. Foci of hemorrhage within the small bowel are often found only at laparotomy and can be attributed to Meckel's diverticula, carcinomas, or less frequently, pulsion-type diverticula. We report our experience with two patients whose jejunal diverticula resulted in recurrent episodes of massive gastrointestinal hemorrhage.