jcoloproctol(rioj).2016;36(1):50–52
w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Case
Report
Jejunal
diverticulitis
as
a
cause
of
acute
abdomen
夽
Cássio
Alfred
Brattig
Cantão
a,
Marley
Ribeiro
Feitosa
a,∗,
Maurício
Godinho
b,
Sandro
Scarpelini
b,
Omar
Féres
a,
José
Joaquim
Ribeiro
da
Rocha
aaDivisionofColoproctology,DepartmentofSurgeryandAnatomy,FaculdadedeMedicinadeRibeirãoPreto,UniversidadedeSãoPaulo
(USP),RibeirãoPreto,SP,Brazil
bDivisionofEmergencySurgery,DepartmentofSurgeryandAnatomy,FaculdadedeMedicinadeRibeirãoPreto,UniversidadedeSão
Paulo(USP),RibeirãoPreto,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory: Received3March2015 Accepted28August2015
Availableonline21December2015
Keywords: Jejunum Diverticulum Diverticulitis Acuteabdomen
a
b
s
t
r
a
c
t
Jejunoilealdiverticulosisisanuncommonandunderdiagnosedcondition.Mostpatients areasymptomaticandrequirenospecifictreatment.Afewpatients,however,present life-threateningcomplicationsthatmayrequiresurgicalintervention.Thepurposeofthisreport istoillustrateacaseofjejunoilealdiverticulosismanifestedasanacuteabdomen.
©2015SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.
Abdome
agudo
por
diverticulite
de
jejuno
Palavras-chave: Jejuno Divertículo Diverticulite Abdomeagudo
r
e
s
u
m
o
Adoenc¸adiverticulardointestinodelgadoéumaentidadeincomumepouco diagnosti-cada.Amaioriadoscasosnãoapresentasintomasenãonecessitadetratamentoespecífico. Algunspacientes,noentanto,podemevoluircomcomplicac¸õesdadoenc¸aenecessitarde tratamentocirúrgico.Oobjetivodesterelatoéilustrarumcasodediverticulosejejunalque evoluiuparaumquadrodeabdomeagudo.
©2015SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todososdireitosreservados.
夽
StudyconductedattheDepartmentofSurgeryandAnatomy,FaculdadedeMedicinadeRibeirãoPreto,UniversidadedeSãoPaulo (USP),RibeirãoPreto,SP,Brazil.
∗ Correspondingauthor.
E-mail:marleyfeitosa@yahoo.com.br(M.R.Feitosa). http://dx.doi.org/10.1016/j.jcol.2015.08.007
jcoloproctol(rioj).2016;36(1):50–52
51
Introduction
Jejunoilealdiverticulosis(JID)wasfirstdescribedby Soemmer-ingandBaillein1794.1Thediseaseischaracterizedbyfalse
diverticula(herniationofthemucosaandserosathroughthe muscularwall)andoccursatthe mesentericattachmentof thegut.2JIDisanuncommoncondition,affecting0.02–4.6%
ofthepopulation.3,4Thecourseisusuallyasymptomatic,but
up to40% of the patients may experience chronicpain or malabsorption.5Theaimofthisreportistoillustrateanacute
complicationofJID.
Case
report
A77-year-oldmanwasadmittedtothe emergency depart-mentwithathree-dayhistoryofaprogressiveabdominalpain, vomitingand fever.Physicalexam revealeddiffuse abdom-inalpainwithrigidity,guardingandreboundtendernessin therightlowerquadrant.Theabdomenwasalsodistended withdecreasedbowelsounds.Thewhitebloodcellcountwas normal.C-reactiveproteinwas19.64mg/L.Abdominalplain radiographrevealeddilatedsmall-bowelloopswithair-fluid levels.CTscanningoftheabdomenevidencedagglomerated jejunalloopswithwallthickeningintheiliacfossa(Fig.1).
The patient underwent a therapeutic laparotomy that identified diverticular disease of the jejunum. The largest diverticulummeasured5cm×4cmandwasadheredtothe ileum and cecum with remarkable inflammation. A 15cm enterectomy with a manual end-to-end anastomosis was performed (Fig. 2). Histopathological study diagnosed an abscedingdiverticulitisinthesurgicalspecimen.Thepatient madeafullrecoveryandwasdischargedonthefourthday afterthesurgery.
Discussion
Most patients with JID are asymptomatic. Forty percent, however, experiencenon-specific symptomssuchas vague
Fig.2–Resectedsegmentofjejunumevidencingalarge diverticulumwithmarkedinflammation.
abdominalpain,nauseaandoccasionalvomitingcausedby anintestinaldyskinesia.6Inalmost70%ofthecases,multiple
diverticulaarefound.Somediverticulamayreachmorethan 5cm,althoughsizedoesnotcorrelatetosymptoms.5
Duode-naldiverticulaarethreetimesmorecommonbutjejunoileal diseaseismorelikelytocomplicate.Complications,suchas inflammation,bleedingandobstructionarefoundin10%of thepatientsandarecommonlymisdiagnosedasappendicitis, cholecystitis,pepticulcerorcolonicdiverticulitis.7
Duetoitsvagueclinicalrepercussionandrelatively inac-cessibleanatomiclocation,preoperativeidentificationofJID is uncommonand challenging forclinicians and surgeons. In the context ofcomplicated disease, usually manifested as an acute abdomen, the surgeon must be aware of this possibilitytoavoidmisdiagnosisand treatmentdelay.Plain radiographs,ultrasoundand CTscansoftheabdomenmay be useful to help the diagnosis of JID complicated with inflammation/perforationorobstruction.8–10Endoscopy,
gas-trointestinalbleedingscintigraphyandarteriographymaybe
52
jcoloproctol(rioj).2016;36(1):50–52ofgreatvalueinthesettingofagastrointestinalhemorrhage. Surgery(laparoscopy/laparotomy)isthegoldstandardfor def-initediagnosisandtreatmentofcomplicateJID.11,12
Asymptomatic patients require no specificintervention. Thosewithsighs ofintestinaldyskinesiashouldhavetheir symptoms treated. Elective surgery should be reserved for patientswithrefractorysymptomsbutresultsare controver-sial.Anenterectomyoftheaffected segmentwithprimary end-to-endanastomosis is thestandard treatment. Indica-tionsforurgentsurgeryarethesameasinanyothercause of acute abdomen and must not be neglected under the riskofhighermortalityrates,thatmay reach40% insome reports.13–15
Conclusion
Jejunoilealdiverticulosisisanuncommonandpotentially life-threateningcondition.Symptomsofthediseaseareunspecific andrelatedtointestinaldyskinesiabutmostpatientshaveno gastrointestinalmanifestations.Treatmentisusuallydirected torelievesymptomsand surgeryisbest indicatedtothose patents with refractory symptoms or acute complications, suchasinflammationwithperforation,bleedingand obstruc-tion.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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