Complicated small bowell diverticulosis – a case report and literature review
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COMPLICATED SMALL BOWEL DIVERTICULOSIS – a case report and literature review L.Tankova, M. Berberova, P. Purvanov Clinical Centre of Gastroenterology, Medical University Hospital “Queen Joanna”, Sofia, Bulgaria
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HISTORY In 1710 - J. B. Chomel described a duodenal diverticulum. In 1794 - S. Sömmering and M.Baille described acquired jejunoileal diverticulosis. In 1807 - Sir Astley Cooper reported the first instance of jejunal diverticulosis in a monograph on hernias.
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In 1906 - Gordinier and Sampson published the first account of an operation for small bowel diverticula. In 1920 - J. T. Case presents the X-ray image of small bowel diverticula. In 1921 - E. Hunt and P. Cook performed the first diverticular resection. In 1962 - Herrington reported a perforation of an acquired diverticulum of the jejunum.
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FREQUENCY Jejunoileal diverticula (excluding the stomach) represent the rarest localization of gastrointestinal diverticular disease. Jejunoileal diverticula are described mainly in the 6th and 7th decade of life with weak predominance of male sex (1,5:1). The frequency of small bowel diverticula is between 0.06 and 1.9% (0.5 – 7.1% of X-ray contrast bowel imaging and in 0.3 – 4.5% at autopsy).
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CASE PRESENTATION Patient History A 79-years-old woman is admitted to the Gastroenterology Clinic because of liver changes, recently detected by abdominal ultrasound. These were interpreted as advanced chronic liver disease with big regeneration nodules. In differential diagnosis liver metastases or multicentric hepatocellular carcinoma are discussed. The patient is hospitalized for fine needle biopsy and evaluation of liver lesions. A history of abdominal discomfort and long lasting tendency of constipation with periodic exacerbation of hemorrhoids is estimated on admission.
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Physical examination At presentation, patient's general condition is good. There`s no jaundice. Abdominal palpation reveals weak to moderate pain in Epigastria; moderate hepatomegaly with hard consistency. Laboratory data Increased ESR – 56mm, Elevated C-reactive protein (14mg/l; normal < 5mg/l), Lightly diminished prothrombin index 68%, albumin fraction of serum proteins - 30g/l, Cholestatic constellation – Alkaline Phosphatase – 677U/l, GGT – 101U/l, total bilirubin – 32,1µmol/l. The other findings of laboratory studies are in referral range.
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Instrumental investigations Ultrasound data: heterogenic liver structure with more hypoechoic zones up to 1cm in size, interpreted as regeneration nodules of liver cirrhosis, less possibly in differential diagnosis – secondary lesions or primary multicentric hepatocellular carcinoma. Gall bladder calculus with slightly enlarged common bile duct arealso found. Fine needle biopsy of liver nodules under US guidance - no malignancy in the aspirate. Fibrocolonoscopy : diffuse noncomplicated large bowel diverticulosis; approximately 10 small polyps, less than 1cm in size, endoscopically removed. Lipoma on the ileocecal valve (histologically proven) is also found.
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Disease course During the hospital stay the patient suddenly complained of moderate abdominal pain without alteration in bowel habit and without blood or mucus in stools. On observation during the day the pain became deeper with signs of peritoneal irritation in the ileocecal region. Abdominal x-rays revealed no free air. On control ultrasound examination there are edematous small bowel loops and small quantity of free abdominal Liquid. All these clinical and instrumental data of acute abdominal problem lead to emergency surgery suspecting acute appendicitis.
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During laparotomy purulent exudate in the abdominal cavity is found with perforation of an inflammated jejunal diverticulum, localized at 20cm beyond lig.Treitz. Multiple diverticula of various sizes between 5mm and 2cm are identified in the small and large intestines. In the ostium of jejunal perforation, a sharp fish bone is found. The diverticulum was excised and the defect closed in two layers. During the surgery a resection biopsy of the liver is taken and consequently weakly active mixed micro- macronodular cirrhosis is histologically diagnosed.
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Patient outcome On control ultrasound investigation one month later, knowing the operative finding of multiple diverticulosis, one of the larger diverticula – 2cm in size is visualized (fig.1). On follow-up one year later the patient is in good health without any abdominal complaints.
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Fig.1. Ultrasound image of a small bowel diverticulum (size 20/12mm) (the evaluation is performed one month after emergency operation)
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DISCUSSION Small intestinal diverticula are far less common than colonic diverticula. In 35% to 75% of small bowel diverticula localization there is association with large bowel diverticulosis. The global increasing of diverticular frequency is associated with the diminished consumption of fibers, characteristic of west civilization and with the increased life expectancy. The cause of this condition is not known. It is believed to develop as the result of abnormalities in peristalsis, intestinal dyskinesis, and high segmental intraluminal pressures.
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Small bowel diverticulosis is asymptomatic in around 60% of cases. Dyspeptic symptoms are found in 25% to 30% of patients. Another 10% to 15% of patients demonstrate complications leading to surgical treatment. Major complications include diverticulitis, GI hemorrhage, intestinal obstruction, acute perforation.
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Diverticulum perforation is seen in 2.3% of cases with small bowel diverticulosis; 82% of diverticula perforations are due to diverticulitis. Other causes of perforation are abdominal trauma (12%) and foreign body in the intestine as in our case (6%). Free perforation may lead to diffuse peritonitis. Perforation and abscess are strong indications for surgery if percutaneous drainage is inapplicable. Perforations lead to death in 21% to 42% of cases
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Negative barium enema study does not exclude presence of intestinal diverticula, because small diverticular sacs might not be adequately filled with contrast. For investigation of ileum and jejunum, enteroclysis is a more specific procedure. Jejunum and ileum can be investigated using either the push or sonde types of enteroscopy. Double balloon enteroscopy can help identify the presence of disease and also the cause of any obscure bleeding. These procedures are excluded in small bowel obstruction, acute diverticulitis, or perforation. Capsule endoscopy helps identify the presence of diverticular disease and also the cause of bleeding.
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CT and ultrasound investigation might be useful in excluding other causes of abdominal pain such as acute appendicitis, abdominal abscess or inflammed large intestine. In cases of diverticulitis, ultrasonography may reveals a hypoechoic or anechoic structure protruding from a segmentally thickened bowel wall. In cases of peridiverticular abscess formation percutaneous drainage under CT or US guidance might be used.
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Intestinal diverticulosis is often underestimated in routine clinical practice and the preoperative diagnosis of its complications is missed. Our patient had a known intestinal diverticulosis at the time when the new abdominal pain appeared. Preoperative ultrasound discloses the pericecal exudation but does not observe the possibility of complicated diverticular pathology. Retrospectively, the advanced age and the previous endoscopic data of large bowel diverticulosis make the diagnosis of perforated diverticulum more appropriate.
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In conclusion the presented case and the review of the literature demonstrate the different clinical manifestations of a relatively common pathology – intestinal diverticulosis in the elderly. Small intestinal diverticula should not be estimated as an innocent, clinically nonsignificant pathology. Patients with incidentally diagnosed small bowel diverticulosis should be strictly surveyed for the complications of this disease.
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Boulos PB. Complicated diverticulosis. Best practice & Research Clinical Gastroenterology 2002; 16: 649-62. Case JT. Diverticula of the small ineine other than Meckel’s diverticulum JAMA 1920; 33: 768. Chiu EJ., YM Shyr, CH Su et al. Diverticular disease of the small bowel. Hepatogastroenterology 2000; 47: 181-4. Chow DC, M.Babaian, HL.Taubin. Jejunoileal diverticula. Gastroenterologist 1997; 5: 78-84. Cools P, E.Bosmans, J.Onsea et al. Small bowel diverticulosis. A forgotten diagnosis. Acta Chir Belg 1995; 95: 261-4. Cooper A. Anatomy and surgical treatment of crural umbilial hernia. London. 1807. Cunningham SC, CJ.Gannon, LM.Napolitano.Small-bowel diverticulosis. Am J Surg. 2005; 190: 37-38. De Bree E., J.Grammatikakis, M.Christodoulakis et al. The clinical significance of acquired jejunoileal diverticula. Am J Gastroenterol 1998; 93: 2523-28. REFERENCES
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Eggenberger JC. Diverticular Disease. Curr Treat Options Gastroenterol. 1999; 2: 507-516. El-Haddawi F. ?t ID. Civil. Acquired jejuno-ileal diverticular disease: a diagnostic and management challenge. ANZ J Surgery 2003; 73: 584. Floch MH, I. Bina The natural history of diverticulitis: fact and theory. J Clin Gastroenterol. 2004; 38 (5 Suppl):S2-7. Frye JN, R. Robertson Complicated small bowel diverticular disease. ANZ J Surg. 2004; 74: 495-496. Gordinier HC, Sampson JA. Diverticulitis (non-Meckel’s) causing intestinal obstruction JAMA 1906; 46: 1585-90. Gross S, S.Katz. Small Bowel Diverticulosis: An Overlooked Entity Curr Treat Options in Gastroenterol. 2003; 6: 3-11. Herrington JL. Perforation of acquired diverticula of the jejunum and ileum. Surgery 1962; 51: 426-33. Kouraklis G, et al.: Diverticular disease of the small bowel: report of 27 cases. Int Surg 2001; 86: 235-9.
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Kouraklis G., A.Glinavou, D.Mantas et al. Clinical Implication of small bowel diverticula IMAJ 2002; 4: 431-434. Lempinen M., K.Salmela, E.Kemppainen. Jejunal diverticulosis: a potentially dangerous entity. Scand J Gastroenterol 2004; 39: 905-909. Longo WE. Clinical implications of jejunoileal diverticular disease. Dis Colon Rectum 1992; 35: 381-388. Nightingale S, M. Nikfarjam, L. Iles et al. Small bowel diverticular disease complicated by perforation. ANZ J Surg 2003; 73: 867-869. Schock J et H.Mainster. Perforation of acquired small bowel diverticulum JAOA Journal of the American Osteopathic Association, 1999; 99: 113-113. Sömmering ST, Baillie M. Anatomie des krankhaften Baues on einigen der wichtigsten Theile im menschlischen Korper. Berlin: Vossiche Buchhandlung, 1794. Zager JS, JE. Garbus, JP. Shaw et al. Jejunal Diverticulosis: A Rare Entity with Multiple Presentations, a Series of Cases. Digestive Surgery 2000; 17: 643-645.
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