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Case Reports

Primary acquired jejunoileal : A rare presentation

Biswajit Mohapatra Department of Surgery, Vesaj Patel Hospital and Research Centre, Rourkela, Orissa, India.

ABSTRACT Primary jejunoileal diverticulitis is a very rare disorder found only in 0.2 to 1.1% of the adult population. The incidence increases with age, peaking in the sixth and seventh decades. In this case report I present a 72-year-old patient who developed intestinal obstruction due to jejunoileal diverticulitis.

KEY WORDS Jejunoileal diverticulitis, Obstruction

How to cite this article: Mohapatra B. Primary acquired jejunoileal diverticulitis, a rare presentation. Indian J Surg 2004;66:289-90.

INTRODUCTION patient started complaining of and stopped passing flatus on the 3rd evening. The patient Small bowel diverticulitis occurs less frequently than was treated conservatively for the next 3 days without large bowel diverticulitis. Acquired jejunoileal any improvement. X-ray abdomen standing view diverticulas are uncommon and asymptomatic in the showed multiple air fluids levels, suggestive of majority of patients. Chow et al have suggested that established intestinal obstruction. On the 7th over 90% patients with jejunoileal diverticula may postoperative day exploratory laparotomy was done manifest non-specific symptoms. Serious complications to relieve the obstruction. Multiple inflamed acquired of jejunoileal diverticulitis include massive jejunoileal diverticula were found on the mesenteric haemorrhage, small bowl obstruction, , border (Figure 1). Obstruction was due to adhesion of perforation, and sepsis. Because of its delayed one of the inflamed jejunal diverticulums with the distal presentation and diagnosis it carries a very high ileal mesentery, causing an acute bent. Simple reported mortality of 25 to 30%, considering most of adhesiolysis was done and the abdomen was closed these patients are elderly and have multiple co-morbid with drains. Patient’s recovery was smooth and was diseases.1 discharged on the 8th day of the second operation.

CASE REPORT DISCUSSION

A 72-year-old patient underwent Freyer’s This case study allows for a review of primary acquired prostadectomy for benign prostatic hyperplasia. The jejunoileal diverticula causing intestinal obstruction. operation was uneventful. The patient developed high- They are formed by herniation of mucosa and grade fever with rigor and chills after 6 hours of submucosa through the muscular wall of the intestinal operation and was treated with dexamethasone 8 wall. They are always multiple and occur on the mg.stat and cold sponging. The total count was 16000/ mesenteric border. They are technically c mm on investigation. The patient was on Ceftriaxone, pseudodiverticula as they lack the muscular coat. Their Amikacine and Metronidazole. The patient passed flatus size varies from a few millimetres to more than 10 cm.2 on the 2nd day and oral liquid was started. But the They tend to be larger and higher in number in the

Address for correspondence: B. Mohapatra, Room No. 1, Vesaj Patel Hospital H/4, Civil Township Rourkela - 769004, Orissa, India. E-mail: [email protected] Paper Received: August 2003. Paper Accepted: September 2003. Source of Support: Nil.

Indian Journal of Surgery 2004 Volume 66 Issue 5 (October) 289 Case Report

The management of primary jejunoileal diverticulitis is quite variable, depending on the presenting symptoms. Initial management is always a conservative approach with antibiotics and bowel rest. The definitive management of perforated diverticulitis is surgical resection of the small bowel segment. In cases of intestinal obstruction not responding to conservative management, laparotomy is indicated. However, simple diverticulectomy is strongly discouraged in the literature due to a very high rate of leakage. Because of the mesenteric location of these diverticula, simple diverticulectomy may impair blood flow and lead to anastomotic leakage.1 The surgical therapy of obstruction due to volvulus consists of simple untwisting or resection of the involved Figure 1: Inflammed jejunoileal diverticuli segment. Sometimes simple adhesiolysis is needed proximal and they are fewer in number and to relieve the obstruction, which was done in my smaller in size towards the distal . patient.

5 Sixty per cent of patients with jejunoileal Cross and Synders reported the use of laparoscopically are asymptomatic. Thirty per cent develop a symptom directed small bowel resection for jejunoileal complex described by Edwards as flatulent dyspepsia, diverticulitis with perforation. The laparoscope was consisting of epigastric pain, abdominal discomfort, and utilised to diagnose the disease and to run the small flatulence an hour after a meal.3 The remaining 10% bowel. A 5-cm incision was given directly over the develop complications requiring surgery. pathology and the involved segment was exteriorised to do the resection and extra corporeal anastomosis. Two main radiological methods to diagnose jejunoileal diverticulitis are enteroclysis and contrast enhanced C.T. In conclusion, jejunoileal diverticulitis should not be scan of abdomen.2 During enteroclysis a water-soluble regarded as an insignificant entity. It is essential to contrast medium is injected into the proximal include the jejunoileal diverticula in the differential th through a tube. Radiological finding diagnosis of abdominal pain in patients of the 6 and th includes saccular outpouching at the mesenteric border 7 decades, as a delayed diagnosis increases the of the . The CT scan findings generally mortality rate significantly in these groups. Liberal use demonstrate an inflammatory mass adjacent to the of C.T. scans for the work-up of abdominal pain will small bowel loop. Small air bubbles within the mass limit the number of missed diagnoses. can be seen. REFERENCES Mechanical intestinal obstruction occurs in 2.3 to 4.6% 4 1. De Beer E, Grammatikakis j, Christodoulakis M, Tsiftsis D. The of cases of jejunoileal diverticulitis. This may be the clinical significance of acquaired jejunoileal diverticula. Am J Gas- result of pressure on the intestinal wall from distended troenterology 1998;93:2523-8. diverticula, stricture or adhesion from recent or past 2. Janus C, Patel G. Radiological case of the month. Appl Radiol diverticulitis, intussusceptions at the site of 2002;31:34-5. 3. Katz L. Cantor B, Fink S. A case Report of jejunal diverticulitis diverticulum, enteroliths developed within the Causing haemolytic uremic syndrome. Department of surgery at diverticula, or volvulus of the diverticula-containing Saint Barnabas- publication. segment. The involved segment with its diverticula 4. Harris LM, Volpe CM, Doerr RJ. Small bowl Obstruction Second- ary to Enterolith Impaction Complicating Jejunal diverticulitis. Am filled with fluid is heavier then the non-involved part. j gastroenterol 1997;92:1538-40. This loaded segment swings like a pendulum to initiate 5. Cross MJ, Snyder SK. Laparoscopic-Directed Small Bowel Resec- the volvulus. In my case adhesion of the inflamed tion for Jejunal Diverticulitis With Perforation. J of Laparoendoscopic Surg 1993;3:47-9. diverticuli to the adjacent mesentery causing intestinal 6. Chow DC, Babaian M, Taubin HL, Jejunoileal diverticula. Gastro- obstruction. enterologist. 1997;5:78-84. Medline.

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