Small Intestinal Intussusception Due to Complicated Giant Jejunal Diverticulosis

Background: Jejunal diverticulosis and jejunal lipomatosis are uncommon conditions. Usually asymptomatic, they may cause severe complications in some cases. Intussusception is unusual in adults, but when diagnosed swiftly it can be treated surgically, usually with good outcome. Case presentation: We present a 60-year-old female patient with a history of chronic malnutrition and anemia, complaining of acute abdominal pain, vomiting and diarrhea. Contrast-enhanced abdominal computed tomography (CT) showed intussusception, multiple giant jejunal diverticula and multiple lipomas. The patient underwent urgent surgery, but radical treatment was not possible due to the extent of the diseases. One month later, another surgery was needed due to ileostomy obstruction caused by lipomas. The patient’s condition deteriorated due to malnutrition and concomitant metabolic disorders, which eventually led to her demise. Conclusions: Radical treatment is not always possible in an extensive jejunal disease. Prolonged malnutrition impairs postoperative healing, and therefore surgical or nutritional treatment should be considered in jejunal diverticulosis before the onset of severe complications requiring urgent surgical intervention.

Azole-resistant Candida albicans Spondylodiscitis After Bariatric Surgery: A Case Report

CASE

We present a case of azole and partial caspofungin-resistant Candida albicans spondylodiscitis, after bariatric surgery with bowel perforation. Treatment included debridement and several months of anidulafungin, complemented with antibacterial therapy because of relapse for bacterial superinfection. After treatment, the infection did not recur clinically or radiologically during one and half years follow-up.

CONCLUSION

Although C. albicans spondylodiscitis is rare, fungi should be suspected as a causative agent. Adequate history, imaging and laboratory testing, and medical and surgical treatment should be performed to successfully eradicate the infection and resolve potential neurological deficits.

Small bowel transit time of capsule endoscopy as a factor for the detection of lesions in potential small bowel bleeding

BACKGROUND

the relationship between small bowel transit time (SBTT) of the capsule endoscopy (CE) and the diagnosis of small bowel bleeding (SBB) is controversial.

OBJECTIVE

to evaluate the relationship between SBTT and CE and the identification of SBB.

MATERIAL AND METHODS

CE was divided according to SBTT into < 4 hours and ≥ 4 hours.

RESULTS

CE with SBTT ≥ 4 hours identified more angioectasias (p = 0.023), single lesions (p = 0.029) and jejunal lesions (p = 0.001) with an OR of 3.13 (95% CI, 1.61-6.10, p = 0.001) to identify the cause of SBB.

CONCLUSIONS

CE SBTT of ≥ 4 hours increases the diagnosis of SBB.

Therapeutic strategies for perforated jejunal diverticulitis. A case report

AIM

The jejuno-ileal diverticulosis is an unusual disease which affects elderly people and its complications can be fatal due to delayed diagnosis. The most frequent complication of jejunal diverticulitis is the perforation.

CASE REPORT

In this report we describe a case of elderly patient presenting with acute abdominal pain and fever. The patient underwent to an urgent exploratory laparotomy that revealed a perforated small bowel diverticulum. An intestinal resection with primary anastomosis was performed.

DISCUSSION

Jejunal diverticulosis often presents with non-specific symptoms like intermittent abdominal pain, dyspepsia, bloating or abdominal fullness and constipation. When, instead, it incurs a complication, it presents with an acute abdominal pain. The most frequent complication of jejunal diverticulitis is the perforation, followed by acute intestinal obstruction and diverticular bleeding. The diverticular perforation is associated with a high mortality, especially among elderly patients. Nowadays the mortality is reduced because of the improvement of the diagnostic, pharmaceutical and surgical protocols.

CONCLUSIONS

With this report we want to discuss about different therapeutic approaches for perforated jejuno-ileal diverticula, which depends on the severity of the disease and the general clinical condition of the patient.

KEY WORDS

Acute abdomen, Surgery, Jejunal Diverticulitis.

Acquired diverticular disease of the jejunum and ileum: imaging features and pitfalls

PURPOSE

To present radiological aspects of jejunoileal diverticulosis and its complications.

RESULTS

Jejunoileal diverticulosis is a relatively rare and underestimated condition, which mostly affects the elderly. It is frequently asymptomatic but it can lead to significant complications requiring surgical treatment. Jejunoileal diverticulosis is far less common than colonic diverticulosis. Acquired small bowel diverticula are often numerous but the complication rate is low. Acute diverticulitis is the most frequent complication; its classic presentation involves the jejunum and is often non-severe. Diverticular hemorrhage is the second most common complication; CT scan examination is essential to determine the accurate topography of the pathological diverticula. Small bowel obstruction can occur through several mechanisms: adhesions, enterolith, and intussusception. Extra-intestinal gas without perforation and "pseudo-ischemic" appearance are non-pathological conditions that are important to diagnose in order to avoid surgery.

CONCLUSION

Jejunoileal diverticulosis usually does not show any symptoms but can lead to diagnostic challenges requiring evaluation by CT. CT scan signs of these complications and some pitfalls must be known.

[Jejunal phlebectasia as a cause of massive gastrointestinal haemorrhage]

Vascular abnormalities of the gastrointestinal tract are a common cause of gastrointestinal bleeding. Most of them are located within the reach of the upper endoscopy or colonoscopy, although once discarded, it forces to consider small bowel as the source of bleeding. The successful management of a gastrointestinal bleeding depends mainly on the timely location of the source of bleeding. Nevertheless this task can be difficult when the cause is not within the reach of conventional methods. We present a case of a 21 year-old men in which the diagnosis of bleeding yeyunal phlebectasia was made by the findings of the capsule endoscopy and laparoscopy.

Primary gastrointestinal amyloidosis with gastrointestinal hemorrhage and intestinal pseudo-obstruction: a report of a rare case

Amyloidosis is a syndrome involving amyloid protein deposition in various organs, resulting in organ dysfunction. Symptoms of gastrointestinal amyloidosis are usually nonspecific, such as diarrhea and body weight loss. We, here, report a patient who presented to the hospital with simultaneous hematemesis, melena, and intestinal pseudo-obstruction, leading to a diagnosis of primary gastrointestinal amyloidosis based on computed tomography (CT) and endoscopic findings. CT showed diffuse wall thickening from the duodenum to the jejunum, jejunal dilation, and fluid accumulation throughout the gastrointestinal tract. Upper gastrointestinal endoscopy revealed duodenal mucosal edema, jejunal dilation, and small hemorrhages from jejunal mucosal erosion. The definite diagnosis was done based on biopsy results. This report describes the early diagnosis of gastrointestinal amyloidosis based on CT and endoscopy findings.

Complicated duodenal-jejunal diverticulosis: case report

BACKGROUND

Bleedings such as melaena are related to diseases in the upper gastrointestinal tract. In 0.06% - 5% of cases these incidents are due to the presence of diverticula of the small intestine, which are asymptomatic and unrecognized in most patients and are only fully diagnosed in cases when complications occur.

CASE REPORT

An 88-year old male patient presented with severe anaemia, asthenia and melaena in the previous days. An esophagogastroduodenoscopy (EGDS) was performed with evidence of stenosis in the second part of the duodenum and a blood clot in the posterior wall without signs of active bleeding. A complete CT scan was carried out of the thorax, abdomen and pelvis using a contrast medium, which revealed a dilation of the stomach and of the first part of the duodenum with a diverticulum of the second. On the fourth day following admission the patient suffered a haemorrhagic shock and underwent an emergency surgical procedure with a bleeding diverticulum on the posterior wall of the duodenum tightly adhering to the pancreas being found. Therefore an atypical duodenal-jejunal resection was performed using a gastrojejunal Roux-en-Y bypass and the closure of the duodenal stump.

CONCLUSION

Diverticulosis of the duodenum and small intestine is considered a rare disease. According to the literature, treatment should be conservative, and surgical options considered only in those very rare cases of complicated and life-threatening diverticulosis.

Jejuno-ileal diverticulosis : a review of literature

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. The majority of cases are discovered incidentally during radiological investigations. Based on a case of a 77 year old woman with jejunal diverticulitis, the current literature about small bowel diverticulosis is reviewed. A jejunoileal diverticulum is usually uncomplicated and can be treated conservatively. Serious complications that require surgery can occur. Abdominal CT is the preferred diagnostic tool.

Massive intussusception caused by a solitary Peutz-Jeghers type hamartomatous polyp

Intussusception is a rare cause of intestinal obstruction in adults and represents a diagnostic challenge for the surgeon. In the majority of cases, presenting symptoms are not specific, making preoperative diagnosis difficult. Several medical conditions may cause intestinal intussusception. We present the case of a 16-year-old female patient with intussusception due to a hamartomatous Peutz-Jeghers type polyp. This is an extremely rare case in which the first manifestation of the intestinal polyp was jejunojejunal intussusception very close to the duodenojejunal junction, with a necrotic intussusceptum about 50 cm long. The patient was treated successfully with enterectomy and end-to-end anastomosis. Postoperative course was uneventful and the patient is currently under gastroenterological and genetic investigation to exclude the diagnosis of Peutz-Jeghers syndrome.

Ectopic pancreatic tissue in the wall of the small intestine: Two rare case reports

RATIONALE

Ectopic pancreas, which is a kind of rare congenital disease, forms during embryonic development. It can occur throughout the whole gastrointestinal tract, but has a low tendency to develop in the wall of the small intestine. It is easy for patients with ectopic pancreases to be misdiagnosed because the symptoms are untypical and can vary.

PATIENT CONCERNS

In the present study, we reported two rare cases of ectopic pancreatic tissue in the wall of the small intestine, which presented with obvious abdominal pain and distention.

DIAGNOSIS

The laboratory tests and computed tomography (CT) scans didn't reveal any evidence of ectopic pancreas.

INTERVENTIONS

The two patients received small intestine masses resection and intestinal anastomosis.

OUTCOMES

During surgery, an intestinal mass with a diameter of 4.0 cm was found in the first patient. An intestinal mass with a diameter of 0.8 cm, jejunum perforation, and diffuse peritonitis were found in the second patient. Histological analyses of the dissected intestinal masses confirmed them as ectopic pancreatic tissue. Interestingly, for the second patient, the intestinal perforation and diffuse peritonitis were not induced by the ectopic pancreas, but by a jujube pit that was found in the perforated site of the intestine.

LESSONS

Our study demonstrated that an ectopic pancreas should be considered in cases of untypical abdominal symptoms with intestinal masses.

[Complicated jejunoileal diverticular disease: a 12 cases' serie and literature review]

OBJECTIVE

To perform a retrospective analysis of a series of complicated JID (jejunoileal diverticulitis) cases surgically treated in our service during the period from 2002 to 2015.

MATERIALS AND METHODS

We treated 12 cases of jejunoileal complicated diverticulosis. 7 women and 5 men. The mean age was 76 years. The clinical presentation in all cases was acute abdominal pain, one with gastrointestinal bleeding. All cases had leukocytosis, neutrophilia and increased acute phase reactants. All patients underwent emergency abdominal CT.

RESULTS

In 11 cases, there was consistency between imaging studies and surgical findings. Diverticula were located: jejunum (9) and ileum (3). Urgent exploratory laparotomy was always done and findings were: diverticular perforation with peritonitis (7 cases), diverticular perforation with abscess (4 cases) and in one case an ischemic area with diverticular perforation after embolization. Intestinal resection and anastomosis was performed in all cases. There were no patients, in which the diagnosis of diverticulosis jejunoileal was previously known. Complications were: Clavien I (2), Clavien IIIa (1), Clavien IVb (1), Clavien V (1).

CONCLUSIONS

Jejunoileal diverticulitis is a rare entity, usually the first sign of onset of diverticular disease not previously known. Abdominal CT is of great diagnostic value. Resection of the affected segment is the treatment of choice.

Gastrointestinal Mucormycosis of the Jejunum in an Immunocompetent Patient: A Case Report

RATIONALE

Gastrointestinal Mucormycosis (GIM) is a kind of opportunistic fungal infection with poor prognosis. It usually occurs in patients with immune deficiency. We reported a case of immunocompetent male patient.

PATIENT CONCERNS

This patient was presented as abdominal distension and gastrointestinal bleeding.

DIAGNOSES

A variety of hemostatic methods was ineffective to stop the bleeding. The patient finally received laparotomy, and the jejunum lesions were found.

INTERVENTIONS

Pathological examination confirmed it to be gastrointestinal mucormycosis in jejunum.

OUTCOMES

However, after systemic anti-fungi therapy, the patient died of septic shock.

LESSONS

The diagnosis mainly relies on pathological examination. Early diagnosis and early application of systemic amphotericin B liposome were fundamental for improving the prognosis.

[Digestive bleeding due to jejunal diverticula: A case report and literature review]

BACKGROUND

Bleeding from the small bowel is a rare pathology that represents 5-10% of gastrointestinal bleeding; 0.06% to 5% of cases are due to the presence of diverticula of the small intestine. The majority of diverticula are asymptomatic and present symptoms when there is a complication.

CLINICAL CASE

We present the case of a 53-year-old male with a history of chronic renal failure and hypertension. While he was hospitalized due to cerebrovascular disease he recurrently presented lower gastrointestinal bleeding that required blood transfusion on several occasions. Upper gastrointestinal bleeding and colon bleeding were ruled out by endoscopy. It was not until an arteriography was performed that we identified bleeding at proximal jejunum level, and therefore we performed a laparotomy. We present the studies and management that the patient underwent.

CONCLUSION

Although jejunal diverticula are rare, they must be included in the differential diagnosis of lower gastrointestinal bleeding when present in a patient. Arteriography is a study of great use in locating the site, provided the bleeding is more than 0.5ml/minute.

A case of gastrojejunocolic fistula with steatohepatitis

A man in his 30s, who had undergone retrocolic Billroth II reconstruction for perforated duodenal ulcer, presented with watery diarrhea for 2 years and suspected fatty liver. He was referred to our hospital for management of chronic diarrhea, weight loss, hepatopathy and hypoalbuminemia. Initial upper and lower gastrointestinal endoscopies were negative. Since a small bowel lesion was suspected, peroral single-balloon enteroscopy was performed, which identified feces-like residue near the Billroth II anastomotic site and a connection to the colon separate from the afferent and efferent loops. Transanal single-balloon enteroscopy identified a fistula between the gastrojejunal anastomosis and transverse colon, with the scope reaching the stomach transanally. Barium enema confirmed flow of contrast medium from the transverse colon through the fistula to the anastomotic site, allowing the diagnosis of gastrojejunocolic fistula. Liver biopsy showed relatively severe steatohepatitis (Brunt's classification: stage 2-3, grade 3). Resection of the anastomotic site and partial transverse colectomy were performed to remove the fistula, followed by Roux-en-Y reconstruction. Postoperatively, watery diarrhea resolved and the stools became normal. Hepatopathy and hypoproteinemia improved. One year later, liver biopsy showed marked improvement of steatosis. This case demonstrated marked improvement of both diarrhea/nutritional status and steatohepatitis after treatment of gastrojejunocolic fistula, suggesting that the fistula caused non-alcoholic steatohepatitis.

Intravascular Papillary Endothelial Hyperplasia of the Jejunum

Intravascular papillary endothelial hyperplasia is considered to be an unusual form of thrombus organization that is marked by an excessive papillary endothelial proliferation. This lesion has the propensity to occur in the skin and the subcutis. Occurrence in the gastrointestinal tract is very rare. The authors report an exceptional case of a 20-year-old young woman with intravascular papillary endothelial hyperplasia in the jejunum. The patient was referred to the hospital with a 1-week history of melena. The lesion did not recur after surgery. Histopathological examination revealed a papillary endothelial hyperplasia with an underlying arteriovenous malformation.

Recurrent Aortoenteric Fistula: Two Different Bridge Solutions

A “recurrent” aortoenteric fistula (AEF) is very rare and in literature anecdotic. Currently, graft excision and extra-anatomic bypass are considered the treatments of choice, but are associated with significant mortality and morbidity. Herein, we describe the case of a “recurrent” AEF treated before definitive extra-anatomic bypass, by two different, staged bridge solutions: allograft in situ replacement and endovascular grafting. At 1, 3 and 6-month follow-up, the patient was asymptomatic and normally active.

Successful Endoscopic Treatment of an Actively Bleeding Jejunal Dieulafoy's Lesion

Although small bowel endoscopy is commonly performed, cases of ongoing bleeding from small bowel lesions have not been commonly encountered. In the present report, we describe a case of successful endoscopic treatment of an actively bleeding jejunal Dieulafoy's lesion in a 79-year-old man with persistent anemia and melena. Capsule endoscopy indicated active bleeding in the jejunum. Thereafter, double-balloon endoscopy-performed via the oral approach-showed active bleeding from a jejunal Dieulafoy's lesion, which was treated using argon plasma coagulation and hemoclips. The melena subsequently resolved, and the patient's condition improved after the endoscopic treatment.

[Perforated jejunal diverticulitis]

Jejunal diverticulosis is a rare disorder and the course of the disease is mostly asymptomatic. Surgical treatment is generally needed in case of complications in the acute phase of the disease, when the disease symptoms most commonly include bleeding and perforation. Jejunum is difficult to examine using the common visualization methods and endoscopic methods. The authors present case reports of a 92 years old female patient and a 66 years old male patient operated for perforated jejunal diverticles.Key words: acute abdomen jejunal diverticulitis perforation.

Small bowel volvulus with jejunal diverticulum: Primary or secondary?

Small bowel volvulus, which is torsion of the small bowel and its mesentery, is a medical emergency, and is categorized as primary or secondary type. Primary type often occurs without any apparent intrinsic anatomical anomalies, while the secondary type is common clinically and could be caused by numerous factors including postoperative adhesions, intestinal diverticulum, and/or tumors. Here, we report a rare case of a 60-year-old man diagnosed with small bowel volvulus using multidetector computed tomography (MDCT) angiography. Further discovery by laparotomy showed one jejunal diverticulum, longer corresponding mesentery with a narrower insertion, and a lack of mesenteric fat. This case report includes several etiological factors of small bowel volvulus, and we discuss the possible cause of small bowel volvulus in this patient. We also highlight the importance of MDCT angiography in the diagnosis of volvulus and share our experience in treating this disease.

Melena as presentation of primary small intestine inflammatory myofibroblastic tumor in an adult woman. A case report

INTRODUCTION

Inflammatory myofibroblastic tumor (IMT), also known as inflammatory pseudotumor, plasma cell granuloma or inflammatory myofibroblastoma, is characterized histopathologically by myofibroblastic spindle cells with inflammatory cell infiltrates ( plasma cell, lymphocytes and eosinophils). Inflammatory myofibroblastic tumor is tipically seen in children or young adults and is most commonly localized in the lung, but it can occur anywhere in the body.

CASE REPORT

We present a case in a young woman with severe acute G.I. bleeding, an uncommon presentation of IMT in adults. The patient was admitted to the emergency department for melena. MRI showed a distal jejunum hypervascular mass. Other exams were negative. Surgical excision was recommended, so the patient underwent surgery with complete removal of the tumoral mass. No adjuvant therapy was employed and the patient is asymptomatic after 6 months of follow-up.

DISCUSSION

IMT is an rare lesion that mimics malignancy and is accompanied by various clinical manifestations. The treatment of choice is believed to be complete surgical excision and long term follow up.

KEY WORDS

Anemia, Inflammatory myofibroblastic tumor (IMT), Small intestine, Surgery.

[Enterolith ileus complicating jejunal diverticulosis]

Jejunal diverticulosis is uncommon and usually asymptomatic. One of the rarest complications is ileus due to migrated enteroliths formed in the diverticula. We present a case of a 95-year-old man admitted with small bowel obstruction. During operation extensive jejunal diverticulosis was found along with intraluminal enteroliths causing obstruction of the ileum. An enterotomy was made and three 3 × 3 × 2 cm enteroliths were removed. The patient was discharged on the sixth post-operative day. Less than 50 similar cases have been reported worldwide.

[A case of enterolith ileus secondary to acute pancreatitis associated with a juxtapapillary duodenal diverticulum]

A 63-year-old woman with abdominal pain was referred to our hospital. Her pancreatic enzymes were elevated, and an abdominal computed tomography (CT) scan showed an enlarged pancreas, consistent with pancreatitis, and gas collection containing an impacted stone adjacent to Vater's papilla. This finding raised the suspicion of a duodenal diverticulum. A subsequent ERCP showed a juxtapapillary duodenal diverticulum (JPDD) filled with calculi and pus. The pancreatitis improved with 2 weeks of conservative treatment. Subsequently, the patient underwent resection of the uterus and bilateral adnexa to remove a large ovarian cyst that was also identified on the admission CT scan. On the third postoperative day, she developed abdominal pain and vomiting. CT revealed small bowel obstruction caused by an enterolith expelled from JPDD. Enterotomy was performed to remove the stone. To our knowledge, only three similar cases have been previously reported in Japan.

Dysbiosis-induced intestinal inflammation activates tumor necrosis factor receptor I and mediates alcoholic liver disease in mice

Intestinal barrier dysfunction is an important contributor to alcoholic liver disease (ALD). Translocated microbial products trigger an inflammatory response in the liver and contribute to steatohepatitis. Our aim was to investigate mechanisms of barrier disruption after chronic alcohol feeding. A Lieber-DeCarli model was used to induce intestinal dysbiosis, increased intestinal permeability, and liver disease in mice. Alcohol feeding for 8 weeks induced intestinal inflammation in the jejunum, which is characterized by an increased number of tumor necrosis factor alpha (TNF-α)-producing monocytes and macrophages. These findings were confirmed in duodenal biopsies from patients with chronic alcohol abuse. Intestinal decontamination with nonabsorbable antibiotics restored eubiosis, decreased intestinal inflammation and permeability, and reduced ALD in mice. TNF-receptor I (TNFRI) mutant mice were protected from intestinal barrier dysfunction and ALD. To investigate whether TNFRI on intestinal epithelial cells mediates intestinal barrier dysfunction and ALD, we used TNFRI mutant mice carrying a conditional gain-of-function allele for this receptor. Reactivation of TNFRI on intestinal epithelial cells resulted in increased intestinal permeability and liver disease that is similar to wild-type mice after alcohol feeding, suggesting that enteric TNFRI promotes intestinal barrier dysfunction. Myosin light-chain kinase (MLCK) is a downstream target of TNF-α and was phosphorylated in intestinal epithelial cells after alcohol administration. Using MLCK-deficient mice, we further demonstrate a partial contribution of MLCK to intestinal barrier dysfunction and liver disease after chronic alcohol feeding.

CONCLUSION

Dysbiosis-induced intestinal inflammation and TNFRI signaling in intestinal epithelial cells mediate a disruption of the intestinal barrier. Therefore, intestinal TNFRI is a crucial mediator of ALD.

Usefulness of Small Intestinal Endoscopy in a Case of Adult-onset Familial Mediterranean Fever Associated with Jejunoileitis

A 66-year-old Japanese man consulted our institution due to paroxysmal and repetitive bouts of fever and abdominal pain that had persisted for more than one week. Capsule and double-balloon endoscopy (DBE) showed petal-shaped mucosal redness with white hemming in the jejunum and ileum, and histopathology of the biopsy specimens revealed villous atrophy and cryptitis with extensive severe neutrophil infiltration. A genetic examination disclosed compound heterozygous MEFV mutations (E84K, P369S), and familial Mediterranean fever was diagnosed. Treatment with colchicine and infliximab was very effective in inducing the complete disappearance of symptoms and normalization of the endoscopic findings. To the best of our knowledge, this is the first report to describe the findings of small intestinal endoscopic images obtained using capsule and DBE.

Non-operative successful management of a perforated small bowel diverticulum

Jejunoileal diverticula are rare and generally asymptomatic. In the few cases of patients who develop complications such as diverticulitis, perforation, obstruction, and/or hemorrhage, conventional treatment consists of surgical resection. We describe a case of perforated jejunoileal diverticulum with localized abscess and highlight the merits of surgical vs medical management. The patient is a 77-year-old male who presented with sharp, constant abdominal pain just inferior to the umbilicus. Administration of intravenous antibiotics results in complete and long-term resolution of the patient’s symptoms. In this report, we establish a framework for safely treating perforated small bowel diverticulum without surgical exploration.

[Jejunal diverticulitis as the cause of acute abdomen]

We present two patients with jejunal diverticulitis. Diverticula in jejunum and ileum are very rare, occurring with an incidence of 0.07-2% in the gastrointestinal tract. They are often associated with unspecific symptoms as intermittent abdominal pain, nausea and diarrhoea. The treatment of mild diverticular disease is intravenous fluids and antibiotics. If there is an occurrence of peritonitis as a complication of jejunal diverticulitis, laparatomy may be indicated. Both of the patients received a conservative treatment with intravenous fluids and antibiotics with good response.

Active gastrointestinal diverticulum bleeding diagnosed by computed tomography angiography

A diverticulum is a bulging sack in any portion of the gastrointestinal tract. Small intestine diverticular disease is much less common than colonic diverticular disease. The most common symptoms include non-specific epigastric pain and a bloating sensation. Major complications include diverticulitis, gastrointestinal bleeding, acute perforation, intestinal obstruction, intestinal perforation, localized abscess, malabsorption, anemia, volvulus and bacterial overgrowth. We report one case of massive jejunal diverticula bleeding and one case of massive colonic diverticula bleeding, both diagnosed by acute abdominal computed tomography angiography and treated successfully by surgery.

Dynamic contrast-enhanced MRI findings of acute pancreatitis in ectopic pancreatic tissue: case report and review of the literature

CONTEXT

Acute pancreatitis in ectopic pancreatic tissue is an uncommon cause of acute abdominal pain and can be difficult to diagnose on imaging. Our aim is to raise awareness and aid in the diagnosis of this entity by highlighting helpful dynamic contrast-enhanced MRI imaging findings.

CASE REPORT

We report a 51-year-old man with acute onset epigastric pain presented to ER. With the presence of elevated serum lipase, the clinical diagnosis of acute pancreatitis was made. Contrast enhanced CT demonstrated normal pancreas and a focal mass at the duodenojejunal flexure, mimicked a neoplasm. Subsequent dynamic contrast enhanced MR images demonstrated enhancement pattern of the lesion similar to the native pancreatic tissue enhancement, a finding raised the possibility of acute pancreatitis in ectopic pancreatic tissue, but tumor was not excluded. Finally, patient undergone surgical bowel resection including the suspected mass that was proved as an ectopic pancreatic tissue on microscopic examination.

CONCLUSION

We concluded that findings on dynamic contrast enhanced MR imaging can be characteristic and diagnostic of acute pancreatitis in ectopic pancreatic tissue in the appropriate clinical setting.

Emergency management of complicated jejunal diverticulosis

Jejunal diverticulosis is a rare condition that is usually found incidentally. It is most often asymptomatic but presenting symptoms are nonspecific and include abdominal pain, nausea, diarrhea, malabsorption, bleeding, obstruction, and/or perforation. A retrospective review of medical records between 1999 and 2012 at a tertiary referral center was conducted to identify patients requiring emergency management of complicated jejunal diverticulosis. Complications were defined as those that presented with inflammation, bleeding, obstruction, or perforation. Eighteen patients presented to the emergency department with acute complications of jejunal diverticulosis. Ages ranged from 47 to 86 years (mean, 72 years). Seven patients presented with evidence of free bowel perforation. Six had either diverticulitis or a contained perforation. The remaining five were found to have gastrointestinal bleeding. Fourteen of the patients underwent surgical management. Four patients were successfully managed nonoperatively. As a result of the variety of presentations, complications of jejunal diverticulosis present a diagnostic and therapeutic challenge for the acute care surgeon. Although nonoperative management can be successful, most patients should undergo surgical intervention. Traditional management dictates laparotomy and segmental jejunal resection. Diverticulectomy is not recommended as a result of the risk of staple line breakdown. The entire involved portion of jejunum should be resected when bowel length permits.

Blue rubber bleb nevus syndrome coexisted with intestinal intussusception: a case report

Blue Rubber Bleb Nevus Syndrome (BRBNS) is an uncommon congenital disorder characterized by sporadic venous malformation which mainly occurs in skin and alimentary canal. Here, we report a BRBNS patient with concomitant intestinal intussusception who diagnosed by intraoperative endoscopy and ultimately managed using surgical resection. A 19-year-old boy was referred to urgent surgery for acute melena and stomachache. He had used to be a long-term iron user for undiagnosed chronic anemia and papules. Abdominal CT on admission demonstrated the presence of intestinal intussusception. The following exploratory laparotomy and intraoperative endoscopy revealed multiple gastrointestinal hemangiomas. The postoperative course was uneventful and pathological examination certified multiple cavernous hemangiomas in the resected gastrointestines.

Adult bowel intussusception: presentation, location, etiology, diagnosis and treatment

Bowel intussusception is rare in adults but common in children. Almost 90% of adult intussusceptions are secondary to a pathologic condition and the clinical picture can be very aspecific and challenging. In this review we discuss the symptoms, location, etiology, characteristics, diagnostic methods and treatment strategies of this rare and enigmatic clinical entity in adults. We have to highlight the high index of suspicion that is necessary for the operating surgeon, when dealing with acute, subacute or chronic abdominal pain in adults, because any misinterpretation may result in unfavorable outcomes.

[Adult transient intestinal intussusception: can abdominal CT guide resolution?]

The purpose of this study was to evaluate the adult transient intestinal intussusceptions on CT before and after the administration of gastrointestinal contrast material. We evaluated two different gastrointestinal contrast materials: hyperdense and hypodense. In all cases the gastrointestinal contrast agent solved the invaginations. In the group of patients treated with hypodense contrast medium relapses occurred in the short and long term; no recurrence was observed in the other group. CT is useful in the recognition of intestinal intussusception. The gastrointestinal contrast agent could define the real transience of intussusceptions and hyperdense contrast agent could be more effective in short and long term resolution.

Chylous jejunal cyst causing volvulus in a child: case report and literature review

Chylous jejunal cysts are extremely rare entities and if not diagnosed promptly may lead to severe complications like bowel obstruction, loss of small bowel and even death. We present the case of a 4 year-old-male referred to our institution with severe abdominal pain, constipation, abdominal distention and radiological findings of large amount of fluid in the lower abdomen with associated bowel obstruction. Operative findings were that of large chylous jejunal cyst causing segmental volvulus. Resection of the involved jejunal segment and cyst along with bowel detorsion was undertaken. Literature review on the subject follows.