Mr Diwa N Das Staff Grade General Surgery Lorn & Islands District General Hospital Glengallan Road Oban PA34 4HH
Dr Jiten Walia. SHO General Surgery Lorn & Islands District General Hospital Glengallan Road Oban PA34 4HH
Dr Santosh R Gone. SHO General Surgery Lorn & Islands District General Hospital Glengallan Road Oban PA34 4HH
Mr D J Scobie Consultant Surgeon General Surgery Lorn
& Islands District General Hospital Glengallan Road Oban PA34 4HH
Corresponding Author: Mr Diwa N Das: E-mail: mrdnd@rediffmail.com.
Abstract:
Proximal jejunal diverticula perforation should be
treated by primary closure and inversion and omental patch.
Key Words:
Introduction:
A
diverticulum of intestinal tract is a pocket or protrusion deriving from the
lumen and extending through wall of the gut. True diverticula are congenital and
have all the layers of gut i.e. serosa, muscle layers and mucosal. False
diverticula are acquired and they lack muscle layer1.
Longo
and Vernava describes first publication about jejunal diverticulitis by Sir
Astley Cooper in 18072.
Osler
described about jejunal diverticula in 1881 in a gentleman who used to have such
loud noise in his belly after each meal that he had to leave room after meals3.
Jejunal
diverticula are not common. It is found in 1%-2% of adult population and is
usually acquired and asymptomatic. They are usually found in adults over 70
years. They are multiple in numbers, more numerous in proximal small intestine.
One explanation is that vasa recta are of large calibre in proximal small
intestine4. Other explanation could be abnormal myenteric plexus
activity2. They are false diverticulum and develops due to pulsion
thought to be the result of intestinal dyskinesia. They are located on
mesenteric side and at times are buried in the mesentery.
The
usual symptoms of Jejunal diverticula are diverticulitis, GI haemorrhage,
intestinal obstruction, acute abdomen, chronic abdominal pain, anaemia and
malabsorption2. Formation of enterolith, fistulation to other
surrounding organs, asymptomatic pneumoperitoneum and malignant transformation
are rare5.
Case Note:
75
year old lady, a Jehovah’s witness, presented to NHS24 with sudden onset of
severe abdominal pain at half past eight in the morning and she was advised to
go to A&E. In A&E she was assessed and was found to have peritonism in
her abdomen. She was given intravenous morphine and that settled her. There was
no history of altered bowel habit or weight loss. She suffered two strokes in
recent past and multiple TIAs. She was taking Aspirin 75mg/day and Persantin. A
provisional clinical diagnosis of duodenal perforation was made. Patient was
fasted and started on IV drip. CXR and AXR were done. Blood report showed
leucocytosis and neutrophilia but normal U&Es and normal liver function
tests including amylase. CXR didn’t show any pneumoperitoneum and AXR was
non-specific.
Patient
remained stable. Next day her leucocytosis increased and CRP went over 200 mg/l.
A repeat CXR again didn’t show pneumoperitoneum. But clinically she had
generalised tenderness and guarding and decision was made to explore the abdomen
with a provisional diagnosis of DU perforation.
On
exploratory Laparatomy there was no escape of gas from peritoneum and no free
peritoneal fluid was seen. On full exploration of small intestine a burst upper
jejunal diverticulum was noticed behind transverse colon about 3-4cm from D-J junction (Photo1). The
content of diverticulum was whitish yellow pus that was sent for culture and
sensitivity. No intestinal content came out through the perforation. There was
evidence of reaction around diverticulum and mesentery with fibrin deposits and
whitish flakes. Further exploration of jejunum showed two more diverticulum
about 10-12cm from the first one but they were not perforated. (Photo2).
The
option of segmental diverticulectomy and primary end-to-end anastomosis (7) was
weighed against the limitation of almost nonexistent proximal loop and found to
be not feasible. It needed the mobilization of third and fourth part of duodenum
from retroperitoneal part, a very complex procedure with many important vascular
and biliary structures in imminent danger of accidental injury. So it was
decided to treat this perforation with primary closure and inversion (Photos
3a,b,c,d.) and omental patch. The diverticulum was over sewn by 4/0 monocryl and
then inverted. An omental patch was fashioned from greater omentum and anchored
around the diverticulum. (Photos 4).
Liberal peritoneal wash out was carried out and abdomen closed in layer
after putting a suction drain. Antibiotic was continued for all together five
days. Patient made excellent recovery.
Discussion:
On literature review in Med Line most of publications are case reports about jejunal diverticulitis.
Four retrospective analysis of jejunoileal disease states that it is a disease of elderly population. It is mostly diagnosed per-operatively. Treatment is usually segmental resection or diverticulectomy7,8,9,10.
The perforation of jejunal diverticulum is rare and in our case it typically presented as DU perforation sans pneumoperitoneum. Preoperative diagnosis is not possible11.
Noble describes a triad of obscure abdominal pain, anaemia and dilated small bowel loops in plain abdominal X-ray as highly suggestive of jejunoileal diverticula disease12.
The
surgical treatment options are segmental jejunal resection and end-to-end
anastomosis. But this is possible if the perforated diverticula are sufficiently
away from DJ junction. The surgical options become limited in perforations very
close to D-J Junction, as there is hardly any length of jejunal available for
joining together. Moreover majority of patients are elderly with co-morbidity13.
In perforated duodenal diverticula, the peritonitis is usually in
retroperitoneal plane and conservative approach is adopted. If at all operation
is decided, it involves complete diversion of gastric and biliary flow from
affected area of duodenum14. But if it is a very proximal jejunal
diverticulum perforation with frank peritonitis and on balance it is better to
treat with primary closure and inversion of diverticulum and an omental patch.
It is simple to do with good result.
Although
jejunal diverticula is a rare entity and usually asymptomatic, it may some times
present as diagnostic challenge. The delay in diagnosis may result in morbidity
and mortality. Thus clinical diagnosis should consider jejunal diverticulum
perforation in obscure abdominal pain in elderly population15.
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