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Complicated Diffuse Giant Small Bowel Diverticulosis: a Case Report

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Complicated Diffuse Giant Small Bowel Diverticulosis: a Case Report Complicated Diffuse Giant Small Bowel Diverticulosis: A Case Report Somayya Ja’afreh MD*, Jehad Odeh MD** ABSTRACT Small bowel diverticulosis is a rare entity that occurs later in life. The majority of diagnosed cases is asymptomatic and is incidentally found in radiological examinations or laparotomy. The significance of this rare disease entity is that it might present with acute life threatening complications. Here, we present a case of diffuse giant small intestine diverticulosis that was complicated with intestinal volvulus. Key words: Acute abdomen, Jejunal diverticula, Small bowel diverticulosis JRMS June 2013; 20(2): 71-75 /DOI: 10.12816/0000082 Introduction Case report Small Bowel Diverticulosis (SBD) is an A 61-year-old female patient presented late at acquired pathology that results in thin walled night to the Emergency room in Prince Ali Bin sacs composed of mucosa and submucosa. These Al-Hassan Hospital with severe acute abdominal occur at the mesenteric border of the bowel pain and vomiting of 2 days duration. The patient where the vasa brevia pierces the muscularis was medically free with no past history of layer resulting in weak points in the wall. It is a surgical intervention. No previous similar attacks rare entity with a reported prevalence of 0.3% - were present. The patient was not receiving any 1.9% on small bowel studies and 0.3% - 1.3% at medications at time of presentation. On autopsy.(1,2) Diverticula of the duodenum, examination, she was alert and oriented with jejunum and ileum, apart from Meckel's, rarely abdominal distension and excessive bowel produce symptoms.(3) They are most frequent sounds. The digital rectal examination was free. later in life occurring during the sixth to the Low grade fever was recorded (37.9oC). The seventh decades of life.(4) Although once laboratory results were as following: White blood considered to be of little clinical significance, cell count (WBCs) 14.500/uL, and hematocrit SBD may be symptomatic, and complications 29%. Erect plain abdomen radiograph showed such as malabsorption, bacterial overgrowth, significant dilatation of small bowel loops with diverticulitis, haemorrhage and intestinal multiple air fluid levels (Fig 1A). A provisional obstruction have become well known.(5,6) A diagnosis of acute small intestinal obstruction recent study conducted in Pakistan concluded was made and the patient was admitted that complicated jejunal diverticula are very rare accordingly. Conservative management was with the most common complication being initiated with insertion of a nasogastric tube. perforation followed by inflammation.(7) Abdominal ultrasound scan showed grossly From the Departments of: *Radiology, Prince Ali Bin Al-Hessian Hospital, (PAHH), Karak-Jordan **General Surgery, PAHH Correspondence should be addressed to Dr. S. Ja’afreh, PAHH, Karak-Jordan Manuscript received May 2, 2012. Accepted August 2, 2012 JOURNAL OF THE ROYAL MEDICAL SERVICES 71 Vol. 20 No. 2 June 2013 A B Fig 1: (A) Erect plain abdomen radiograph obtained on admission showing dilated small bowel loops with multiple air fluid levels. (B) Scout view obtained next day to admission showing grossly dilated small bowel loops mainly in the centre of the abdomen. A B C Fig 2: Multiple sections of abdominal CT scan showing (A) dilated small bowel loops with multiple air fluid levels and intraperitoneal free fluid, (B) grossly dilated bowel and pneumoperitoneum, (C) Whirl sign. Fig 3: Multiple diverticula with dusky appearing dilated small bowel loops during operation. dilated small bowel loops with excessive bowel only fluid filled without any air element, while motion. Free intraperitoneal fluid was seen at others showed multiple air fluid levels (Fig 2A, time of examination. B). Evidence of intraperitoneal free fluid and Abdominal CT scan was done on the next day pneumoperitoneum was also noted (Fig 2A). of admission. Scout view showed grossly dilated "Whirl sign" which is highly suggestive of small bowel loops (Fig 1B). It revealed grossly midgut volvulus, a rare yet life threatening dilated small bowel loops some of them were surgical emergency, was reported (8) (Fig 2C). 72 JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 20 No. 2 June 2013 Accordingly a diagnosis of small bowel volvulus was made. The patient was operated on immediately. Laparotomy confirmed the presence of volvulus with "dusky "appearance and perforations and enumerable large sized diverticula involving the whole small bowel starting from the duodenum until the ileum (Fig 3). There was no evidence of bands, rather a diverticulum was obstructed, fluid filled and formed an anchor around which the volvulus occurred. This diverticulum had a dusky wall with multiple perforation points. The Fig 4: Pathogenesis of the formation of jejunal diverticula: obstructed loop was excised with satisfactory only the mucosa and submucosa are herniating through a safety margins. End-to-end anastomosis was weakened point in the muscular layer. made. The post operative course was uneventful. parts of the small bowel which is mostly due to Discussion greater diameter of the penetrating jejunal (11) Small bowel diverticulosis was first described artery. Fig 4 demonstrate the hypothesis of the (15) by Sommering in 1794 and later by Astley etiology as presented by Surov and Stock. Cooper who was the first to report the same The coexistence of diverticula is variable lesion at autopsy 1809 while Gordinier and Shil between the studies, the colon is involved in 20- performed the first operation for diverticula in 70% of cases, duodenum 10-40% and in the (9) 1906.(9) stomach and oesophagus are 2%. Gregory Diverticulosis of the small bowel is a rare Kouraklis et al. reported that about 62% occurs disease and may be congenital or acquired with a in the jejunum, 24% in the ileum, and about 14% prevalence of about 1% in general population.(10) in both jejunum and ileum while 25% of cases (11) The incidence of jejunoileal diverticula in studies were multiple. The case we report represents a of the small bowel by enteroclysis is 2-2.3% rare occurrence of diverticula disease involving which is comparable to autopsy data presenting the whole length of small bowel loops at the an incidence of 1.3-4.6% for diverticula of the same time. Generally this condition is (15) jejunum and ileum.(9) The only congenital form is asymptomatic unless complications occur. In Meckel's diverticula, which is a true diverticula 20-30% of cases, symptoms are vague and non in which all layers are present in its wall and is specific like chronic abdominal pain, located on the antimesenteric border of the small postprandial periumbilical pain with bloating bowel about 40 cm of the ileocecal valve.(11) sensation after meals, nausea and vomiting along (15,16) Acquired type is due to pathologies such as with alternating diarrhoea and constipation. inflammatory disease or abdominal operations In more severe cases the patient may present with which result in weakness and dismotility of the intestinal obstruction and even anaemia and (17) intestinal wall, leading to diverticula steatorrhea. Acute complications that require formation.(12) Etiology of diverticulosis is not yet surgical intervention occur in 8-30% of (16) well known, however the current hypothesis patients. These complications include focuses on abnormalities in the smooth muscle or diverticulitis, haemorrhage, intestinal obstruction myenteric plexus.(13) This hypothesis postulates and perforation. The significance of this disease mucosal herniation of mucosal and submucosal is that it can result in diagnostic difficulties, first layers through weakened points in the muscular because it is rare and because of lack of specific (18) layer of the bowel wall on the mesenteric side so tests for definite diagnosis. Small bowel lacking the muscularis layer; false volvulus is uncommon in Western countries, (19) diverticula.(13,14) These points represent places of being more common in Africa and Asia. The minor resistance to the intraluminal pressure rarity and consequent delay in diagnosis accounts where blood vessels penetrate. This explains the for the higher incidence of gangrenous small (19) higher frequency in jejunum (61%) than the other bowel volvulus in the Western world. The JOURNAL OF THE ROYAL MEDICAL SERVICES 73 Vol. 20 No. 2 June 2013 patient in this report had presented with acute 4. Palder SB, Frey CB. Jejunal Diverticulosis. complete small bowel obstruction. This diagnosis Arch Surg 1988 Jul;123(7):889-894 was made by abdominal CT scan which showed 5. Fintelmann F, Levine MS, Rubesin SE. dilated small bowel loops, multiple air fluid Jejunal Diverticulosis: Findings on CT in 28 levels, pneumoperitoneum .The diverticula were Patients. AJR Am J Roentgenol. 2008 May; 190(5):1286-1290. missed for the fluid filled dilated small bowel 6. Maglinte DT, Chernish SM, De Weese R, et loops. “Whirl sign” was also evident. This sign is al. Acquired Jejunal Diverticular disease: highly suggestive of intestinal volvulus when Subject Review. Radiology 1986; 158: 577-580. afferent and efferent bowel loops rotate around a 7. Ijaz A, Naeem M, Samad A, et al. fixed point of obstruction resulting in twisting of Complicated Jejunal Diverticula As A Surgical mesentery along the axis of rotation.(8) This complication: experience At A Tertiary Care malrotation was complicated by volvulus which Hospital In Peshawar, Pakistan. J Ayub Med caused congestion of the mesenteric veins Coll Abbottabad 2010; 22(1): 157-159. resulting in mesenteric oedema which in turn 8. Khurana B. The Whirl Sign. Signs in caused obstruction and so ischemia of the bowel. Radiology. Radiology 2003; 69-70. Midgut volvulus is a rare complication of 9. Falidas E, Vlachos K, Mathioulakis S, et al. (20) Multiple giant diverticula of the jejunum intestinal malrotation in adults. This case causing intestinal obstruction: report of a case represents two rare pathologies, first is the and review of the literature. World J Emerg involvement of the whole length of small Surg 2011; 6: 8.
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