Midgut volvulus due to jejunal diverticula: A case report

Acute Chyloperitoneum with Small Bowel Volvulus: Case Series and Systematic Review of the Literature

Introduction: Chyloperitoneum arises from lymph leakage into the abdominal cavity, leading to an accumulation of milky fluid rich in triglycerides. Diagnosis can be challenging, and mortality rates vary depending on the underlying cause, with intestinal volvulus being just one potential acute cause. Despite its rarity, our case series highlights chyloperitoneum associated with non-ischemic small bowel volvulus. The aims of our study include assessing the incidence of this association and evaluating diagnostic and therapeutic approaches. Material and Methods: We present two cases of acute abdominal peritonitis with suspected small bowel volvulus identified via contrast-enhanced computed tomography (CT). Emergency laparotomy revealed milky-free fluid and bowel volvulus. Additionally, we conducted a systematic review up to 31 October 2023, identifying 15 previously reported cases of small bowel volvulus and chyloperitoneum in adults (via the PRISMA scheme). Conclusions: Clarifying the etiopathogenetic mechanism of chyloperitoneum requires specific diagnostic tools. Magnetic resonance imaging (MRI) may be useful in non-emergency situations, while contrast-enhanced CT is employed in emergencies. Although small bowel volvulus infrequently causes chyloperitoneum, prompt treatment is necessary. The volvulus determines lymphatic flow obstruction at the base of the mesentery, with exudation and chyle accumulation in the abdominal cavity. Derotation of the volvulus alone may resolve chyloperitoneum without intestinal ischemia.

Variability in the presentation of complicated jejunal diverticulosis

Jejunal diverticulosis is a rare disease which normally presents for the first time with acute complications, often requiring surgical intervention. The diverticulae are acquired, occurring more commonly after middle age, but their aetiology is unclear. We discuss this condition in the context of four cases which presented to our hospital as emergencies over a five year period: small bowel obstruction, gastrointestinal haemorrhage, small bowel volvulus, and visceral perforation. Our aim is to encourage clinicians to include jejunal diverticular disease as a differential diagnosis in patients with abdominal symptoms.

Small bowel volvulus due to jejunal diverticula: a rare case of acute abdomen

Jejunal diverticula are rare, and small bowel diverticular disease resulting in volvulus can lead to severe complications; as symptoms are non-specific, many patients are misdiagnosed and treated wrongly for other conditions. When a small bowel volvulus is detected, urgent surgical treatment is needed to avoid troublesome difficulties. We present the case of a 36-year-old woman who presented to the emergency room with an acute abdomen due to small bowel obstruction. After further testing, a volvulus was detected and promptly treated. Jejunal diverticula that caused a small bowel volvulus was the final diagnosis.

Jejunal Diverticulitis: A Rare Diverticular Disease of the Bowel

Diverticulosis is an out-pocketing of the bowel wall that can affect the small bowel through the large bowel. Small bowel diverticulosis is rare and not as common as colonic diverticulosis, which is an important diagnosis for hospitalizations. Moreover, jejunal diverticulosis is rare among cases of small bowel diverticulosis. Jejunal diverticulitis is one of the complications of jejunal diverticulosis that can be conservatively managed with antibiotics instead of surgery.

We report a case of a 41-year-old African American man who presented with vague epigastric pain and was diagnosed with adhesive jejunal diverticulitis upon contrast-enhanced computed tomography of the abdomen. The patient did not develop any life-threatening complications such as perforation or peritonitis, and recovered after conservative management with antibiotics. Adhesive jejunal diverticulitis with fat stranding was the distinctive finding in our patient, as he might have had multiple asymptomatic episodes.

Initial diagnostic modalities include radiography and contrast-enhanced computed tomography. Enteroclysis is the most reliable and accurate diagnostic modality, but is not available in all urgent settings. Recently, endoscopy has replaced radiological studies. Conservative management is adequate for uncomplicated cases of jejunal diverticulitis. However, surgical intervention is required in most cases of complicated jejunal diverticulosis, or mortality rates will be high.

Recurrent midgut volvulus in an 83-year-old female

We present a rare case of recurrent primary midgut volvulus in an elderly female with an interesting intraoperative finding of an abnormally elongated small bowel mesentery. This patient presented with symptoms of obstruction, including nausea, vomiting and obstipation, similar to previous episodes of volvulus for which she underwent exploratory laparotomies and reduction of the volvulus. We describe a novel use for enteropexy in which we effectively shortened the small bowel mesentery in an effort to eliminate the source of recurrent volvulus. The patient’s post-operative course was complicated by prolonged ileus requiring total parenteral nutrition. However, she had not developed signs or symptoms of bowel ischemia or recurrent volvulus at the time of this writing. Our findings suggest that enteropexy is an effective technique for preventing recurrent midgut volvulus primarily caused by abnormally elongated mesentery.

Acute abdomen caused by a large solitary jejunal diverticulum that induced a midgut volvulus. Report of a case

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Diverticuli are found throughout the gastrointestinal tract from esophagus to rectum.

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In the jejunum diverticuli are most commonly proximal, multiple and asymptomatic.

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A large solitary jejunal diverticulum caused life endangering midgut volvulus.

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In the absence of timely surgical intervention the condition would have been fatal.

Background

Jejunal diverticula are a rare subtype of false diverticula found in the gastrointestinal tract. When present, they are usually multiple, in the proximal jejunum and asymptomatic. Rarely, they can cause acute complications that can develop into an acute abdomen requiring surgical intervention. We present the rare manifestation of a single jejunal diverticulum causing midgut volvulus and bowel ischemia. Early surgical intervention with small bowel derotation allowed complete recovery.

Methods

Data regarding the case, operative intervention, and patient follow-up was prospectively accumulated with permission of the patient at an academic institution. All patient identifiers were removed. All research steps were performed under guidance outlined in the SCARE criteria.

Results

We present the case of a 78-year-old man who presented to our institution with an acute abdomen. CT imaging demonstrated a whirlpool sign without an obvious lead point. The patient was without prior surgical intervention. Urgent exploratory laparotomy revealed a midgut volvulus with associated bowel ischemia and impending infarction secondary to adhesive disease from a large single jejunal diverticulum. Derotation resulted in gradual recovery of bowel vascularity. Resection of the portion of the jejunum containing the diverticulum resulted in full clinical recovery of the patient.

Conclusions

Complications of jejunal diverticula, although rare, should be considered as part of the differential diagnosis of an acute abdomen of unknown etiology. Urgent surgical intervention was required to avoid a potential catastrophic outcome.

Jejunal diverticulosis complicated with perforation: A rare acute abdomen etiology

INTRODUCTION

Jejunal diverticulosis is a rare intestinal pathology with an incidence of 0.5-1%. While most cases are asymptomatic, 30-40% of the cases may become symptomatic with chronic abdominal pain, malabsorption, hemorrhage, diverticulitis, obstruction, abscess formation and, rarely, diverticula perforation. It is generally localized on the mesenteric side and it develops from the entry points of the vessels into the jejunum.

CASE PRESENTATION

Case 1 - A 36-year Case 2 a 75 old female patient patient was admitted to the emergency department with the complaint of widespread abdominal pain, Case 1 8 diverticules, one with diverticule perforation, was observed in the jejunum segment between the 50th and 90th centimeters after the Treitz Ligament. Case 2 - In the diverticulum 100 cm distal from the Treitz ligament, mesenteric perforation area of 4-5 mm were observed.

RESULTS

Segmentary small bowel resection and side-by-side anastomosis were performed in these cases. In the histopathological examination, the Diverticula were seen to be pseudodiverticullar lesions including herniation of the mucosa and submucosa.

CONCLUSION

Jejunoileal diverticulosis is a rare disease with life-threatening complications such as perforation, obstruction and bleeding, it is usually asymptomatic or presents with nonspecific symptoms. It should be considered in the differential diagnosis of acute abdomen.

Primary midgut volvulus in a patient with Marfan syndrome

Marfan syndrome is a mutation in the fibrillin-1 gene resulting in a connective tissue disorder primarily affecting musculoskeletal, cardiovascular and ocular systems. However, patients with Marfan's rarely manifest gastrointestinal symptoms. Midgut volvulus is abnormal twisting of small bowel around its mesentery that can result in compromising blood flow to the bowel causing intestinal ischemia and obstruction. Primary midgut volvulus is a term used when there is no underlying cause for the volvulus. This case describes an 80-year-old female with Marfan syndrome presenting with primary midgut volvulus, which preoperatively was suspected based on imaging, and later confirmed upon operative exploration. The small bowel mesentery was long with a narrow base twisted around its mesentery 360°. The long narrow base and floppy mesentery likely contributed to hypermobility leading to volvulus and small bowel obstruction. To our knowledge, this is the first reported case of primary midgut volvulus associated with Marfan's syndrome.

Volvulus

Intestinal volvulus, regardless of location, is a rare disease process, but one that requires high suspicion and timely diagnosis given the increased incidence of intestinal necrosis and potential mortality. Most patients with intestinal volvulus require some form of surgical intervention. However, over the last few decades, the work-up and management of intestinal volvulus has changed given constant advancements in technology and patient care. Most importantly, however, is recognizing the need for emergent versus more elective surgery because this influences the morbidity and mortality for the individual patient.

Small Bowel Diverticulosis and Jejunal Perforation in Marfan Syndrome

Marfan syndrome is an autosomal dominant disorder involving mutation in the FBN1 gene, which encodes fibrillin-1, a protein critical to maintain the integrity of connective tissue. A mutation in this gene can affect multiple organ systems, but it is not classically associated with gastrointestinal complications. We describe a man with Marfan syndrome with multiple small bowel diverticula leading to small intestinal bacterial overgrowth and recurrent small bowel perforations.

Complicated Jejunal Diverticulosis: Small Bowel Volvulus with Obstruction

The incidence of the diverticulum of the small bowel varies from 0.2-1.3% in autopsy studies to 2.3% when assessed on enteroclysis. It occurs mostly in patients in the 6^th decade of their life. Of all the small bowel diverticuli, jejunal diverticulum is the most common type. This rare entity is usually asymptomatic. However, they may cause chronic non-specific symptoms for a long period of time like dyspepsia, chronic postprandial pain, nausea, vomiting, borborgymi, alternating diarrhoea and constipation, weight loss, anaemia, steatorrhea or rarely lead to complications like haemorrhage, obstruction, perforation. Obstruction can be due to enterolith, adhesions, intussusception, and volvulus. The condition is difficult to diagnose because patients are generally presented with symptoms that mimic other diseases. It is important for clinicians to have awareness of this entity. Here, we present a case of multiple jejunal diverticuli with a history of repeated attacks of diverticulitis over past 20 years, which were misdiagnosed and now presented with intestinal obstruction due to volvulus of the involved segment along with mesentery around its axis. Resection of the diverticuli segment of jejunum was done with end-to-end jejuno-jejunal anastomosis. The patient is asymptomatic since 10 months of follow-up.

A rare case of large jejunal diverticulum presenting as intestinal obstruction due to small bowel volvulus

Jejunal diverticula are quite rare. Furthermore, small bowel diverticular disease resulting in volvulus can lead to complications necessitating surgical intervention. In this manuscript, we report a case of large sacculated jejunal diverticulum causing small bowel volvulus in a 40-year male. The jejunal mesentery at the base of the diverticulum was adhered to the terminal ileal mesentery forming a narrow base and complete small bowel going into volvulus by rotating around the narrow base. This case highlights a large jejunal diverticulum causing small bowel volvulus as an uncommon mechanism of complete small bowel volvulus. Although a rare entity, familiarity with jejunal diverticular disease, its complications and its management should be part of every surgeon's base of knowledge when considering abdominal pathology.