Mid-jejunal diverticulitis with closed-loop bowel obstruction, strangulation, and contained perforation

Abstract

Key clinical message: Closed-loop bowel obstruction and contained perforation secondary to acute on chronic jejunal diverticulitis is rare and should be included in the differential diagnosis of acute abdomen. The association between polymyalgia rheumatica and diverticular disease requires further research but may prompt clinicians to consider appropriate therapies in patients with both diseases.

Abstract: Jejunal diverticulosis is a sac-like outpouching of the intestinal wall that can cause complications such as diverticulitis, obstruction, abscess, perforation, or fistula formation. Complicated jejunal diverticulosis may present with acute abdomen and nonspecific symptoms which can lead to misdiagnosis and delayed treatment. A 76-year-old male with a remote history of polymyalgia rheumatica (PMR) presented with sudden onset abdominal pain, fever, nausea, vomiting, and inability to pass flatus. Physical exam revealed a distended and diffusely tender abdomen with signs of peritonitis. Laboratory test results were significant for neutrophil-dominant leukocytosis and elevated inflammatory markers. CT scan of the abdomen with IV contrast revealed a contained perforation and a closed-loop small bowel obstruction in the mid-abdomen. The patient underwent emergent exploratory laparotomy and resection of 100 cm of mid-jejunum which was found to have numerous diverticula surrounding the closed-loop obstruction and contained perforation. Pathology findings showed evidence of acute on chronic jejunal diverticulitis. Jejunal diverticulosis with complications may present with an acute abdomen and peritonitis. Closed-loop bowel obstruction and contained perforation secondary to acute on chronic jejunal diverticulitis is uncommonly thought of and should be considered in the differential diagnosis. Additionally, the association between PMR and diverticular disease is notable. While the patient had a remote history but no active PMR on presentation, studies suggest a possible association between gut inflammation and rheumatologic disease. This association should prompt clinicians to consider appropriate therapies and bear in mind the potential risk for diverticular perforation if glucocorticoids are given to treat PMR. Jejunal diverticulosis with multiple complications such as closed-loop bowel obstruction and contained perforation secondary to acute on chronic jejunal diverticulitis is rare and may present with an acute abdomen and nonspecific symptoms. Including rare pathologies as such in the differential diagnosis may prevent misdiagnosis and delayed treatment. While further investigation is needed, the association between diverticulosis and PMR is noteworthy as patients who present with both diseases would require mindful management due to the potential risk of diverticular perforation after treatment with steroids.

Keywords: diverticular diseases; diverticulitis; intestinal obstruction; intestinal perforation; jejunal diseases; polymyalgia rheumatica.

FIGURE 1

CT abdomen and pelvis with IV contrast, coronal view, showing a decompressed loop of small intestine (green arrow), phlegmon and contained perforation (blue arrows), and dilated fluid‐filled small intestine (yellow arrows).

FIGURE 2

CT abdomen and pelvis with IV contrast, coronal view, showing contained perforation with inflammatory changes (blue arrow) located posteriorly and to the left of the decompressed loop of the small intestine in Figure 1.

FIGURE 3

CT abdomen and pelvis with IV contrast, axial view, showing the decompressed small bowel loop as seen in Figure 1 (green arrow). There is also a contained perforation with extraluminal fecal content and free air posterior to the margin of the small intestine and associated phlegmon (blue arrow).

FIGURE 4

CT abdomen and pelvis with IV contrast, axial view, showing contained perforation with phlegmon (blue arrows) and diverticulum (yellow arrow).

FIGURE 5

CT abdomen and pelvis with IV contrast, coronal view, showing severely dilated small bowel (blue arrows) and fecalization (yellow arrow) of the small bowel from the closed‐loop obstruction.

FIGURE 6

Gross appearance of the resected segment shows a mass‐like lesion consisting of multiple diverticula with fibrous adhesions (arrows); proximal and distal segments of the jejunal wall are thickened and congested (arrowheads). The serosal surface is covered by fibrinopurulent exudates.

FIGURE 7

Histologic examination of the wall of the jejunal diverticulum shows vascular congestion, absent muscularis propria, serosal edema, and acute inflammation (Hematoxylin and eosin stain. Magnification X 100).

FIGURE 8

Histologic examination shows inflammatory changes in the diverticulum with abundant neutrophils and edema, indicative of acute diverticulitis (Hematoxylin and eosin stain. Magnification X 200).

FIGURE 9

Transmural necrosis of the diverticular wall visualized on histologic examination (Hematoxylin and eosin stain. Magnification X 100).

FIGURE 10

Immunostaining for smooth muscle Actin at the neck of the diverticulum shows the presence of the muscularis mucosa around the diverticulum, but the absence of the muscularis propria (Immunoperoxidase stain. Magnification X 100).