• ileal diverticulum
• inguinal hernia
• laparoscopic repair
• non-meckel diverticulum
• strangulated hernia

• Case report
• Diverticulitis
• Gastrointestinal stromal neoplasm
• Intestinal perforation
• Jejunal disease

The jejunal diverticula are relatively rare. A female patient was admitted at our emergency department with acute abdominal pain and vomiting. CT-scan of the abdomen showed multiple diverticula in the colon and multiple intra-abdominal fluid collections, also in the left quadrants of the abdomen. Free intraperitoneal extraluminal air was also observed, suggesting bowel perforation. Surgical exploration showed multiple diverticula of the jejunum with a perforated jejunal diverticulum extending approximately 10 cm from ligament of Treitz. Jejunal resection was performed. Jejunal diverticulitis is rare, but it can lead to an acute abdomen increasing mortality especially in elderly patients. Jejunal diverticulitis usually starts with features that mimic colonic diverticulitis. In patients with personal history of colonic diverticulosis and suspected diverticulitis, jejunal or ileal diverticulitis must be excluded occurring with a frequency of 2.3% in patients with known diverticulosis. In absence of pathognomonic colonic diverticulitis CT findings, small intestine acute complicated diverticulitis should be always suspected. In complicated jejunal diverticulitis surgical treatment is mandatory and a laparotomy can be needed for a better management. (www.actabiomedica.it)

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.

• abdominal surgery
• diverticulosis
• intussusception
• jejunum
• lipoma
• malnutrition
• visceral surgery

• Diverticulum/complications
• Diverticulum/diagnostic imaging
• Diverticulum/surgery
• Female
• Humans
• Intestine, Small
• Intussusception/diagnosis
• Intussusception/diagnostic imaging
• Jejunal Diseases/complications
• Jejunal Diseases/diagnostic imaging
• Jejunum/surgery
• Middle Aged

• Diverticular
• Jejunal
• Perforation

•

Jejunal diverticula (JD) are uncommon occurrences that frequently present as a diagnostic dilemma.

Jejunal diverticular (JD) disease is an uncommon occurrence that frequently present as a diagnostic dilemma. The correct diagnosis from complications of JD is typically made at laparotomy. Most JD are asymptomatic. Of clinically significant small bowel diverticula, only 15% present with surgical problems including obstruction, gastrointestinal bleed, and perforation.

A 90-year-old man presented to the hospital with abdominal pain. He was clinically stable with local tenderness in the left lower quadrant. Computed tomography demonstrated a dot of free air near the sigmoid and sigmoid diverticula. He continued to have pain and clinically deteriorated following a short period of observation. He underwent an exploratory laparotomy that revealed perforated JD.

Perforation from JD is exceedingly rare. Due to their infrequent clinical significance, complications from JD are difficult to diagnose and therapeutic options are typically made intraoperatively. Any deviation from the expected positive pathway in the management of a suspected entity should prompt an immediate reassessment as well as definitive therapeutic options.

• Acute abdomen
• Case report
• Diverticulitis
• Perforated viscus
• Peritonitis

This case report highlights the value of prompt intervention of diagnostic laparoscopy in a patient suspects of having an acute abdomen due to an intestinal perforation, where there is a limitation of performing Contrast Enhanced Computed Tomography of abdomen. A previously healthy young adult presenting with an acute abdomen due to a spontaneous ileal perforation, without any associated risk factors is a rare clinical entity in a developing country. Therefore, entertaining an early diagnosis will possibly prevent a fatal consequence.

A male patient, 29 years old, recently diagnosed as a young hypertensive without any associated factors, currently on antihypertensive treatment, was admitted to our hospital presenting with an acute severe abdominal pain. During initial assessment, the patient was febrile (101 °F), ill looking, tachycardic (pulse rate 121 bpm) with rapid shallow breathing. Abdominal examination reviled diffuse guarding and rigidity, more severe on right iliac fossa. Following history and clinical examination probable clinical diagnosis was made as an acute appendicitis with perforation. However, ultrasonography was found to have normal appendix. Contrast Enhanced Computed Tomography was not performed as a subsequent investigation because of the impairment of renal functions of this patient. Though, non-contrast CT would have been ascertained more diagnostic yield, given the critically ill status of this patient we decided to perform urgent diagnostic laparoscopy. It reviled pus in several abdominal cavities and dense adhesions. Therefore, the procedure was converted to a laparotomy and found to have an ileal perforation with diffuse peritoneal contamination. Diseased ileal segment was resected and anastomosed. Followed by peritoneal lavage.

Ileal perforation due to diverticular disease in a healthy young adult is rare. This case report highlights the importance of considering this clinical entity as a differential diagnosis, the value of early diagnostic laparoscopy, especially in clinical settings with limitations to CT scan, since late diagnosis can give rise to fatal outcome.

• Diverticular
• Ileal
• Laparoscopy
• Perforation

Diverticulitis in the terminal ileum is uncommon. Past reports suggested that conservative therapy may be feasible to treat terminal ileum diverticulitis without perforation; however, there is no consensus on the therapeutic strategy for small bowel diverticulitis. We present a 37-year-old man who was referred to our hospital for sudden onset of abdominal pain and nausea. He was diagnosed with diverticulitis in the terminal ileum by computed tomography (CT). Tazobactam/piperacillin hydrate (18 g/day) was administered. The antibiotic treatment was maintained for 7 days, and the symptoms disappeared after the treatment. Thirty-eight days after antibiotic therapy, he noticed severe abdominal pain again. He was diagnosed with diverticulitis in terminal ileum which was flare-up of inflammation. He was given antibiotic therapy again. Nine days after antibiotic therapy, laparoscopy assisted right hemicolectomy and resection of 20 cm of terminal ileum were performed. Histopathology report confirmed multiple ileal diverticulitis. He was discharged from our hospital 12 days after the surgery. Colonoscopy was performed two months after the surgery and it revealed no finding suggesting inflammatory bowel disease. Surgical treatment should be taken into account as a potential treatment option to manage the diverticulitis in the terminal ileum even though it is not perforated.

• Acute abdomen
• Perforation
• Small bowel diverticulum
• Surgery

•

Jejunal diverticular disease is rare in Africa.

Diverticular disease is uncommon among Africans though increasing number of cases is now being reported, mainly of colonic diverticulosis. This condition afflicts all parts of the gastrointestinal tract but commonly the colon. Jejunal diverticula are rare, usually asymptomatic but may lead to an acute abdomen.

A 68 year old female trader, who was referred from a peripheral center with insidious onset of severe colicky, generalized abdominal pain, repeated vomiting of recently ingested meal, no hematemesis. There was constipation and abdominal distension. The working diagnosis was dynamic intestinal obstruction of small bowel origin.

She had emergency exploratory laparotomy following resuscitation. The findings were: volvulus of the jejunum and multiple jejunal diverticula. A resection of 80 cm of the jejunum with most of the diverticula involved in the torsion was done with an end-to-end anastomosis of the jejunum. Her out-patient follow-up has been uneventful.

Jejunal diverticular disease is rare in Africa. Our patient presented with small bowel obstruction due to volvulus. Other complications are discussed.

Intestinal obstruction from diverticular disease is not always of colonic origin. It can occur in the jejunum.

• Diverticula
• Jejunum
• Volvulus

Jejunal diverticula are rare and subsequent complications even more so. The usual small bowel diverticulum encountered by general surgeons is a Meckel’s. These are embryological remnants of the vitello-intestinal duct and are on the anti-mesenteric surface of the terminal ileum. They may contain heterotopic gastric or pancreatic mucosa. Herein we explore the case of a young girl who presented with features of peritonitis secondary to a complication from a jejunal diverticulum. The case, pathology, complications and treatment of jejunal diverticulosis and heterotopic gastric mucosa in the jejunum are explored.

• Jejunum
• Perforation
• Heterotopic gastric mucosa
• Meckel’s gastrointestinal diverticulum

AIM: To study and provide data on the evolution of medical procedures and outcomes of patients suffering from perforated midgut diverticulitis.

METHODS: Three data sources were used: the Medline and Google search engines were searched for case reports on one or more patients treated for perforated midgut diverticulitis (Meckel’s diverticulitis excluded) that were published after 1995. The inclusion criterion was sufficient individual patient data in the article. Both indexed and non-indexed journals were used. Patients treated for perforated midgut diverticulitis at Vestfold Hospital were included in this group. Data on symptoms, laboratory and radiology results, treatment modalities, surgical access, procedures, complications and outcomes were collected. The Norwegian patient registry was searched to find patients operated upon for midgut diverticulitis from 1999 to 2007. The data collected were age, sex, mode of access, surgical procedure performed and number of patients per year. Historical controls were retrieved from an article published in 1995 containing pertinent individual patient data. Statistical analysis was done with SPSS software.

RESULTS: Group I: 106 patients (48 men) were found. Mean age was 72.2 ± 13.1 years (mean ± SD). Age or sex had no impact on outcomes (P = 0.057 and P = 0.771, respectively). Preoperative assessment was plain radiography in 53.3% or computed tomography (CT) in 76.1%. Correct diagnosis was made in 77.1% with CT, 5.6% without (P = 0.001). Duration of symptoms before hospitalization was 3.6 d (range: 1-35 d), but longer duration was not associated with poor outcome (P = 0.748). Eighty-six point eight percent of patients underwent surgery, 92.4% of these through open access where 90.1% had bowel resection. Complications occurred in 19.2% of patients and 16.3% underwent reoperation. Distance from perforation to Treitz ligament was 41.7 ± 28.1 cm. At surgery, no peritonitis was found in 29.7% of patients, local peritonitis in 47.5%, and diffuse peritonitis in 22.8%. Peritonitis grade correlated with the reoperation rate (r = 0.43). Conservatively treated patients had similar hospital length of stay as operated patients (10.6 ± 8.3 d vs 10.7 ± 7.9 d, respectively). Age correlated with hospital stay (r = 0.46). No difference in outcomes for operated or nonoperated patients was found (P = 0.814). Group II: 113 patients (57 men). Mean age 67.6 ± 16.4 years (range: 21-96 years). Mean age for men was 61.3 ± 16.2 years, and 74.7 ± 12.5 years for women (P = 0.001). Number of procedures per year was 11.2 ± 0.9, and bowel resection was performed in 82.3% of patients. Group III: 47 patients (21 men). Patient age was 65.4 ± 14.4 years. Mean age for men was 61.5 ± 17.3 years and 65.3 ± 14.4 years for women. Duration of symptoms before hospitalization was 6.9 d (range: 1-180 d). No patients had a preoperative diagnosis, 97.9% of patients underwent surgery, and 78.3% had multiple diverticula. Bowel resection was performed in 67.4% of patients, and suture closure in 32.6%. Mortality was 23.4%. There was no difference in length of history or its impact on survival between Groups I and III (P = 0.241 and P = 0.198, respectively). Resection was more often performed in Group I (P = 0.01). Mortality was higher in Group III (P = 0.002).

CONCLUSION: In cases with contained perforation, conservative treatment gives satisfactory results, laparoscopy with lavage and drainage can be attempted and continued with a conservative course.

• Intestinal
• Small bowel
• Jejunum
• Ileum
• Perforation
• Diverticulitis
• Conservative treatment

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life-threatening and require early surgical treatment. Small bowel perforation secondary to jejunal diverticulitis by enteroliths is rare. The aim of this study was to report a case of small intestinal perforation caused by a large jejunal enterolith. An 86-year-old woman was admitted with signs of diffuse peritonitis. After initial fluid recovery the patient underwent emergency laparotomy. The surgery showed that she had small bowel diverticular disease, mainly localized in the proximal jejunum. The peritonitis was due to intestinal perforation caused by an enterolith 12 cm in length, localized inside one of these diverticula. The intestinal segment containing the perforated diverticulum with the enterolith was removed and an end-to-end anastomosis was done to reconstruct the intestinal transit. The patient recovered well and was discharged from hospital on the 5th postoperative day. There were no signs of abdominal pain 1 year after the surgical procedure. Although jejunal diverticular disease with its complications, such as formation of enteroliths, is difficult to suspect in patients with peritonitis, it should be considered as a possible source of abdominal infection in the elderly patient when more common diagnoses have been excluded.

• Diverticulitis
• Diverticulum
• Intestinal perforation
• Intestines
• Lithiasis

Jejunal diverticulosis is a rare entity with variable clinical and anatomical presentations. Its reported incidence varies from 0.05% to 6%. Although there is no consensus on the management of asymptomatic jejunal diverticular disease, some complications are potentially life threatening and require early surgical treatment. We report a case of an 88-year-old man investigated for acute abdominal pain with a high biological inflammatory syndrome. Inflammation of multiple giant jejunal diverticulum was discovered at abdominal computed tomography (CT). As a result of the clinical and biological signs of early peritonitis, an emergency surgical exploration was performed. The first jejunal loop showed clear signs of jejunal diverticulitis. Primary segmental jejunum resection with end-to-end anastomosis was performed. Histopathology report confirmed an ulcerative jejunal diverticulitis with imminent perforation and acute local peritonitis. The patient made an excellent rapid postoperative recovery. Jejunal diverticulum is rare but may cause serious complications. It should be considered a possible etiology of acute abdomen, especially in elderly patients with unusual symptomatology. Abdominal CT is the diagnostic tool of choice. The best treatment is emergency surgical management.

• Jejunal diverticulum
• Diverticulitis
• Surgery
• Tomography

• Aged
• Aged, 80 and over
• Diverticulum/complications
• Diverticulum/diagnosis
• Diverticulum/therapy
• Female
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/surgery
• Humans
• Ileal Diseases/complications
• Ileal Diseases/diagnosis
• Ileal Diseases/therapy
• Intestinal Diseases/etiology
• Intestinal Diseases/therapy
• Jejunal Diseases/complications
• Jejunal Diseases/diagnosis
• Jejunal Diseases/therapy
• Male
• Middle Aged
• Retrospective Studies

• Aged
• Aged, 80 and over
• Calculi/etiology
• Diverticulum/complications
• Humans
• Ileal Diseases/etiology
• Intestinal Obstruction/etiology
• Jejunal Diseases/complications
• Jejunal Diseases/etiology
• Male
• Middle Aged