|Year : 2013 | Volume
| Issue : 1 | Page : 20-22
Perforated solitary giant true jejunal diverticulum
AF Salama, F Belgrami, ME Abd Ellatif
Department of Surgical, Al Jahra Hospital, Ministry of Health, Kuwait
|Date of Web Publication||13-Sep-2013|
A F Salama
Surgical Department, Al-Jahra Hospital, Ministry of Health
Source of Support: None, Conflict of Interest: None
Jejunal diverticula are rare and usually asymptomatic. However, they may cause chronic non-specific symptoms or rarely lead to an acute presentation. Here, we report a rare case of a child presenting with a perforated congenital jejunal diverticulum. We report a case of 10-year-old female who presented with severe acute abdominal pain, repeated vomiting, hypotension, and tachycardia of 1 day duration. Chest X-ray showed free air under diaphragm and abdominal X-ray displayed dilated bowel loops. Laboratory investigations showed leukocytosis and hyperamylasemia. After intravenous (IV) fluid resuscitation, diagnostic laparoscopy was performed that detected the presence of perforated solitary giant jejunal diverticulum, about 25 cm from the duodenojejunal junction, in addition to diffuse peritonitis. We had to convert to laparotomy due to the presence of huge amount of undigested food particles. Resection of the diverticulum-bearing segment and anastomosis was done along with thorough peritoneal decontamination and washout. Solitary giant jejunal diverticulum is a rare condition which can present with chronic vague abdominal pain and altered bowel habits, and can present acutely with complications as perforation with significant morbidity.
Keywords: Congenital, diverticulum, jejunal, perforation
|How to cite this article:|
Salama A F, Belgrami F, Ellatif MA. Perforated solitary giant true jejunal diverticulum. Saudi Surg J 2013;1:20-2
| Introduction|| |
Jejunal diverticulosis is a rare disease with an incidence of less than 0.5%.  Pathologically, it is classified as true and false. False diverticula of the pulsion type result from increased intraluminal pressure and weakening of the bowel wall. They are only formed of mucosal and submucosal layers. True diverticula contain all three layers of the intestinal wall. Meckel diverticulum is a true diverticulum presenting congenitally in 2-3% of individuals.  We present a rare cause of acute abdominal pain with perforated true jejunal diverticulum.
| Case Report|| |
A 10-year-old girl presented to the emergency department with 1 day history of generalized abdominal pain and repeated vomiting. She had history of vague abdominal pain and altered bowel habits over the preceding 2 months. She had no history of chronic medical diseases.
Physical examination revealed tachycardia (170/min), hypotension (BP 80/50), fever (38°C), and tachypnea (respiratory rate 30/min). There was abdominal tenderness, guarding rigidity, and rebound tenderness. She had elevated white blood cell count (WCC, 18 × 10 9 /l), mild elevation of serum amylase (173 mmol/l), and normal renal function tests. Abdominal X-ray showed dilated small bowel loops and erect chest X-ray displayed free air under the diaphragm.
Resuscitation of the patient to optimize her condition before proceeding to surgery started in the form of intravenous (IV) fluids, oxygen supplementation, IV antibiotics, and antipyretics. The patient underwent diagnostic laparoscopy that detected the presence of perforated solitary giant jejunal diverticulum (about 12 × 7 × 5 cm), about 25 cm from the duodenojejunal junction, in addition to diffuse peritonitis. We had to convert to laparotomy due to the presence of huge amount of undigested food particles. Resection of the diverticulum-bearing segment and anastomosis was done along with thorough peritoneal decontamination and extensive washout [Figure 1] and [Figure 2]. Our patient's postoperative course was complicated by pneumonia, bilateral pleural effusion, delayed weaning from the ventilator support, and wound infection with partial wound dehiscence, but eventually she made a full recovery from all these complications.
|Figure 1: A perforated huge jejunal diverticulum 12 × 7 × 5 cm at the mesenteric border|
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|Figure 2: Total resection of the diverticulum-bearing area and re-anastomosis|
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Histopathology showed a 12 × 7 × 5 cm diverticulum arising from the anti-mesenteric border of the jejunum with marked inflammation and necrosis of the mucosa. This was a true diverticulum containing all the intestinal layers. There was no evidence of any malignancy or any ectopic gastric or pancreatic mucosa in the diverticulum.
| Discussion|| |
The majority of jejunal diverticula in elderly persons are of acquired (false) type and multiple. They are probably developed from a combination of abnormal peristalsis, intestinal dyskinesis, and high segmental intraluminal pressure. These diverticula arise on the mesenteric border where the mesenteric vessels penetrate the jejunum. Jejunal diverticula are very uncommon in individuals less than 40 years of age, and thus, the incidence of jejunal diverticular disease in childhood has not been reported till date. 
True (congenital) non-Meckelian jejunal diverticula are very rare and present early in the childhood. They are single, present along the anti-mesenteric border, and contain all three layers of the intestinal wall. Only three cases of non-Meckelian jejunal diverticula in children have been reported in the literature. Two of them presented with bowel obstruction secondary to jejunal diverticula and the third one was reported to have presented with bowel perforation resulting from jejunal diverticulitis. This is the second reported case of a giant congenital jejunal diverticulum presenting with diverticulitis and perforation in a child.  The etiology of true jejunal diverticulosis is unknown.
Most cases of this diverticulosis remain completely asymptomatic. When symptomatic, patients may describe a vague, chronic abdominal pain of varying severity, localized either to the epigastrium or periumbilical region. Complications of jejunal diverticulosis warranting surgical intervention occur in 8-30% of patients.  Common acute complications include diverticulitis, bleeding, intestinal obstruction, and perforation.  It is thought that the acidic, stagnant environment of these sacs encourage bacterial overgrowth and low-grade inflammation and, thus, give rise to these symptoms. 
Jejunal diverticulosis is a challenging disorder from a diagnostic perspective, with no truly reliable diagnostic tests. Abdominal radiographs and/or chest radiographs may demonstrate evidence of perforation, such as free air under the diaphragm or free peritoneal air; evidence of intestinal obstruction, or evidence of ileus, including multiple air-fluid levels and bowel dilatation. Computed tomography (CT) may identify thickening or inflammation of the jejunum or localized abscess formation. 
Diagnostic laparoscopy can be very useful in investigating patients with a complicated symptomatology. It enables an accurate conclusive diagnosis to be made, avoiding the need for unnecessary laparotomy. In the presence of laparoscopic findings such as perforation, abscesses, and mechanical obstruction, exploratory laparotomy is required with resection of the diseased bowel and primary anastomosis. If the perforation of a jejunal diverticulum causes only localized peritonitis and the patient remains stable, it has been reported that a trial of non-surgical management with IV antibiotics and other supportive measures alongside percutaneous CT-guided aspiration of localized intraperitoneal collections may be suitable and avoid the need for surgery. 
The current treatment of choice for perforated jejunal diverticula causing generalized peritonitis is prompt laparotomy with segmental intestinal resection and primary anastomosis. The extent of the bowel resection depends upon the length of the bowel that is affected by the diverticula and the patient's peri-operative condition.  If diverticula are extensive, resection may have to be limited to include only the segment containing the perforated diverticulum and leave a segment of small bowel that still contains non-perforated diverticula, in order to avoid short bowel syndrome. 
In our case, the decision was to go ahead after resuscitation for diagnostic laparoscopy, based on the clinical findings and the presence of pneumoperitoneum, without any further imaging investigations. As it was a solitary jejunal diverticulum, we performed resection of the diverticulum-bearing segment only with anastomosis.
In summary, we have described a case of a girl who presented with perforated jejunal diverticulum. She had a combination of two rarities, that is, giant solitary jejunal diverticulum in this age that presented acutely as peritonitis due to perforation.
| Conclusion|| |
Solitary giant jejunal diverticulum is a rare condition that can present with chronic vague abdominal pain and altered bowel habits, and can present acutely with complications as perforation with significant morbidity.
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[Figure 1], [Figure 2]