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American Board of Abdominal Surgery


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ABDOMINAL SURGERY

Official Journal of the American Society of Abdominal Surgeons, Inc.

This article originally appeared in the Winter 2013 / Spring 2014 issue of the Journal.

A Complicated Jejunal Diverticulum as a Cause of Intestinal Obstruction

Dr. Faris Dawood Alaswad, M.D., M.B.CH.B.,
F.I.C.M.S., F.I.C.S., F.A.C.S., F.E.B.S.


NMC Speciality Hospital

Vinod Kumar Singhal, M.D., M.S., F.R.C.S.,
F.A.C.S., F.I.C.S, F.M.A.S., F.I.A.G.E.S., D.I.P.L.S.

Address for correspondence:
Dr. Faris Dawood Alaswad
NMC Speciality Hospital
P.O. Box 7832
Dubai, UAE
Tel: 00971-509523829
Fax: 00971-4 2678889
Email: faris_alaswad@yahoo.com


ABSTRACT

Context

Jujenal diverticulum is a rare and usually asymptomatic. More commonly it is usually seen as an incidental finding on CT images or during surgery. Complications such as bleeding, perforation, obstruction, maalabsorption, blind loop syndrome, volvolus and intussusceptions may warrant surgical intervention.

Case Report

We are reporting a case of 43 years male who had suffered from intestinal obstruction for 4 days post laparoscopicappendectomy. The symptoms did not improve after conservative treatment. An exploratory laparotomy found small bowel obstruction due to proximal jujenaldiverticulum with an adhesion epiploic band. Strangulation of the jejunum resulted from the internal hernia caused by the band. The band was removed and the proximal jejunum diverticulum was resected. The post operative course was uneventful.

Conclusion

Although this phenomenon is rare, we should keep in mind that intestinal diverticulum may induce intestinal obstruction of different kinds, repeat physical examinations and X-ray films are needed and CT is helpful in diagnosis. Surgery is indicated for acute abdominal or repeated intestinal obstruction.

CASE REPORT

A 43 years man presented with a 3 days history of central abdominal pain, distension and vomiting. He was treated with oral spasmolytic drugs without improvement. Medical history revealed no history of digestive disorders. The patient had no significant previous surgical history. Examination of his abdomen revealed tenderness and no abdominal mass digital rectal examination was normal. Rebound tenderness was positive and history of pain shifting was also positive and a diagnosis of acute appendicitis was made for which he underwent laparoscopicappendectomy after a brief intensive resuscitation and gangrenous appendix removed. After surgery patient recover well from anesthesia and after 48 hours starts to have a clear picture of mechanical obstruction for which he received a conservative treatment of suck and drip to which he didn't respond so a decision to explore through laparotomy midline after frequent plain X-rays and CT with contrast study done and prove a picture of intestinal obstruction. At exploration a single 8 cm jejuna diverticulum was seen at about 20 cm from the duodenojujunal junction with a band attached to its apex and extending to the site of previous surgery (cesium) causing a band like internal herniation intestinal obstruction. A diverticulectomy without small bowel resection was performed because the swollen purple intestines were well perfused after 20 minutes of observation and there was no suspect of end luminal tissue. A final pathology exam confirmed the jujunal diverticulum with no signs of malignancy. The patient had an uneventful postoperative course and was discharged 5 days after the procedure.

DISCUSSION

Jejuna diverticulum is rare entity with an incidence rate ranging from 0.3% to 1.3%.3 It was first described in 1794 by Sommering and later in 1807 by Sir Astley Cooper and is characterized by herniation of mucosa and submucosa through the muscular layer at the point where blood vessels penetrate the intestinal wall (false diverticula).2,5 This explains their typical location at the mesenteric side.2, 3, 10 Diverticula are more frequent in jejunum (61%) than the other parts of the small bowel and it is attributed to the greater diameter of the penetrating jejuna artery.5 Diverticuliare usually multiple,5, 11 in contrast to the congenital Meckel'sdiverticulum and tend to be larger and higher in number in the proximal jejunum and smaller and fewer caudally. Coexistent diverticuli are found in many other digestive localization.

The etiology is unclear; it is believed to develop as the result of abnormalities in peristalsis, intestinal dys-kinesis, and high segmental intraluminal pressures. The current hypothesis focuses on abnormalities in the smooth muscles or mynteric plexus. Careful microscopic evaluation of jejuna specimens with diverticula has shown that these abnormalities are of three types:

  • Fibrosis and decreased numbers of normal muscle cells consistent with progressive systemic sclerosis
  • Fibrosis and degenerated smooth muscle cells suggestive of viscersl myopathy
  • Neuronal and axonal degeneration indicative of visceral neuropathy

Any of these abnormalities could lead to distorted smooth muscle contractions of the affected small bowel generating increased intraluminal pressure. Consequently mucosa and submucosa would pass through the weakest mesenteric site in the bowel wall with penetration induced by paired blood vessels from the mesentery. In our case the diverticulumwas arising from the antimesentric surface as seen clearly in the preoperative images.

Jejunoileal diverticuli are usually asymptomatic and are found incidently. Most patients have chronic abdominal pain and bloated sensation. If symptomatic, vague and chronic abdominal pain of varying severity localized epigastricallyor periumblically with a bloated sensation after food intake is frequent and may be the earliest symptom. Complications requiring surgical intervention occur in 8%-30% of patients. Common acute complications include diverticulitis, hemorrhage, perforation and intestinal obstruction. Mechanical intestinal obstruction occurs in 2%-4% of cases and may arise from enterolith formation,intussusceptions or volvulus. In the latter situation the diverticulum acts as a pivot especially where previous diverticulitis results in adhesive band formation arising from themesodiverticulum. Such adhesions may also cause obstruction by direct kinking of the bowel or by trapping another loop of bowel underneath as it occurred in our case.

The diagnostic work up in symptomatic patients can start with plain abdominal X-ray film that could show distension of jejuna loops and gas fluid levels into the diverticulum when it is giant. Barium enema study probably reveals the diverticulum as a contrast filled out pouching 0, 5-10 cm long that is located on the mesenteric border of the jejunum and has a junction fold pattern. Computed tomography is helpful in complicated diverticula. It is reasonable to conclude that asymptomatic diverticula incidentally discovered on routine contrast studies or at lapratomy do not need resection. However other authors have suggested that surgical treatment is indicated for incidental large diverticula with dilated hypertrophied bowel loops that represent a progressive form of the disease.

Treatment of acute complications of jejunoilelal diverticulumis mostly operative and non specific. Higher complication rate is associated with jejunoileal diverticulosis and as such may justify less conservative approach to its management. Diagnostic laparoscopy is very useful in evaluating patients with a complicated course. It ensures an accurate diagnosis and avoids unnecessary laparotomy.

People with multiple diverticula have higher incidence of complications than people with solitary diverticulum. However, the treatment for diverticulos is often perform edemergently is either resection with end to end anastomosis. A simple diverticulectomy by wedge excision is most commonly used for symptomatic diverticulum or bleeding diverticulum. The diverticulum is simply excised and the bowel is closed longitudinally or transversely ensuring minimal luminal stenosis.

In case of obstruction due to an enterolith some authors suggest conservative management by performing the manual breakage of all stones intradiverticular and blocking ones pushing their fragments to the colon. If this is proved to be impossible or in appropriate the stone is removed through an enterotomy which is made in a less edematous segment of proximal small bowel. The outcome of operated jejunoileal diverticula is generally good. Mortality is influenced by the patient's age, nature of complications and time of intervention.

CONCLUSION

This is a new case of intestinal obstruction caused by jejunal diverticulum acting as a band. The band may have been formed during recurrent diverticulitis because it arose from the mesodiverticulum. Although this phenomenon is rare we should keep in mind that intestinal diverticulosis may induce intestinal obstruction of different kinds repeat physical examinations and X-rays films are needed and CTscan is helpful in diagnosis. Surgery is indicated for acute abdominal or repeated intestinal obstruction.


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REFERENCES

1. Lin CH, Hsieh HF, Yu CY ,Yu JC, Chan DC, Chen TW, Chen PJ, Liu YC. Diverticulosis of the jejunum with intestinal obstruction: A case report, World J Gastroenterol. 2005; 11(34):5416-5417.

2. Sibille A, Willocx R. Jejunal diverticulitis. Am J Gastroenterol. 1992; 87:655-658.

3. Sager J, Kumar V, Shah DK. Meckels diverticulum; a systematic review. J R Soc Med. 2006; 99(10):501-505.

4. Huang A, McWhinnie DL, Sadler GP, An unusual cause of bowel obstruction. Postgrad Med J. 2000; 76:183-185.

5. Krishnamurthy S, Kelly MM, Rohrmann CA, SCHUFFLER MD, Jejunal diverticulosis. A heterogeneous disorder caused by a variety of abnormalities of smooth muscleor myenteric plexus. Gastroenterology. 1983; 85;538-547.

6. Wilcox RD, Shatney CH. Surgical implications of jejunal diverticulosis: perceptions and reality. J. 1988; 81: 1386-1391.

7. Wilcox RD, Shatney CH. Surgical significance of acquired ileal diverticulosis. Am Surg. 1990; 56:222-225.

8. Chiu EJ, Shyr YM, Su CH, Wu CW, Lui WY. Diverticular disease of the small bowel. Hepatogastroenterology. 2000; 47(31):181-184.

9. Chow DC, Babaian M, Taubin HL. Jejunoileal diverticular. Gastroenterologist. 1997; 5(1):78-84.

10. Kassahun WT , Fangmann J , Harms J, Bartels M, Hauss J. Complicated small bowel diverticulitis: a case report and review of the literature. World J Gastroenterol. 2007; 13:2240-2242.



Journal CoverOFFICIAL PUBLICATION OF:
The American Board of Abdominal Surgery
The American Society of Abdominal Surgeons, Inc.
Foundation for Abdominal Surgery

Louis F. Alfano, Jr., M.D., Editor-in-Chief
Diane M. Pothier, Executive Editor and
Director of Continuing Medical Education


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