Multiple jejunal diverticula with repeated gastrointestinal bleeding: A case report

Abstract

BACKGROUND

Jejunal diverticula (JD) are rare clinical conditions that are typically incidentally detected and asymptomatic. When acute complications arise, surgical exploration may be necessary for accurate diagnosis and appropriate treatment. In this report, we present a case of multiple JD complicated by gastrointestinal bleeding and review the pathogenesis, diagnosis, and treatment of JD to increase clinician awareness of this condition.

CASE SUMMARY

A 70-year-old male patient with multiple JD presented with repeated massive gastrointestinal bleeding. The patient did not respond to symptomatic conservative treatment. Additional diagnostic investigations, including digestive endoscopy and abdominal angiography, did not reveal any relevant abnormalities. An exploratory laparotomy was subsequently performed, during which a segment of the bowel containing numerous diverticulum-like structures was surgically removed. Following successful discharge from the hospital, the patient did not experience any further episodes of gastrointestinal bleeding during subsequent follow-up.

CONCLUSION

Complications caused by JD are often difficult to diagnose, and surgical exploration is sometimes the most appropriate method.

Key Words: Jejunal diverticula; Gastrointestinal bleeding; Complication; Surgery; Case report

Core Tip: Jejunal diverticula (JD) are rare clinical conditions that can lead to nonspecific symptoms, making diagnosis challenging. Gastrointestinal bleeding caused by JD is observed in 3%-8% of patients and may manifest as either fresh rectal bleeding or dark red bloody stools. In cases of complications, early diagnosis can be facilitated through the use of endoscopy and computed tomography scans, with surgical resection of the affected bowel being the most suitable treatment option. In this report, we present a case of multiple JD associated with recurrent gastrointestinal bleeding, and we discuss its pathogenesis, diagnosis, and treatment options.

INTRODUCTION

Jejunal diverticula (JD) are rare clinical conditions that are typically incidentally detected and asymptomatic[1]. Unlike Meckel's diverticula, JD tend to be acquired pseudodiverticula and are more common in older patients, particularly those over 60 years of age, with a slight male predominance[2,3]. Owing to the lack of a true muscular wall, they are usually thin and fragile, making them more susceptible to serious complications such as hemorrhage, perforation, or inflammation than true diverticula[3,4]. Massive gastrointestinal bleeding from JD is exceedingly rare, and delayed diagnosis may result in a high mortality rate. Here, we present a male patient with multiple JD who experienced recurrent gastrointestinal bleeding. After several examinations, the condition was ultimately diagnosed and treated during exploratory surgery.

CASE PRESENTATION

Chief complaints

A 70-year-old male with a one-day history of bloody stools presented at our center.

History of present illness

The patient experienced a significant amount of dark red bloody stools without an obvious cause, accompanied by abdominal distension, nausea, and vomiting the day prior. Additionally, he exhibited signs of hypovolemia, including panic, fatigue, and pallor. A comprehensive abdominal computed tomography (CT) scan revealed suspected blood accumulation in the rectal lumen, but no significant abnormalities were noted in the surrounding areas. He was subsequently transferred to gastrointestinal surgery for further management.

History of past illness

Prior to this episode, the patient was in good health and denied any history of gastrointestinal bleeding conditions or related medications.

Personal and family history

No relevant personal or family history was recorded.

Physical examination

His vital signs were not stable, with a blood pressure of 12.7/7.1 kPa and a blood oxygen saturation of 98%. Upon examination, his abdomen appeared flat and soft, without any signs of swelling or tenderness.

Laboratory examinations

The laboratory results revealed a low hemoglobin level (6.5 g/dL) and slightly increased white blood cell count (12.1 × 10⁹/L). The rest of the routine blood and biochemical examinations revealed no obvious abnormalities.

Imaging examinations

When his condition stabilized, he underwent gastroscopy and colonoscopy, which did not reveal any active bleeding sites except for one colonic polyp and stagnant blood in the intestinal lumen. To further identify the cause and location of the bleeding, the patient underwent abdominal angiography, which again was negative.

FINAL DIAGNOSIS

On the basis of clinical evidence, it was preliminarily identified as unexplained gastrointestinal bleeding. After exploratory surgery, the final diagnosis was confirmed as gastrointestinal bleeding due to multiple JD.

TREATMENT

His condition recurred, and he remained in a state of moderate anemia. Positive conservative treatment such as blood transfusion and intravenous fluid replenishment had no obvious effect. Exploratory surgery was conducted, revealing multiple diverticula of the jejunum located 25-55 cm from the flexural ligament (Figure 1A). Additionally, the mesenteric rim vessels showed signs suggestive of hemangiomas (Figure 1B). To further rule out other potential causes of bleeding, an incision was made adjacent to the small bowel diverticulum, followed by another endoscopy to thoroughly examine the bowel both proximally and distally. No active bleeding was observed, with only stagnant blood residue visible in the ascending colon. Ultimately, approximately 55 cm of the proximal jejunum was resected, and an intestinal anastomosis was performed. The anatomical specimen revealed multiple diverticula-like structures characterized by a significantly thinned intestinal wall.

Figure 1 Surgical exploratory findings. A: Multiple jejunal diverticula located 25 to 55 cm from the ligament of Treitz; B: Mesenteric marginal vessels showing signs of hemangioma.

OUTCOME AND FOLLOW-UP

After the operation, the patient received symptomatic support treatment, and he was discharged from the hospital successfully. The final pathological examination of the resected specimen confirmed the presence of multiple JD with increased vascularization, bruising, and bleeding. Subsequent follow-up assessments indicated that the patient did not experience any further gastrointestinal bleeding (Figure 2), confirming that multiple JD were the source of the bleeding.

Figure 2 Timeline of interventions and outcomes. CT: Computed tomography.

DISCUSSION

Most JD are asymptomatic, difficult to identify and typically treated by observation when they are incidentally discovered. Acute complications, including bleeding, perforation, and obstruction, occur in less than 10% of patients[2,3]. These critical issues pose life-threatening risks and often necessitate surgical intervention following thorough evaluation[3,4].

The development of JD is commonly attributed to localized elevated intraluminal pressure and inherent weaknesses in the intestinal wall, which facilitate the penetration of mesenteric vessels through the intestinal wall[3,5]. Abnormal clumping of intestinal smooth muscle, resulting in uncoordinated movements and localized areas of high intestinal pressure, is believed to be a contributing factor[2,6]. However, JD typically manifest at the mesenteric margin, possibly due to the vulnerability of this area, where mesenteric vessels penetrate the intestinal wall[7]. Regardless, the end result is a sac-like protuberance of the mesenteric margin. Furthermore, peristalsis of the small intestine tends to fill these protruding pouches with liquid chyme, and if accompanied by a small caliber of the pouch, its contents remain difficult to empty even with normal peristalsis of the intestine[8]. The acquired diverticula lack a muscular wall and often exhibit paper-thin walls, as observed during surgical procedures. Alternatively, peripheral inflammation due to repeated irritation of the luminal contents of the bowel, as described above, can lead to edema and wall thickening[3].

JD typically remain silent until some acute and chronic complications arise[3,9]. Chronic complications such as abdominal discomfort, intermittent bloating, and malabsorption are most often due to pseudo-obstruction or bacterial growth in the intestines, and relief can usually be achieved with aggressive medical treatment[2,10]. In cases where symptoms persist or become severe, surgical resection of a portion of the intestines may be necessary to alleviate the patient's condition[2,11]. Gastrointestinal bleeding caused by JD occurs in 3%-8% of patients and can manifest as either acute or chronic bleeding[12,13]. Unfortunately, traditional diagnostic methods such as history-taking and physical examination are not reliable for identifying bleeding from JD[12]. In addition, in the case of bleeding from the small intestine, gastroscopy and colonoscopy are unlikely to reveal the true source of bleeding except to help rule out other intestinal abnormalities. However, in instances where acute hemorrhages are not promptly identified during the initial presentation, there is a risk of recurrent bleeding, as observed in our patient.

Primary calculi in the small intestine are rare. Reduced bowel motility and long-term stasis of bowel contents are the most common triggers, and diverticula are a common cause[14]. Luminal stasis promotes bacterial overgrowth, resulting in bile salt dissociation, precipitate condensation, and, eventually, the formation of solid particles, namely, intestinal stones[15]. JD complicated by enterolithiasis can result in both acute and chronic small bowel obstruction, and surgical intervention can offer a definitive diagnosis and treatment[16]. The perforation of JD occurs in 2%-6% of cases[17]. Clinical diagnosis is challenging at this time because the symptoms resemble those of other causes of acute abdomen, such as peptic ulcer perforation and appendicitis[18]. In cases of acute complications, a thorough surgical examination of the bowel is imperative, even though identifying jejunal or ileal diverticula can be challenging, as they are often concealed within the mesenteric fat[4]. Successful outcomes can be achieved by resecting the affected bowel segment and performing an end-to-end anastomosis. To prevent the development of short bowel syndrome, large resections should be avoided during surgery, as the potential risks may outweigh the benefits[19].

Early diagnosis and prompt treatment can reduce morbidity and mortality[20]. However, rare complications often result in missed or delayed diagnosis, presenting a significant challenge for clinicians. CT angiography, a valuable diagnostic tool for acute gastrointestinal bleeding, can assist in identifying ongoing bleeding by revealing active contrast leakage into the intestine during the arterial phase[12]. Although our patient underwent a CT angiogram to locate the bleeding site, no significant findings were observed, likely due to the cessation of bleeding. While mesenteric vascular embolization has proven effective in treating colonic bleeding, its efficacy in treating small bowel bleeding is limited, possibly due to the narrower vasculature of the small bowel, leading to potential rebleeding even after successful initial treatment[21,22]. Capsule endoscopes can pass through the entire intestine and rely on the peristalsis of the intestine itself to provide images of the intestinal cavity in a nonsurgical manner, providing a new perspective for identifying the source of bleeding. Push colonoscopy can be used to examine a portion of the proximal jejunum to assist in diagnosing and treating angiodysplasia[23,24]. These endoscopic procedures may help identify gastrointestinal bleeding caused by the JD and provide further hemostatic treatment, to some extent avoiding surgery, although this was not done in our patient due to acute hemorrhage. Preoperative diagnosis of acute complications from JD is achieved in only 14% of cases, with surgical exploration sometimes being necessary to confirm the correct diagnosis[2].

CONCLUSION

In conclusion, diagnosing acute or chronic complications arising from JD is challenging. Timely surgical exploration may provide greater benefits to patients. The existing literature primarily consists of case reports, with relatively few retrospective analyses available. Further research is warranted to improve the diagnosis and management of complications related to JD.

ACKNOWLEDGEMENTS

The authors thank the patient for his collaboration.