Gastrointest Radiol 16:24-28 (1991)

Gastrointestinal

Radiology 9 Springer-VerlagNewYorkInc.1991

Diverticulitis of the Jejunum: Clinical and Radiological Features Ellen C. Benya, Gary G. Ghahremani, and Jerome J. Brosnan Department of Diagnostic Radiology, Evanston Hospita~McGaw Medical Center of Northwestern University, Evanston, Illinois, USA

Abstract. This article describes three cases of jejunal diverticulitis in elderly women, who had presented with pain and tenderness in the periumbilical region or the left side of the abdomen, lowgrade fever, anemia, and weight loss. The findings were initially attributed to possible inflammatory or neoplastic lesions of the colon. However, gastrointestinal barium studies and computed tomography (CT) of the abdomen proved crucial in establishing the preoperative diagnosis of jejunal diverticulitis and its associated abscess in the adjacent mesentery or abdominal wall. The clinical and radiological manifestations of this uncommon entity are herein presented along with a brief review of the pertinent literature. Key words: Abdomen, CT - Jejunum, diverticulitis - Intestinal diverticula, complications.

Acquired small bowel diverticula are present in approximately 2-3% of adults beyond the age of 40 years and predominantly involve the proximal jejunum [1, 2]. These mucosal outpouchings develop on the mesenteric aspect of an intestinal loop along the pathway of supplying blood vessels [3]. Most jejunal diverticula remain asymptomatic and are detected as an incidental finding during barium studies of the gastrointestinal tract, abdominal surgery, or autopsy. However, they can also produce a wide spectrum of complications and present as a formidable diagnostic challenge [1-6]. Our recent experience with three cases of jejunal diverticulitis prompted us to review the clinical and radiological manifestations of this uncommon entity. Address offprint requests to: Gary G. Ghahremani, M.D., Department of Diagnostic Radiology, Evanston Hospital, 2650 Ridge Avenue, Evanston, IL 60201, USA

Case Reports

Case 1 A 73-year-old woman developed an acute onset of cramping pain in the left paraumbilical region, with chills and fever of 41 ~ C on the evening prior to admission. She also experienced indigestion, abdominal bloating, and loss of appetite during the previous 2 weeks. A similar episode 6 months earlier had been presumptively diagnosed as colonic diverticulitis; it had responded to conservative treatment with dietary measures and antibiotics. Her past medical history included multiple abdominal operations for uterine cancer, cholecystitis, and lysis of adhesions. Physical examination revealed guarding and rebound tenderness in the left paraumbilical region, associated with diminished bowel sounds. Radiographs of the abdomen demonstrated two calcified mesenteric lymph nodes and several surgical clips in the pelvis, but no evidence for free air or intestinal distention. Laboratory tests showed a white blood cell count (WBC) of 18,000/mm 3, hemoglobin of 13 g/dl, blood urea nitrogen (BUN) of 13 mg/dl, and guaiac-negative stools. The patient was started on intravenous ampicillin sodium because of suspected diverticulitis of the colon. However, abdominal CT scan 2 days later revealed a distinct inflammatory mass involving the proximal jejunum and its mesentery (Fig. 1 A and B). Small bowel series showed numerous jejunal diverticula; one of them was deformed and surrounded by a tender mesenteric mass (Fig. 1 C and D). These radiological findings indicated a jejunal diverticulitis, but the possibility of an ulcerated or infected tumor led to surgical exploration. At laparotomy there was diffuse jejunal diverticulosis and a 7-cm segment of it, as well as the attached mesentery, were involved by severe inflammatory changes. Histopathologic evaluation of the resected specimen confirmed the diagnosis of a perforated jejunal diverticulitis with mesenteric abscess. The patient's postoperative course was uneventful.

Case 2 A 60-year-old woman presented with a 3-week history of lowgrade fever, malaise, and a dull periumbilical pain. She had undergone a segmental colectomy for carcinoma of the splenic flexure 9 years earlier and had been in good health during this interval. Her physical examination revealed an obese woman with an ill-defined, fluctuant, and tender mass beneath the scar of her left paramedian incision. Laboratory tests showed WBC

E.C. Benya: Diverticulitis of the Jejunum

Fig. I. Case 1. CT and radiographic features of jejunal diverticulitis. A This section of abdomen at the level of iliac crest shows the engorged mesenteric vessels and inflammatory changes of the jejunal loop (arrows) anterior to the left psoas muscle. B The section 2 cm lower demonstrates an irregular gas collection within the mesenteric abscess caused by perforated diverticulum (arrows). C Small bowel examination with barium shows diverticulosis of jejunal loops proximal to a segment with thickened and distorted mucosa (arrows). D Spot film obtained 1 h later reveals partial opacification of the perforated diverticulum (arrows), which is the center of an interloop abscess.

of 12,900/mm 3, hemoglobin of 11.6 g/dl, carcinoembryonic antigen (CEA) of 1.0 ng/ml (normal range, 0-3.0 ng/ml), and guaiac-positive stools. CT of the abdomen revealed an incisional hernia containing a bowel loop and an adjacent large

25

encapsulated fluid collection in the subcutaneous fat (Fig. 2A and B). There was no evidence of an intraabdominal mass or liver metastases. A drainage catheter was inserted into the fluid collection within the anterior abdominal wall and 550 ml of purulent opaque material was removed; its cultures grew Morganella morganni and Bacteroides fragilis. Despite antibiotic therapy there was continued discharge from the abdominal wall drain, suggesting the possibility of an enterocutaneous fistula. A barium enema showed postsurgical shortening of the otherwise normal colon. Small bowel series revealed diverticulosis of the proximal jejunum, with a loop of it herniating anterolaterally and communicating with a large lobulated diverticulum measuring about 5 cm in diameter (Fig. 2 C). A sinogram performed via the drainage catheter showed opacification of the same structure and the attached jejunal loop (Fig. 2D). The patient subsequently underwent surgical repair of the incisional hernia and resection of a jujunal segment involved by chronic diverticulitis.

26

E.C. Benya: Diverticulitis of the Jejunum

E.C. Benya: Diverticulitis of the Jejunum

Case 3 This 72-year-old woman with a past history of duodenal ulcer was found to have microcytic anemia and hemoccult-positive stools during a routine medical evaluation. She had recently experienced postprandial epigastric discomfort and loss of appetite. An upper gastrointestinal endoscopy revealed a hiatus hernia with mild reflux esophagitis, and colonoscopy showed moderate diverticulosis of the descending colon and sigmoid. However, a visible source of intestinal hemorrhage was not identified. Small bowel examination with barium demonstrated a solitary 4-cm diverticulum on the mesenteric side of proximal jejunum. Fluoroscopy and multiple spot films revealed that this diverticulum would not empty its content even after applying external pressure with a compression device. There was also localized tenderness of the ulcerated diverticulum and its separation from the adjacent jejunal loops by probable mesenteric edema or inflammation (Fig. 3A). A provisional diagnosis of jejunal diverticulitis was made, and the patient was treated conservatively with antibiotics and dietary regimen. However, a persistent epigastric tenderness and passage of maroon-colored stools led to further evaluation. CT of the abdomen showed that the jejunal diverticulum had a patent lumen and slightly thickened wall, surrounded by mesenteric fat with somewhat prominent vessels (Fig. 3 B). Scintigraphy after injection of Tc99m labeled red blood cells disclosed gradual pooling of radioactivity in the proximal small bowel, suggesting extravasation from the area of jejunal diverticulum. At laparotomy, a 10-cm segment of jejunum harboring a large diverticulum with partially denuded mucosa and congested serosal surface was resected. It showed subacute and chronic inflammatory changes involving both the diverticulum and the mesenteric side of the adjoining jejunum.

Discussion

Two distinct types of small bowel diverticula with a combined incidence of about 3-5% occur among

Fig. 2. Case 2. A and B Two CT sections of the lower abdomen demonstrate the herniated bowel loop (arrows) and a large encapsulated pus collection (open arrows) within the thick subcutaneous fat of this obese women. C Small bowel examination shows diverticulosis of the jejunal loop, which is projecting laterally into incisional hernia related to previous left hemicolectomy. Note the presence of a very large diverticulum with lobulated margins (arrows). D Fistulogram after percutaneous abscess drainage reveals direct communication with a jejunal loop through the large irregular cavity of the same jejunal diverticulum as seen in Fig. 2C (arrows). Fig. 3. Case 3. A Spot film shows a large solitary diverticulmn of the proximal jejunum with focal ulceration (arrow). Peridiverticular mesenteric edema and inflammation caused localized tenderness with separation and intermittent spasm of adjacent jejunal segments, as well as rigidity and barium retention in the involved diverticulum. B Follow-up CT of the abdomen demonstrates the same diverticulum with slightly serrated margins connected to the medial aspect of proximal jejunum (white arrow). Thickening of the adjacent jejunal wall and diverticular neck are visible (black arrows) along with prominent superior mesenteric vessels, but focal infiltration of the mesenteric fat was better seen at the next levels.

27

the general population. A true diverticulum containing all three intestinal layers is present on congenital basis in 2-3% of individuals, usually as a Meckel's diverticulum located on the antimesenteric aspect of the ileum 30-60 cm from the ileocecal valve [7, 8]. This is in contrast to the acquired form of small bowel diverticula, which are thinwalled mucosal herniations through the gaps in muscular layers along the pathway of visceral vessels. These "pseudodiverticula" are often multiple and typically situated on the mesenteric aspect of intestinal loops where the blood supply through vasa recta is derived [3]. Acquired small bowel diverticula are detectable by enteroclysis in 2-2.3% of adults over 40 years of age; they are usually much larger and more numerous in the proximal jejunum than elsewhere in the small intestine [1, 2]. Most jejunal diverticula remain asymptomatic and are found incidentally during gastrointestinal radiography, surgery, or autopsy. However, they can present with clinical symptoms due to complications, such as acute diverticulitis [4-6, 9], hemorrhage [10, 11], intestinal obstruction [1, 5], contained perforation with interloop abscess [4, 9], pneumoperitoneum [12, 13], and megaloblastic anemia due to vitamin B12 malabsorption secondary to chronic stasis and bacterial overgrowth within the jejunal diverticula [14-17]. These and other serious complications of jejunal diverticulosis led to surgical intervention in 24 to 62 (38%) patients in the series reported by Altmeier et al. [18] and in about 10% of 87 cases reviewed by Baskin and Mayo [4]. In contrast to their counterparts in the colon, the jejunal diverticula are an uncommon site of inflammation, possibly due to their larger size and better intraluminal flow of the relatively sterile, liquid content of the jejunum [1, 9, 16]. Our three patients were elderly women, who had presented with rather nonspecific clinical findings of epigastric or left abdominal pain, low-grade fever, anemia, and/or weight loss. They were initially thought to suffer from diverticulitis of the descending colon or sigmoid. In each instance, however, the combination of abdominal CT and small bowel series proved crucial in establishing the correct preoperative diagnosis. The radiological features of jejunal diverticulitis in our series and the five previously reported cases are quite similar [9, 19-22]. The most significant finding is the demonstration of a saccular outpouching, presenting as an air- or contrast-filled structure juxtaposed to the mesenteric side of the proximal small bowel. An inflamed diverticulum is usually deformed, showing an elongated irregu-

28

lar outline with rigidity and tenderness on compression during fluoroscopy. The adjacent jejunal loop is often narrowed due to localized inflammation, edema, or spasm (Figs. 1 C and D and 3 A). On CT scans the jejunal diverticula that are filled with air or contrast have a barely visible l-2-mm wall consisting of mucosa and submucosa without muscular elements. Localized thickening of these two very thin layers may not be appreciable, whereas peridiverticular edema, inflammation, hemorrhage, or abscess within the mesenteric fat (Figs. 1 A and B, 2 A, and 3 B) are easily recognized on CT examination [9, 21, 22]. Diverticulosis has become the most frequent disorder of the colon in the United States, affecting about 20-40% of individuals beyond the age of 40 years. Approximately 10-20% of them also develop small bowel diverticulosis, and its prevalence has increased two- to threefold over the past half century as indicated by statistical data published in this interval [1, 2, 18]. The contributing factors might be the increased longevity of Americans, their changing dietary habits, and better detection of diverticula due to improved radiological methods. CT of the abdomen and small bowel series play a crucial role in the diagnosis of jejunal diverticulitis as illustrated here and in a few recent case reports [19-22]. Selective superior mesenteric arteriography and radionuclide imaging techniques may also help in localizing intestinal hemorrhage secondary to jejunal diverticulitis [11]. This entity has relatively nonspecific clinical signs and an insidious course, and its delayed diagnosis can lead to interloop abscesses or perforation with up to 40% mortality [4-6, 9, 18]. However, a favorable prognosis can be expected if an early diagnosis is followed by aggressive antibiotic therapy and/or surgical intervention. References 1. Maglinte DDT, Chernish SM, DeWeese R, et al. : Acquired jejunoileal diverticular disease: Subject review. Radiology 158: 577-580, 1986

E.C. Benya: Diverticulitis of the Jejunum 2. Salmonowitz E, Wittich G, Hajek P, et al. : Detection of intestinal diverticula by double-contrast small bowel enema: Differentiation from other intestinal diverticula. Gastrointest Radiol 8:271-278, 1983 3. Meyers MA: Clinical involvement of mesenteric and antimesenteric borders of small bowel loops: Radiologic interpretation of pathologic alterations. Gastrointest Radiol 1:49-58, 1976 4. Baskin RH, Mayo CW: Jejunal diverticulosis: A clinical study of 87 cases. Surg Clin North Am 32:1185-1196, 1952 5. Donald JW: Major complications of small bowel diverticula. Ann Surg 190:183-188, 1979 6. Eckhauser FE, Zelenock GB, Frier DT: Acute complications ofjejunoileal pseudodiverticulosis : Surgical complications and management. Am J Surg 138: 320-323, 1979 7. Ghahremani G G : Radiology of Meckel~ diverticulum. Crit Rev Diag Imaging 26: 1-43, 1986 8. Maglinte DDT, Elmore MF, Isenberg M, et al. : Meckel's diverticulum: Radiologic demonstration by enteroclysis. A JR 134:925-932, 1980 9. Freimanis MG, Plaza-Ponte M : Radiologic diagnosis of jejunal diverticulitis. Gastrointest Radiol 13: 312-314, 1988 10. Mayo CW, Baskin RH Jr, Hagedorn AB: Hemorrhagic jejunal diverticulosis. Ann Surg 136:691-700, 1952 11. Tisando J, Konerding KF, Beachley MC, et al. : Angiographic diagnosis of a bleeding jejunal diverticulum. Gastrointest Radiol 4:291-293, 1979 12. Dunn V, Nelson JA: Jejunal diverticulosis and chronic pneumoperitoneum. Gastrointest Radiol 4:165-168, 1979 13. Madura MJ, Craig RM: Duodenal and jejunal diverticula causing a pneumoperitoneum. J Clin Gastroenterol 3: 61-63, 1981 14. Knauer CM, Svoboda AL: Malabsorption and jejunal diverticulosis. Am J Med 4,4:606-610, 1968 15. Cooke WT, Cox EV, Forte DJ, et al. : The clinical and metabolic significance of jejunal diverticula. Gut 4:115-117, 1963 16. Goldstein F, Wirts CW, Salen G, Mandle R J: Diverticulosis of the small intestine : Clinical, bacteriologic and metabolic observations in a group of seven patients. Am J Dig Dis 14:170 181, 1969 17. Krishnamurthy S, Kelly MM, Rohrmann CA Jr, et al. : Jejunal diverticulosis. Gastroenterology 85: 538-547, 1983 18. Altmeier WA, Bryant LR, Wulsin JH: The surgical significance of jejunal diverticulosis. Arch Surg 86.'732-741, 1963 19. Giustra PE, Killoran PJ, Root JA, et al. : Jejunal diverticulitis. Radiology 125: 609-611, 1977 20. Radecki PD, Hricak H, Oh HK, et al. : Jejunal diverticulitis with perforation. J Clin Gastroenterol 3:375 377, 1981 21. Greenstein S, Jones B, Fishman EK, et al.: Small bowel diverticulitis: CT findings. A JR 147: 271~74, 1986 22. Merine D, Fishman EK, Jones B: CT of the small bowel and mesentery. Radiol Clin North Am 27:707-715, 1989 Received: February 8, 1990; accepted." April 5, 1990

Diverticulitis of the jejunum: clinical and radiological features.

This article describes three cases of jejunal diverticulitis in elderly women, who had presented with pain and tenderness in the periumbilical region ...
2MB Sizes 0 Downloads 0 Views