Diverticulosis of the terminal ileum and its complications

Complicated jejunal diverticulitis with small bowel obstruction due to enterolith: A case report

INTRODUCTION AND IMPORTANCE

Small bowel diverticular disease (DD) is encountered and managed much less frequently than colonic DD, leading to a significantly less developed body of evidence for managing small bowel diverticulum and its associated complications.

CASE PRESENTATION

This case report discusses a rare occurrence of simultaneous perforated jejunal diverticulitis and mechanical small bowel obstruction (SBO) due to a migrating diverticular enterolith. The patient's condition was ultimately managed operatively through laparoscopically assisted small bowel resection.

CLINICAL DISCUSSION

A review of the literature reveals only eight reported cases of jejunal diverticulitis with simultaneous enterolith obstruction. All cases were managed operatively, with approaches including small bowel resection encompassing both pathologies, milking the enterolith back to the diverticulitis site and resecting en bloc to avoid extensive resection, or enterotomy and enterolith retrieval.

CONCLUSION

The prevalence of small bowel diverticular disease is increasing, and as a result, clinicians may encounter more complications associated with this condition in the future. This case highlights the importance of considering alternate complications of small bowel DD.

Small Bowel Diverticulosis: Pathogenesis, Clinical Management, and New Concepts

PURPOSE OF REVIEW

Small bowel diverticulosis is a well-known clinical entity whose diagnosis and management has evolved in recent years. This review covers pathophysiology, incidence, and prevalence, and it also provides an update on modern diagnosis and management. Meckel's diverticula are covered elsewhere in this volume.

RECENT FINDINGS

CT scan and MRI have largely supplanted barium follow-through for diagnosis. No intervention is needed in asymptomatic individuals. Endoscopic management is playing an increasing role for both bleeding and resection of intraduodenal diverticula, but surgical intervention remains the only definitive intervention for other complications like diverticulitis and small bowel obstruction. Small bowel diverticulosis is an uncommon condition which is associated with numerous possible complications. While endoscopy is playing an increasingly large role in management, surgical resection remains the treatment of choice for most complications. A high index of suspicion is needed in order to diagnose this entity.

Flare-Up Diverticulitis in the Terminal Ileum in Short Interval after Conservative Therapy: Report of a Case

Diverticulitis in the terminal ileum is uncommon. Past reports suggested that conservative therapy may be feasible to treat terminal ileum diverticulitis without perforation; however, there is no consensus on the therapeutic strategy for small bowel diverticulitis. We present a 37-year-old man who was referred to our hospital for sudden onset of abdominal pain and nausea. He was diagnosed with diverticulitis in the terminal ileum by computed tomography (CT). Tazobactam/piperacillin hydrate (18 g/day) was administered. The antibiotic treatment was maintained for 7 days, and the symptoms disappeared after the treatment. Thirty-eight days after antibiotic therapy, he noticed severe abdominal pain again. He was diagnosed with diverticulitis in terminal ileum which was flare-up of inflammation. He was given antibiotic therapy again. Nine days after antibiotic therapy, laparoscopy assisted right hemicolectomy and resection of 20 cm of terminal ileum were performed. Histopathology report confirmed multiple ileal diverticulitis. He was discharged from our hospital 12 days after the surgery. Colonoscopy was performed two months after the surgery and it revealed no finding suggesting inflammatory bowel disease. Surgical treatment should be taken into account as a potential treatment option to manage the diverticulitis in the terminal ileum even though it is not perforated.

Giant enterolith in ileal diverticulum following ileoplastic bladder augmentation

INTRODUCTION

When adhesions, internal hernias, malignant intra- and retro-peritoneal neoplasms are excluded in patients presenting with new onset constipation and abdominal mass appearance after previous abdominal surgery, other causes must be considered.

PRESENTATION OF CASE

Giant enteroliths formed within ileal diverticula in the site of small bowel anastomosis may extrude and produce a palpable abdominal lump. Recent experience with such a patient is the basis of this report.

DISCUSSION

Ileal diverticula with interior enteroliths may be suspected in patients presenting with an abdominal lump following previous small bowel resection.

CONCLUSION

Open or laparoscopic assisted surgical resection of the involved segment is the treatment of choice.

CT diagnosis of ileal diverticulitis

The preoperative diagnosis of ileal diverticulitis has been reported during small-bowel series when inflammatory changes are associated with ileal diverticula. Previous CT reports of this entity have failed to establish the specific diagnosis preoperatively. We report the CT findings in a patient with right lower quadrant pain that enabled the specific diagnosis of ileal diverticulitis to be made.

Perforated ileal diverticulitis. An atypical presentation with definitive diagnosis by laparoscopy

An atypical presentation of ileal diverticulosis definitively diagnosed and treated with laparoscopy is presented. While jejunoileal diverticula are often asymptomatic, they may lead to chronic or acute symptoms. The large majority of complications secondary to small-bowel diverticulitis present with an acute abdomen similar to appendicitis but they also may appear with atypical symptoms. As a result, identification of jejunoileal diverticulosis can be quite difficult and surgery is often required in order to reach an absolute diagnosis. Surgical exploration, resection of the involved segment, and primary reanastomosis may be indicated in instances of symptomatic diverticular disease of the small bowel. Current laparoscopic techniques make this procedure well suited for both diagnosis and treatment of jejunoileal diverticula. In this report, the surgical incision was directed and limited under laparoscopic guidance while still allowing the benefit of thorough examination of the abdominal contents.

Clinical implications of jejunoileal diverticular disease

Congenital and acquired diverticula of the jejunum and ileum in the adult are unusual and occur in approximately 1 percent to 2 percent of the population. They are pulsion diverticula thought to be the result of intestinal dyskinesia. These lesions can produce a significant diagnostic and therapeutic dilemma. They are multiple in the jejunum and solitary distally and are characteristically found in 60- or 70-year-old males. The diagnosis may be confirmed with contrast studies of the small intestine, arteriography, or nuclear scan. Consider these disorders in patients with 1) unexplained gastrointestinal bleeding, 2) unexplained intestinal obstruction, 3) an unexpected cause of acute abdomen, 4) chronic abdominal pain, 5) anemia, or 6) malabsorption. Medical therapy is helpful in controlling diarrhea and anemia, while surgical therapy is reserved for hemorrhage, obstruction, perforation, or failure of medical management. Asymptomatic diverticula discovered on routine contrast studies need not be resected. At surgery, incidental diverticula should be removed when evidence of dilated, hypertrophied loops of small bowel with large diverticula is found. Intraoperative air distention will aid in diagnosis. Resection and primary anastomosis is the preferred treatment for non-Meckelian diverticula. Diverticulectomy is reserved for a Meckel's diverticulum without evidence of ulceration. An incidental Meckel's diverticulum should be removed in the presence of mesodiverticular bands or ectopic tissue. Removal of a Meckel's diverticulum is not advised in the patient with Crohn's disease but may be performed in the patient undergoing restorative proctocolectomy for ulcerative colitis.

Enteroliths of small bowel diverticula

The formation of an enterolith within a diverticulum of the small bowel is a very rare occurrence. Complications of this include abscess formation, perforation and obstruction of the small bowel. We report four cases. One patient presented with intermittent pain relieved after calculus removal. One case was an incidental finding on barium follow through but presented with obstruction of the small bowel 3 years later. One patient presented with obstruction and perforation and a fourth patient showed several asymptomatic linear calculi in a single diverticulum.

Diverticula of the terminal ileum

The radiological appearances are described of acquired ileal diverticula, seen in four patients as an incidental finding. All the diverticula were small and sited on the mesenteric border of the terminal ileum. Solitary diverticula were seen in three patients and in the fourth case there were three diverticula.

Radiologic diagnosis of jejunal diverticulitis

A patient with jejunal diverticulitis diagnosed on a barium small bowel examination is presented. Criteria for diagnosis of colonic peridiverticular inflammation were applied to the small bowel, and were correlated with computed tomographic and radionuclide scans, which showed evidence of abscess formation in the jejunal mesentery.

Acquired diverticulosis of the small intestine: case reports and literature review

Eleven cases of small bowel diverticulosis are discussed. Four patients presented with perforation, five with other symptoms attributable to this condition and in two patients diverticulosis was considered an incidental finding. A review of the literature suggests that small bowel diverticulosis may be: present in up to 1.3% of the population; associated with symptoms in approximately 50% of patients, and associated with acute surgical complications in 10% of patients. This may be a disorder of intestinal motility associated with colonic diverticulosis and related to other disorders of smooth muscle and myenteric plexus. Small bowel diverticulosis should not be regarded as a rare, incidental and inconsequential finding.

Diverticulitis of the terminal ileum: report of a case and review of the literature

In the past two decades, several reports have documented inflammatory changes in acquired diverticula of the terminal ileum and their associated complications, namely, perforation, intestinal obstruction, gastrointestinal hemorrhage, and fistulization. A comprehensive review revealed 28 cases of diverticulitis of the terminal ileum documented in the world medical literature. Only one case of internal fistula (ileovesical) has been reported previously. This report describes another patient with diverticulitis of the terminal ileum with associated perforation and jejunoileal fistula and reviews the world literature.