Hindawi

Case Reports in Surgery

Volume 2020, Article ID 8891521, 6 pages
https://doi.org/10.1155/2020/8891521

Case Report
Small Intestinal Diverticulosis: A Rare Cause of Intestinal
Perforation Revisited

Ahmed Faidh Ramzee ,1 Mohamed H. Khalaf,1 Khalid Ahmed ,2 Ejaz Latif,1

Noreddin Aribi ,1 Nizar Bouchiba,2 Rajvir Singh ,1 and Ahmad Zarour 2
1
Department of Surgery, Hamad General Hospital, Doha 3050, Qatar
2
Department of Acute Care Surgery, Hamad General Hospital, Doha 3050, Qatar

Correspondence should be addressed to Ahmed Faidh Ramzee; faidhramzee@live.com

Received 9 June 2020; Revised 5 October 2020; Accepted 13 October 2020; Published 21 October 2020

Academic Editor: Muthukumaran Rangarajan

Copyright © 2020 Ahmed Faidh Ramzee et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Jejunoileal diverticulosis (JID) is a rare and nonspecific symptomatic disease. It is usually an acquired condition associated with
false diverticula and integrated with colonic diverticulosis which can be diagnosed incidentally or later with complications. A
sixty-nine-year-old male presented with sudden onset generalized abdominal pain. Computed tomography (CT) imaging was
suggestive of ileal diverticulitis with localized perforation. The patient was treated conservatively with IV fluids and antibiotics
and kept nil per orem for three days and discharged after symptoms subsided. The patient returned with a similar presentation
but with a greater intensity. CT with oral contrast revealed evidence of distal ileal perforation. The terminal ileum was resected,
and a double barrel ileostomy was created. Six months later, the stoma was reversed after resecting 50 cm of proximal terminal
ileum which included all diverticula. The patient had a smooth postoperative recovery. Small bowel diverticulitis is generally
managed conservatively unless the patient’s clinical condition mandates urgent exploration. This report may add knowledge and
lead to a change in clinical practice.

1. Introduction of the diseased bowel and primary anastomosis if the condi-

tions allow [3]. We present a case of a 69-year-old male who
Jejunoileal diverticular disease is rare with a reported inci- presented with abdominal pain and was diagnosed with a
dence of 0.02–7.1% on imaging and 0.03–8.0% on autopsy. computed tomography scan to have a localized ileal divertic-
It is usually found in patients over the age of 40 and is more ular perforation and was initially managed conservatively
common in males (male/female ratio 2 : 1). Initially described and discharged. He subsequently returned with recurrent
by Somerling in 1794, jejunoileal diverticulosis is rarer than symptoms and was diagnosed with perforation requiring
duodenal diverticulosis; however, it is associated with a four- operative intervention in terms of a laparotomy, bowel resec-
fold higher risk of complications including diverticulitis, fis- tion, and stoma creation with reversal three months later.
tula formation, perforation, and hemorrhage [1, 2]. Most The patient had a smooth postoperative course, and the diag-
small bowel diverticulae are asymptomatic; however, almost nosis was confirmed on histopathological examination.
10% may go on to develop complications as described, and
thus, a more aggressive surgical approach has been warranted 2. Case Presentation
in such cases [3].
However, given the advanced age of patients presenting A 69-year-old, diabetic, South Asian male presented to the
with complicated jejunoileal diverticular disease, nonopera- emergency department of Hamad Medical Corporation
tive treatment may be a feasible option depending on the (HMC) in October 2019 with sudden onset generalized
clinical condition of the patient [3]. The current practice abdominal pain more pronounced in the right lower quad-
related to perforated small bowel diverticulitis is resection rant and hypogastric region. He also had associated nausea
2 Case Reports in Surgery

and fever. On initial examination, he was afebrile and vitally

stable and abdominal examination revealed tenderness in the
right lower quadrant and suprapubic area with rebound ten-
derness. The remainder of his review of systems and physical
exam was unremarkable. Computed tomographic (CT)
examination of the abdomen showed multiple ileal diverticu-
lae with focal wall thickening of the distal ileum and sur-
rounding fat stranding and air loculi along the wall of the
distal ileum suggestive of ileal diverticulitis with localized
perforation (Figure 1). He was admitted and managed con-
servatively with IV fluids and antibiotics and kept nil per
orem. His symptoms subsided, and he was discharged three
days later.
Two days after discharge, the patient returned to the Figure 1: CT scan depicting focal wall thickening of the distal ileum
and surrounding fat stranding and air loculi along the wall of the
emergency department with abdominal pain like the initial
distal ileum (arrow).
presentation but worse in intensity. A repeat CT with oral
contrast revealed evidence of distal ileal perforation
(Figure 2). Lebert et al. also reported a multicenter retrospective
The patient was taken for a laparoscopic exploration, and study of 33 patients with jejunoileal diverticulitis over a 10-
extensive peritonitis was noted; therefore, the procedure was year duration. Most of whom were female (73 percent) with
converted to a laparotomy. We noted a perforation in the a median age of 78. Most patients had localized left side flank
ileum 50 cm from the ileocecal valve on the mesenteric aspect pain and elevations in inflammatory factors (leukocyte count
of the bowel with a purulent exudate covering the terminal and CRP). Thirty out of 33 patients had a positive CT scan,
ileum (Figure 3). The terminal ileum was resected, and a which detected an inflammatory diverticulum. They used
double-barrel ileostomy was created. His recovery was Kaiser et al.’s modification of the Hinchey classification for
uneventful, and he was discharged on postoperative day 6. acute diverticulitis and described peri-jejunoileal inflamma-
Histopathological examination of the resected bowel revealed tion or phlegmon as stage IA, confined peri-jejunoileal
3 diverticulae with diverticulitis along with ulceration. abscess as stage IB, distant mesenteric abscess as stage II,
Enteroscopic examination through the stoma showed multi- and stage III as generalized purulent peritonitis. More than
ple diverticulae up to 50 cm within the proximal limb 70% of patients were stage IA. Eight patients who were found
(Figure 4). Three months postoperatively, his stoma was to have a severe presentation underwent emergent surgery.
reversed after resecting 50 cm of proximal terminal ileum Conservative therapy was effective in 18 patients, all with
which included all diverticulae. Postoperative course was moderate disease, and 5 patients underwent surgery after
uneventful, and the patient made a full recovery. Final histo- conservative treatment.
pathology revealed diverticular disease in the resected por-
tion of the ileum with no evidence of diverticulitis.
4. Discussion
3. Review of Literature Jejunoileal diverticulosis was first described over 200 years
ago by Soemmering and Baille in their book titled Anatomy
The literature review yielded 14 cases of small intestinal of the Pathological Structure of Some of the Most Important
diverticulitis presented in Table 1. All patients except two Parts in the Human Body in 1794 [2]. In contrast to large
were above the age of 70 (age ranging from 29 to 87), the bowel diverticulae, those arising in the small bowel are quite
majority of whom were male (male to female ratio of uncommon, with the frequency of prevalence as well as the
2.5 : 1). Four patients were operated on an emergency basis. number of diverticulae descending from the duodenum
Two patients underwent surgery due to the failure of conser- (0.02% to 6%) to the jejunoileum (0.07% to 1%), with only
vative treatment (Case No. 8 and 10—Table 1). Three of the 2.3-6.4% of these patients going on to develop diverticulitis
patients had complicated perforated diverticulitis and were [3, 4]. Most small bowel diverticulae produce no symptoms
successfully managed conservatively (Cases 3, 6, and unless complicated by inflammation, perforation, bleeding,
10—Table 1). One patient was managed conservatively and small bowel obstruction, or malabsorption [5]. Complica-
discharged but returned 2 months later with recurring symp- tions were noted to occur in approximately 10% of individ-
toms and was operated upon, while another patient with uals, with jejunoileal diverticulae 3-4 times more likely to
recurrent symptoms was managed conservatively. Interest- develop complications than duodenal diverticulae [6]. Mor-
ingly, one patient had recurrent presentation after having tality from perforated diverticulae is high, ranging from 21
resection and anastomosis of jejunal diverticulitis a few years to 40%; this has been attributed to the delay in diagnosis as
prior (Case No. 6—Table 1). The distribution of the type of well as the inherent risks associated with the elderly age of
treatment administered is displayed in Figure 1. None of patients presenting with this disease [7]. Up to 60% of
the cases reported malignancy in the studied bowel speci- patients with small bowel diverticular disease may have con-
mens. Figure 5 depicts the mode of management for all cases. comitant colonic diverticulae [1].
Case Reports in Surgery 3

There are no pathognomic signs or symptoms of ileal

diverticulitis; hence, it needs a high index of suspicion.
Patients may have diffuse acute abdominal pain or lower
abdominal pain and tenderness with right lower quadrant
features mimicking appendicitis. Fever and leukocytosis
may also be commonly associated [10, 11]. Elderly individ-
uals may pose a challenge in diagnosis due to a lack of clear
physical signs; however, in rare circumstances, patients may
present with subcutaneous emphysema due to intraperito-
neal air causing rupture of the anterior abdominal wall which
may help guide the clinician towards a diagnosis of intestinal
perforation [12, 13].
Figure 2: CT scan revealing perforation and collection at the distal The suggested method of radiological examination for
ileum (arrow). diverticulitis is computed tomography. In a study where CT
and ultrasound (US) of the abdomen was compared, CT
was found to have a slightly greater ability to detect colonic
diverticulitis than US [14]. Bowel gas may compromise US,
therefore making detection of small bowel diverticulitis even
more challenging. Ileal diverticulitis can mimic acute appen-
dicitis; therefore, detection by CT abdomen has an additional
benefit of the reduction in negative appendectomies, thereby
preventing unnecessary surgery [1, 15]. CT with intravenous
contrast is recommended [1, 16, 17]. The use of oral contrast
in the treatment of patients with acute abdomen, however, is
debated [1, 5].
Unlike the management of colonic diverticulitis, there is
no grading system to stratify disease severity. The decision
to proceed with conservative or surgical management is an
area of controversy owing to the rarity of the condition and
therefore a dearth of literature. It is generally accepted that
any patient with perforated small intestinal diverticulae with
generalized peritonitis and deterioration of the clinical status
of the patient should undergo an operative segmental resec-
Figure 3: Intraoperative image depicting the site of ileal diverticular tion examination [7]. Diverticulae may be widespread
perforation on the mesenteric border. throughout the intestine; therefore, the question arises as to
how much length of the bowel needs to be resected and can
we leave behind grossly normal diverticulae in order to avoid
the risk of short bowel.

5. Conclusion
Non-Meckel’s small intestinal diverticulitis is a rare entity
and usually a disease of the elderly and thus carries a high
potential for mortality. Delay in diagnosis may also increase
the burden of morbidity and mortality. CT scans of the abdo-
Figure 4: Postoperative enteroscopy depicting multiple men are the diagnostic modality of choice. However, in the
diverticulae. presence of a negative CT and complicated patient symptom-
atology, diagnostic laparoscopy may be an acceptable option.
The choice of conservative versus surgical management is a
Small bowel diverticulae are commonly seen in elderly point of debate given that patients with complicated perfo-
males, in the sixth to seventh decade of life [8]. Acquired rated diverticulae have been successfully managed conserva-
small bowel diverticulae are pseudo (false) diverticulae, con- tively. However, the risk of recurrence with a more severe
sisting of a thin-walled outpouching formed by the mucosa presentation needs to be kept in mind as was the case in
and submucosa bulging through the muscular layer as our patient. It is advisable to perform surgery for those
opposed to Meckel’s diverticulae (congenital) which contain patients with evidence of generalized peritonitis and deterio-
all layers of the intestinal wall [1]. The pathogenesis has been rating clinical parameters. Recurrent symptoms after conser-
explained to occur in areas of muscular weakness at the vative management may warrant surgical exploration
points of penetration of the vasa recta vessels along the mes- depending on the clinical presentation of the patient. Resec-
enteric edge of the bowel [9]. tion of the affected segment of the bowel loop is the current
 4
Table 1: Details of all 14 cases.

WBC-
No. Age Sex Symptoms Signs Past medical history Method of diagnosis and findings Management Histology Follow-up Ref.
/L
Multiple
LLQ and
Diffuse CT: jejunal diverticulitis with jejunal
1 82 M hypogastric 18.2 Surgical resection Uneventful [4]
tenderness perforation diverticulae.
pain
No malignancy
Multiple
Localized CT: thickening of the distal jejunal jejunal
2 48 F RLQ pain 15.6 Surgery resection NA [4]
tenderness loop with extraluminal air bubbles inflamed
diverticulae
6 monthly follow-up
Abdominal Tenderness CT: small intestinal diverticulitis
3 87 M 13.8 Conservative for 5 years, no [5]
pain & fever in LLQ with perforation
recurrence
Hypertension,
Small bowel
hyperlipidemia, atrial
obstruction one year
Abdominal fibrillation, and CT: small intestine diverticulitis,
later, managed
4 78 F pain NA 16.4 diabetes. with a large diverticulum (4.7 cm) Conservative [5]
conservatively. Dead
+diarrhea Osteosarcoma of the near the jejunum
at 7 years-esophageal
thigh with lung
adenocarcinoma
metastasis
Right hemicolectomy
Postprandial
for hepatic flexure CT: multiple jejunal diverticulae 8 months follow-up,
5 76 M abdominal NA 19.9 Conservative [5]
adenocarcinoma one with an inflammatory process no recurrence
pain
year prior
Segmental resection CT: localized perforation of the
Epigastric
RUQ and anastomosis of small bowel with multiple dilated
pain for one
guarding perforated jejunal loops of small bowel surrounding
6 87 M week, 7.7 Conservative No recurrence [7]
and diverticulum 3 years an area of marked soft tissue
bloating,
tenderness prior. Colonic stranding with multiple small
loose stools
diverticulae locules of gas
Guarding
and Conservative. Readmitted
Ileal & colonic CT: Sigmoid diverticulitis. Repeat Elective surgery
7 35 M RLQ pain tenderness 15.5 2 weeks later, managed [8]
diverticulosis CT on 2nd admission confirmed performed later
in RLQ. conservatively.
Febrile
Multiple Died post-op day 8-
Diffuse Diffuse LGI bleeding 3 Conservative for 10 days- diverticulae in acute myocardial
+lower tenderness, months prior. laparotomy-right the terminal ischemia. Autopsy-
8 73 F 5.8 Barium enema X-ray [10]
abdominal hypobowel Descending colon hemicolectomy due to ileum, one multiple small bowel
pain sounds diverticulosis suspicion of cancer perforated. No diverticulae, not
malignancy inflamed
Right-sided Diffuse Recently diagnosed Diagnostic laparoscopy
9 29 M 23 Diagnostic laparoscopy [18]
lower guarding renal disease converted to laparotomy
Case Reports in Surgery
 Table 1: Continued.

WBC-
No. Age Sex Symptoms Signs Past medical history Method of diagnosis and findings Management Histology Follow-up Ref.
/L
Case Reports in Surgery

abdominal and rigidity, due to adhesions.

Single inflamed
pain more on the Resection and
diverticulum.
RLQ. anastomosis
No malignancy
Febrile
Multiple
jejunal
Conservative till day 6;
Right lower Tender diverticula with
CT: cavitated thin-walled lesion in laparotomy with Discharged on day 5
10 81 M abdominal mass in the 13.9 Significant weight loss mucosal [19]
RIF resection and post-op
painful mass right flank ulceration and
anastomosis
inflammatory
lesions
Hypertension,
Generalized CT: thickening of the distal jejunal Multiple
Diffuse chronic obstructive
tenderness loop and thickening and Surgical resection and jejunal
11 79 M abdominal 16 pulmonary disease, [20]
with signs of infiltration of the mesenteric fat anastomosis diverticuale.
pain diabetes, and
peritonitis and free air in the mesentery No malignancy
cholecystectomy
Initially conservative.
Colonic diverticulosis
CT: colonic diverticulosis. Presented 2 months later
and an episode of
Abdominal Multiple diverticula of the small with recurrence, managed No evidence of
12 67 M NA 12.2 gastrointestinal NA [21]
pain intestine, with signs of with surgical resection malignancy
bleeding one year
inflammation underwent double
before
enterectomy
Gunshot wound to CT: focally thickened loop of small
Localized the abdomen bowel in the anterior midabdomen
RLQ Well after 1 year
13 77 M abdominal 11.4 requiring an with a small collection adjacent to Conservative [22]
tenderness the thickened small bowel follow-up
pain exploratory
laparotomy measuring 2:8 cm × 1 cm
Generalized
Generalized CT: multiple small bowel
abdominal Laparotomy-2 pin hole
abdominal diverticulae with surrounding
14 82 F tenderness 18.2 perforations-primary NA [23]
pain for one pockets of free air adjacent to the
with signs of closure
day jejunal diverticula
peritonitis
WBC: white blood cell count; NA: not available; RUQ: right upper quadrant; RLQ: right lower quadrant; LLQ: left lower quadrant; CT: computed tomography; references: [4, 5, 7, 8, 10, 16–21].
5
6 Case Reports in Surgery

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Conflicts of Interest [15] S. Y. Lee, B. Coughlin, J. M. Wolfe, J. Polino, F. S. Blank, and
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