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Jejuno–ileal diverticulitis with localized perforation: CT and US findings
European Journal of Radiology 71 (2009) 318–323
Jejuno–ileal diverticulitis with localized perforation: CT and US findings Luc´ıa Gra˜na ∗ , I˜nigo Pedraja, Ramiro Mendez, Ricardo Rodr´ıguez Department of Diagnostic Imaging, Hospital Cl´ınico San Carlos, Profesor Mart´ın Lagos, 28040 Madrid, Spain Received 12 January 2008; received in revised form 12 April 2008; accepted 22 April 2008
Abstract Purpose: To describe the computed tomography and ultrasound findings of five cases of small bowel diverticulitis with localized perforation. Material and methods: Our database, from April 2003 to August 2007, was reviewed and five cases of small bowel diverticulitis were identified. Results: Jejuno–ileal diverticulitis with covered perforation usually presents as wall thickening of a small bowel loop and an adjacent inflammatory mass containing air bubbles. Conclusion: Small bowel diverticula are rare and mostly asymptomatic. They become clinically relevant when complications arise, such as diverticulitis. The symptoms of jejuno–ileal diverticulitis are non-specific and the diagnosis is performed mainly by imaging studies. © 2008 Published by Elsevier Ireland Ltd. Keywords: Small bowel diverticulitis; Perforation; US; Computed tomography
1. Introduction
2. Material and methods
Although diverticula of the gastrointestinal tract are fairly common in the colon and duodenum, they are a rare finding in the small intestine, being reported in less than 1% of autopsied patients and predominantly involving jejunum [1,2]. Acute complications occur in 6.5–10.4% of the patients with jejuno–ileal diverticulosis, and the most common are diverticulitis (with or without associated haemorrhage), obstruction and perforation, the last one having a high mortality rate if unrecognized (up to 21–40%), due to the delay in surgical treatment [3–5]. Clinical symptoms of acute jejuno–ileal diverticulitis are not specific and, due to its relative rarity, diagnosis is often difficult and delayed. Abdominal plain radiographs usually show no positive findings, so an abdominal US or CT examination is often practised. Therefore, it could be very important to consider this uncommon entity in the differential diagnosis of patients with acute abdominal pain as well as to recognize the imaging findings in the US and CT examinations that could lead to the diagnosis of acute small bowel diverticulitis.
Five patients with small bowel diverticulitis and localized perforation were diagnosed in our department from April 2003 to August 2007. All patients underwent emergency US and CT examination in the same 24-h period. CT examinations were performed using a single detector CT machine (GE Medical Systems, WI, USA) and images were acquired using 7 mm collimation and 7 mm reconstruction interval, 120 kVp and 200–250 mAs. In three cases 100 ml of non-ionic iodinated contrast material were intravenously injected at a rate of 2–3 ml/s; with 70 s imaging delay. Two of the patients received oral contrast. Two of the CT scans were done without oral or intravenous contrast. The US and CT studies were performed by third or fourth year residents and then reviewed by staff abdominal radiologists. Clinical presentation and treatment were reviewed. Diagnosis was confirmed by surgery and histological findings in all patients.
∗
Corresponding author at: Hospital Cl´ınico San Carlos, Servicio de Radiodiagn´ostico, Profesor Mart´ın Lagos, 28040 Madrid, Spain. Tel.: +34 91 3303589. E-mail addresses: lu [email protected] (L. Gra˜na), [email protected] (I. Pedraja), [email protected] (R. Mendez), [email protected] (R. Rodr´ıguez). 0720-048X/$ – see front matter © 2008 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrad.2008.04.023
3. Results The diagnosis of small bowel diverticulitis with localized perforation was made in five patients at our department over a 4-year period; four of them had a jejunal diverticulitis and the
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other one was ileal. The patients were 2 men and 3 women, with a mean age of 70 years (range 48–86).
and the adjacent fat were infiltrated by polymorphonuclear leukocytes. The postoperative course was uneventful.
3.1. Case report 1
3.2. Case report 2
An 82-year-old man presented with a left lower quadrant and hypogastric pain and vomiting of 2 days’ duration. Physical examination revealed diffuse abdominal tenderness, selectively painful at the left iliac fossa and hypogastrium, without rebound tenderness. Laboratory data were significant for increase of the white blood cell count (18,210 cells/mm3 ). A plain film of the abdomen was normal. The patient underwent an US and a contrast enhanced CT scans of the abdomen, were we found a 5 cm mass lesion containing multiple air bubbles in the left mid abdomen, adjacent to a hyperenhancing jejunal loop (Fig. 1A). Multiple uncomplicated diverticula were identified in the small bowel, sigma and colon (Fig. 1B). Both examinations were read as jejunal diverticulitis with localized perforation. Intraoperatively, an inflammatory mass involving the small bowel was found and resected. The histological findings were multiple jejunum pseudodiverticula, one of them being perforated. The diverticular wall, with only mucosa and submucosa,
A 48-year-old woman, with a previous history of seizures was admitted to the Emergency Department with intermittent right lower quadrant pain and fever that lasted for 36 h. The clinical examination showed right iliac fossa pain without rebound tenderness. The serum white blood cell count was 15,600/mm3 . At the US examination we found wall thickening of a small bowel loop, surrounded by mesenteric fluid and inflamed (hyperechoic) fat and lymph nodes. At the unenhanced CT examination there was wall thickening of a distal jejunal loop, with increase in the attenuation of the perienteric fat. Extraluminal air bubbles were detected, leading to the diagnosis of small bowel perforation (Fig. 2). A small bowel acute process was suspected. At laparotomy they found an inflammatory mass surrounding a 20 cm long jejunal segment with wall perforation. Thirty centimetres of jejunum were resected. The pathologist described several “false” jejunum diverticula with infiltration by inflammatory cells, ulceration and a peritoneal abscess with peritonitis. A lymph node with reactive hyperplasia was also found. 3.3. Case report 3 A 75-year-old man was hospitalized because of a right iliac fossa pain migrating to the scrotum. At physical examination, the right lower abdominal quadrant was tender and a soft tissue mass was palpable. There was not rebound tenderness. The laboratory values were normal. A supine radiograph of the abdomen showed a dilated small intestine loop in right mid-abdomen. At the US study we saw, in the right lower quadrant, a segment of bowel with thickened wall and hypoechoic small irregular projections with hyperechoic centre, being suggestive of small bowel diverticula. An extraluminal fluid collection, measuring 35 mm × 17 mm, with air bubbles in it, surrounded by hypere-
Fig. 1. An 82-year-old man with jejunal diverticulitis. (A) Contrast enhanced abdominal CT shows a mass lesion (arrows), 5 cm in diameter, containing multiple extraluminal air bubbles in the left mid abdomen in contiguity with an adjacent jejunum loop (J) with hyperenhancing and thickened wall. There is inflammation of the adjacent fat tissue (hyperdense). (B) More caudal image demonstrating an uncomplicated diverticulum in a different small bowel (arrow).
Fig. 2. A 48-year-old woman with jejunal diverticulitis. A CT scan without IV contrast reveals thickening of the distal jejunal (J) wall and extraluminal air bubbles (arrow), compatible with bowel perforation, and hyperdense appearance of the perienteric fat.
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Fig. 3. A 75-year-old man with ileal diverticulitis. (A and B) Abdominal US demonstrates thickening of the ileal wall and hypoechoic irregular formations with hyperechoic centre, connected to the ileum and suggestive of diverticula (arrowheads). Diffuse hyperechoic tissue around these structures characterized the inflamed fat. An extraluminal collection with air bubbles is also visualized (arrows). (C and D) Computed tomography confirms the extraluminal air (black arrows) and the inflammation of the adjacent fat. It also shows a thin hypodense rim, probably mesenteric fat, separating the inflammatory mass from the sigmoid colon wall (white arrows). There are some uncomplicated jejunal diverticula (arrowheads).
choic tissue indicating inflamed fat was also identified (Figs. 3A and B). Sigmoid diverticulitis was proposed as diagnosis and a CT scan was performed to confirm it. The CT, with neither intravenous nor oral contrast, confirmed the fluid collection with air bubbles, adjacent to the ileum, and showed also multiple uncomplicated diverticula in the sigmoid colon separated from the inflammatory mass by normal mesenteric fat. Some uncomplicated jejunal diverticula were also found (Figs. 3C and D). The diagnosis of ileal diverticulitis with covered perforation was made. The patient was taken to the operating room and found to have an inflammatory mass around the terminal ileum and perforation of the small bowel. A right hemicolectomy and resection of 40 cm of terminal ileum were performed with uneventful recovery of the patient. Microscopically, there were multiple small bowel pseudodiverticula and perforated ileal diverticulitis with a 2 cm abscess cavity located in the surrounding adipose tissue.
3.4. Case report 4 An 83-year-old woman presented with a 5 days history of abdominal pain and vomiting. Physical examination showed diffusely tender abdomen associated with positive Blumberg sing and a palpable abdominal mass. Laboratory data demonstrated neutrophilia without leukocytosis. At the abdominal plain film there were some dilated small bowel loops in left mid-abdomen. The US examination showed a segment of jejunum with thickened wall surrounded by hyperechoic tissue that was suggestive of inflamed fat. The contrast-enhanced CT study demonstrated an air–fluid collection, 1.3 cm in diameter, surrounded by jejunal loops. These small bowel loops were slightly dilated, their walls were thickened and the surrounding fat was infiltrated suggesting inflammation (Fig. 4A). As uncomplicated diverticula were identified in the small bowel (Fig. 4B) and also in the colon the radiological diagnosis was small bowel diverticulitis with local perforation.
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Fig. 4. An 83-year-old woman with jejunal diverticulitis. (A) Contrast-enhanced CT demonstrates an air–fluid collection (arrow) in contiguity with small bowel loops. The bowel loops were slightly dilated, and their walls were thickened. (B) At the CT images one can also see uncomplicated small bowel diverticula (arrowheads).
At laparotomy there was a perforated diverticulum in the jejunum contiguous to a small inflammatory mass. Resection of 15 cm of jejunum was carried out. Microscopic examination demonstrated a small bowel diverticulum, its wall having both mucosa and muscular layers. The diverticular wall was infiltrated by leukocytes. An abscess cavity located within the surrounding adipose tissue was associated. Other non-inflamed diverticula were identified. After a week of uncomplicated postoperative evolution, the patient suddenly died in hospital due to a cerebral haemorrhage. 3.5. Case report 5 An 86-year-old woman was hospitalized with abdominal pain without rebound tenderness in the physical examination. The white blood cell count was not increased. The supine abdominal plain film was normal. An US study, followed by a contrast enhanced CT to confirm the echographic findings were performed. These findings were jejunum diverticula associated to inflammatory changes (thickening and hyperenhancement) in the intestinal wall. Adjacent to one of the diverticula there was a fluid collection, 2 cm in diameter, containing small extraluminal air bubbles and a 6.2 cm × 2.4 cm inflammatory mass was identified in the surrounding adipose tissue (Fig. 5A). The CT scan also showed some enlarged lymph nodes within the inflammatory fat and
Fig. 5. An 86-year-old woman with perforated jejunal diverticulitis. (A) The ultrasound examination shows several jejunum diverlicula (arrowheads). In contiguity with one of them there is a collection containing small extraluminal air bubbles (arrow). (B) The abdominal CT, performed with intravenous contrast, demostrates an inflammatory mass containing air bubbles (white arrows) adjacent to a jejunal loop. (C) It shows several diverticula in the small bowel loop with thickening of its wall (arrowheads).
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other uncomplicated small bowel diverticula (Fig. 5C). The radiological diagnosis of an abscess secondary to a covered perforation of an inflamed jejunal diverticulum was made. The patient was initially treated conservatively with antibiotics; but eight days after, she was taken to the operating room due to clinical worsening and acute abdominal pain. The surgical examination showed multiple jejunum diverticula and a 10 cm long segment of the jejunum having inflammatory changes. A 40 cm long segment of jejunum was resected. Pathological analysis demonstrated multiple thin walled jejunal diverticula; one of them showing chronic inflammation and fibrosis and microabscesses within the surrounding fat. 4. Discussion Small bowel diverticula are usually acquired and “false,” with only mucosa and submucosa [6,7] layers that herniate through the muscular and serosa. The inflamed diverticula of our cases were all pseudodiverticula, except for one. The small bowel diverticula are more frequently placed along the mesenteric border at the sites where penetrating vessels pass through the bowel wall [6,7]. They may be primary, resulting from either raised intraluminal pressure or an underlying visceral myopathy [8,9], or secondary to conditions such as abdominal surgery, tuberculosis, and Crohn’s disease [7,9]. Reported incidence at autopsy varies between 0.5 and 2.3% [2,8,9]. Jejuno–ileal diverticula are observed four times less often than duodenal diverticula [9]. They are found almost exclusively in individuals older than 40 [7–9], most patients being in the seventh decade of life or older [7,9], and they are twice more frequent in men than in women [2,7,8]. The diverticula are usually multiple [3,4,7,9] and they have a tendency to be larger and higher in number in the proximal jejunum and smaller and fewer as one progresses distally in the small bowel [2,6,8,9]. An exception is the terminal ileum, where the diverticula are often multiple [9]. Associated diverticula are found in the colon in 35–75%, of patients; in the duodenum in 15–42%, in the oesophagus in 2%, in the stomach in 2%, and in the urinary bladder in 12% of cases [9]. Sixty to seventy percent of small bowel diverticula are asymptomatic and are incidentally discovered during autopsy, laparotomy, or barium studies [7,9]. Acute diverticulitis is one of the more common complications of jejuno–ileal diverticulosis (2.3–6.4% of the cases), but free perforation, intestinal obstruction, and haemorrhage also have been reported. Acute necrotizing inflammatory reaction is the most common cause of diverticular perforation (82%), however it may also result from penetration of the intestinal wall by a foreign body (6%) or from blunt trauma to the abdominal wall (12%) [6]. Usually a localized peritonitis results, because the diverticulum is walled off by adjacent small bowel mesentery [9]. Gangrene is the most serious complication, with a reported mortality up to 40%, mainly attributed to a delay in the correct diagnosis and the advanced age of most of the patients [8,9]. No pathognomonic features or clinical symptoms indicating small bowel diverticulitis have been reported. The spectrum of complaints varies from intermittent abdominal pain to an
Table 1 Radiological findings of small bowel diverticulitis with localized perforation Ultrasound findings Thickening of the intestinal wall (4 patients) Diverticula (hypoechoic irregular formations with hyperechoic centre connected to the intestine) (3 patients) Inflamed fat (hyperechoic tissue around the diverticula) (4 patients) Extraluminal fluid collections with air bubbles (tiny hyperechoic reverberating dots) (4 patients) Computed tomography findings Dilated small bowel loop with thickened and hyperenhancing wall (3 patients) Inflammation of the mesenteric fat (hyperdense appearance) (4 patients) Mass lesion containing extraluminal air bubbles or air fluid levels (5 patients) Uncomplicated diverticula elsewhere in the small bowel (4 patients)
acute abdomen with leukocytosis and fever [2,4]. The presentation commonly mimics acute appendicitis, a perforated cancer, Crohn’s disease of the ileocecal region [2,6,9]. Since the symptoms are non-specific, the diagnosis is performed mainly by imaging studies or at an exploratory laparotomy. Ultrasound is an inexpensive and available imaging test that can be used as a first screening method for acute abdominal pain. It can reveal thickening of the intestinal wall; hypoechoic irregular formations with hyperechoic centre connected to the intestine suggestive of diverticula; hyperechoic tissue around the diverticula indicating inflamed fat and extraluminal fluid collections with air bubbles (small tiny hyperechoic reverberating dots) (Table 1). Computed tomography can show a mass lesion containing extraluminal air bubbles or air fluid levels in contiguity with an adjacent dilated small bowel loop with thickened and hyperenhancing wall; hyperdense appearance of the mesenteric fat suggesting inflammation and uncomplicated diverticula elsewhere in the small bowel (Table 1). All CT examinations in the five patients were performed in a single detector CT scanner using 7 mm slice thickness. With multidetector CT thinner slices will increase spatial resolution, and could facilitate an accurate diagnosis. Although diagnosis can be made on CT without oral or intravenous contrast, as in two of our cases, the, administration of oral and intravenous contrast is recommended for most patients. The injection of an intravenous bolus of contrast material is helpful to detect the inflammatory changes showing the enhancement of the bowel wall and the rim enhancement of the collections, often associated with perforated diverticulitis. With the distension and opacification of the bowel with positive oral contrast it is easier to assess the thickening of the bowel wall and to differentiate between intra- and extraluminal structures. Most authors recommend the administration of 750–1000 ml of oral contrast material and 100–120 ml of iodinated intravenous contrast at a rate of 2–3 ml/s with an imaging delay of 60–90 s [10]. Patient condition can prevent for the administration of oral or iv contrast.
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Although similar findings can be seen on CT or US images in other intestinal diseases, such as, a perforated neoplasm, Crohn’s disease, Meckel’s diverticulitis or in foreign body perforation [2,6,9,11,12], there are some clues that can suggest the diagnosis. In our report, in four of the five patients, uncomplicated small bowel and colon diverticula were also found, being an important feature in order to make the diagnosis. A precise diagnosis of small bowel diverticulitis was made preoperatively, based on CT and US findings, in three out of these five cases. In the patients presented, CT imaging was useful to confirm the US findings, to localize the inflammatory process near to the small bowel and to assess the extension of the inflammatory reaction. Although making the correct diagnosis has allowed successful medical management in some reported cases [13,14], surgery in the acute setting, with or without a period of preoperative antibiotic therapy, is the most common treatment approach [11]. 5. Conclusion Jejuno–ileal diverticulitis is frequently overlooked as a cause of acute abdominal pain in the elderly patient. A delayed diagnosis can be fatal, because perforation is associated with a high mortality and complication rate. The CT and US findings are useful to suggest this diagnosis and to exclude other causes of acute abdominal pain, so it is important to recognise these imaging findings and to include this entity in the differential diagnosis of patients with acute abdomen, because clinical symptoms are not specific.
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References [1] Caplan JH, Jacobson HG. Small intestinal diverticulosis. AJR 1964;92: 1048–60. [2] Peters R, Grust A, Gerharz CD, et al. Perforated diverticulitis as a rare cause of acute abdomen. Eur Radiol 1999;9:1426–8. [3] El-Haddawi F, Civil ID. Acquired jejuno–ileal diverticular disease: a diagnostic and management challenge. ANZ J Surg 2003;73:584– 9. [4] Kelekis AD, Poletti PA. Jejunal diverticulitis with located perforation diagnosed by ultrasound: a case report. Eur Radiol 2002;12:S78– 81. [5] Roses DF, Gouge TH, Scher KS. Perforated diverticula of the jejunum and ileum. Am Surg 1976;132:649–52. [6] Prakash C, Clouse RE. Acute ileal diverticulitis. Am J Gastroenterol 1998;97:452–4. [7] Coulier B, Maldague P, Bourgeois A, et al. Diverticulitis of the small bowel: CT diagnosis. Abdom Imaging 2007;32:228–33. [8] Gayer G, Zissin R, Apter S, et al. Acute diverticulitis of the small bowel: CT findings. Abdom Imaging 1999;24:452–5. [9] De Bree E, Grammatikakis J, Christodoulakis M, et al. The clinical significance of acquired jejunoileal diverticula. Am J Gastroenterol 1998;93:2523–8. [10] Urban BA, Fisman EK. Tailored helical CT evaluation of acute abdomen. Radiographics 2000;20:725–49. [11] Macari M, Faust M, Liang H, Pachter HL. CT of jejunal diverticulitis: imaging findings, differential diagnosis, and clinical management. Clin Radiol 2007;62:73–7. [12] Grobmyer S, Gollub MJ, Shia J, Guillem JG. Ileal diverticulitis: clinical and radiographic presentation. Dig Dis Sci 2004;49:498– 502. [13] Gotian A, Katz S. Jejunal diverticulitis with located perforation and intramesenteric abscess. Am J Gastroenterol 1998;93:1173–5. [14] Novak JS, Tobias J, Barkin JS. Nonsugical management of acute jejunal diverticulosis: a review. Am J Gastroenterol 1997;92:1929–31.
Jejuno–ileal diverticulitis with localized perforation: CT and US findings Luc´ıa Gra˜na ∗ , I˜nigo Pedraja, Ramiro Mendez, Ricardo Rodr´ıguez Department of Diagnostic Imaging, Hospital Cl´ınico San Carlos, Profesor Mart´ın Lagos, 28040 Madrid, Spain Received 12 January 2008; received in revised form 12 April 2008; accepted 22 April 2008
Abstract Purpose: To describe the computed tomography and ultrasound findings of five cases of small bowel diverticulitis with localized perforation. Material and methods: Our database, from April 2003 to August 2007, was reviewed and five cases of small bowel diverticulitis were identified. Results: Jejuno–ileal diverticulitis with covered perforation usually presents as wall thickening of a small bowel loop and an adjacent inflammatory mass containing air bubbles. Conclusion: Small bowel diverticula are rare and mostly asymptomatic. They become clinically relevant when complications arise, such as diverticulitis. The symptoms of jejuno–ileal diverticulitis are non-specific and the diagnosis is performed mainly by imaging studies. © 2008 Published by Elsevier Ireland Ltd. Keywords: Small bowel diverticulitis; Perforation; US; Computed tomography
1. Introduction
2. Material and methods
Although diverticula of the gastrointestinal tract are fairly common in the colon and duodenum, they are a rare finding in the small intestine, being reported in less than 1% of autopsied patients and predominantly involving jejunum [1,2]. Acute complications occur in 6.5–10.4% of the patients with jejuno–ileal diverticulosis, and the most common are diverticulitis (with or without associated haemorrhage), obstruction and perforation, the last one having a high mortality rate if unrecognized (up to 21–40%), due to the delay in surgical treatment [3–5]. Clinical symptoms of acute jejuno–ileal diverticulitis are not specific and, due to its relative rarity, diagnosis is often difficult and delayed. Abdominal plain radiographs usually show no positive findings, so an abdominal US or CT examination is often practised. Therefore, it could be very important to consider this uncommon entity in the differential diagnosis of patients with acute abdominal pain as well as to recognize the imaging findings in the US and CT examinations that could lead to the diagnosis of acute small bowel diverticulitis.
Five patients with small bowel diverticulitis and localized perforation were diagnosed in our department from April 2003 to August 2007. All patients underwent emergency US and CT examination in the same 24-h period. CT examinations were performed using a single detector CT machine (GE Medical Systems, WI, USA) and images were acquired using 7 mm collimation and 7 mm reconstruction interval, 120 kVp and 200–250 mAs. In three cases 100 ml of non-ionic iodinated contrast material were intravenously injected at a rate of 2–3 ml/s; with 70 s imaging delay. Two of the patients received oral contrast. Two of the CT scans were done without oral or intravenous contrast. The US and CT studies were performed by third or fourth year residents and then reviewed by staff abdominal radiologists. Clinical presentation and treatment were reviewed. Diagnosis was confirmed by surgery and histological findings in all patients.
∗
Corresponding author at: Hospital Cl´ınico San Carlos, Servicio de Radiodiagn´ostico, Profesor Mart´ın Lagos, 28040 Madrid, Spain. Tel.: +34 91 3303589. E-mail addresses: lu [email protected] (L. Gra˜na), [email protected] (I. Pedraja), [email protected] (R. Mendez), [email protected] (R. Rodr´ıguez). 0720-048X/$ – see front matter © 2008 Published by Elsevier Ireland Ltd. doi:10.1016/j.ejrad.2008.04.023
3. Results The diagnosis of small bowel diverticulitis with localized perforation was made in five patients at our department over a 4-year period; four of them had a jejunal diverticulitis and the
L. Gra˜na et al. / European Journal of Radiology 71 (2009) 318–323
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other one was ileal. The patients were 2 men and 3 women, with a mean age of 70 years (range 48–86).
and the adjacent fat were infiltrated by polymorphonuclear leukocytes. The postoperative course was uneventful.
3.1. Case report 1
3.2. Case report 2
An 82-year-old man presented with a left lower quadrant and hypogastric pain and vomiting of 2 days’ duration. Physical examination revealed diffuse abdominal tenderness, selectively painful at the left iliac fossa and hypogastrium, without rebound tenderness. Laboratory data were significant for increase of the white blood cell count (18,210 cells/mm3 ). A plain film of the abdomen was normal. The patient underwent an US and a contrast enhanced CT scans of the abdomen, were we found a 5 cm mass lesion containing multiple air bubbles in the left mid abdomen, adjacent to a hyperenhancing jejunal loop (Fig. 1A). Multiple uncomplicated diverticula were identified in the small bowel, sigma and colon (Fig. 1B). Both examinations were read as jejunal diverticulitis with localized perforation. Intraoperatively, an inflammatory mass involving the small bowel was found and resected. The histological findings were multiple jejunum pseudodiverticula, one of them being perforated. The diverticular wall, with only mucosa and submucosa,
A 48-year-old woman, with a previous history of seizures was admitted to the Emergency Department with intermittent right lower quadrant pain and fever that lasted for 36 h. The clinical examination showed right iliac fossa pain without rebound tenderness. The serum white blood cell count was 15,600/mm3 . At the US examination we found wall thickening of a small bowel loop, surrounded by mesenteric fluid and inflamed (hyperechoic) fat and lymph nodes. At the unenhanced CT examination there was wall thickening of a distal jejunal loop, with increase in the attenuation of the perienteric fat. Extraluminal air bubbles were detected, leading to the diagnosis of small bowel perforation (Fig. 2). A small bowel acute process was suspected. At laparotomy they found an inflammatory mass surrounding a 20 cm long jejunal segment with wall perforation. Thirty centimetres of jejunum were resected. The pathologist described several “false” jejunum diverticula with infiltration by inflammatory cells, ulceration and a peritoneal abscess with peritonitis. A lymph node with reactive hyperplasia was also found. 3.3. Case report 3 A 75-year-old man was hospitalized because of a right iliac fossa pain migrating to the scrotum. At physical examination, the right lower abdominal quadrant was tender and a soft tissue mass was palpable. There was not rebound tenderness. The laboratory values were normal. A supine radiograph of the abdomen showed a dilated small intestine loop in right mid-abdomen. At the US study we saw, in the right lower quadrant, a segment of bowel with thickened wall and hypoechoic small irregular projections with hyperechoic centre, being suggestive of small bowel diverticula. An extraluminal fluid collection, measuring 35 mm × 17 mm, with air bubbles in it, surrounded by hypere-
Fig. 1. An 82-year-old man with jejunal diverticulitis. (A) Contrast enhanced abdominal CT shows a mass lesion (arrows), 5 cm in diameter, containing multiple extraluminal air bubbles in the left mid abdomen in contiguity with an adjacent jejunum loop (J) with hyperenhancing and thickened wall. There is inflammation of the adjacent fat tissue (hyperdense). (B) More caudal image demonstrating an uncomplicated diverticulum in a different small bowel (arrow).
Fig. 2. A 48-year-old woman with jejunal diverticulitis. A CT scan without IV contrast reveals thickening of the distal jejunal (J) wall and extraluminal air bubbles (arrow), compatible with bowel perforation, and hyperdense appearance of the perienteric fat.
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Fig. 3. A 75-year-old man with ileal diverticulitis. (A and B) Abdominal US demonstrates thickening of the ileal wall and hypoechoic irregular formations with hyperechoic centre, connected to the ileum and suggestive of diverticula (arrowheads). Diffuse hyperechoic tissue around these structures characterized the inflamed fat. An extraluminal collection with air bubbles is also visualized (arrows). (C and D) Computed tomography confirms the extraluminal air (black arrows) and the inflammation of the adjacent fat. It also shows a thin hypodense rim, probably mesenteric fat, separating the inflammatory mass from the sigmoid colon wall (white arrows). There are some uncomplicated jejunal diverticula (arrowheads).
choic tissue indicating inflamed fat was also identified (Figs. 3A and B). Sigmoid diverticulitis was proposed as diagnosis and a CT scan was performed to confirm it. The CT, with neither intravenous nor oral contrast, confirmed the fluid collection with air bubbles, adjacent to the ileum, and showed also multiple uncomplicated diverticula in the sigmoid colon separated from the inflammatory mass by normal mesenteric fat. Some uncomplicated jejunal diverticula were also found (Figs. 3C and D). The diagnosis of ileal diverticulitis with covered perforation was made. The patient was taken to the operating room and found to have an inflammatory mass around the terminal ileum and perforation of the small bowel. A right hemicolectomy and resection of 40 cm of terminal ileum were performed with uneventful recovery of the patient. Microscopically, there were multiple small bowel pseudodiverticula and perforated ileal diverticulitis with a 2 cm abscess cavity located in the surrounding adipose tissue.
3.4. Case report 4 An 83-year-old woman presented with a 5 days history of abdominal pain and vomiting. Physical examination showed diffusely tender abdomen associated with positive Blumberg sing and a palpable abdominal mass. Laboratory data demonstrated neutrophilia without leukocytosis. At the abdominal plain film there were some dilated small bowel loops in left mid-abdomen. The US examination showed a segment of jejunum with thickened wall surrounded by hyperechoic tissue that was suggestive of inflamed fat. The contrast-enhanced CT study demonstrated an air–fluid collection, 1.3 cm in diameter, surrounded by jejunal loops. These small bowel loops were slightly dilated, their walls were thickened and the surrounding fat was infiltrated suggesting inflammation (Fig. 4A). As uncomplicated diverticula were identified in the small bowel (Fig. 4B) and also in the colon the radiological diagnosis was small bowel diverticulitis with local perforation.
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Fig. 4. An 83-year-old woman with jejunal diverticulitis. (A) Contrast-enhanced CT demonstrates an air–fluid collection (arrow) in contiguity with small bowel loops. The bowel loops were slightly dilated, and their walls were thickened. (B) At the CT images one can also see uncomplicated small bowel diverticula (arrowheads).
At laparotomy there was a perforated diverticulum in the jejunum contiguous to a small inflammatory mass. Resection of 15 cm of jejunum was carried out. Microscopic examination demonstrated a small bowel diverticulum, its wall having both mucosa and muscular layers. The diverticular wall was infiltrated by leukocytes. An abscess cavity located within the surrounding adipose tissue was associated. Other non-inflamed diverticula were identified. After a week of uncomplicated postoperative evolution, the patient suddenly died in hospital due to a cerebral haemorrhage. 3.5. Case report 5 An 86-year-old woman was hospitalized with abdominal pain without rebound tenderness in the physical examination. The white blood cell count was not increased. The supine abdominal plain film was normal. An US study, followed by a contrast enhanced CT to confirm the echographic findings were performed. These findings were jejunum diverticula associated to inflammatory changes (thickening and hyperenhancement) in the intestinal wall. Adjacent to one of the diverticula there was a fluid collection, 2 cm in diameter, containing small extraluminal air bubbles and a 6.2 cm × 2.4 cm inflammatory mass was identified in the surrounding adipose tissue (Fig. 5A). The CT scan also showed some enlarged lymph nodes within the inflammatory fat and
Fig. 5. An 86-year-old woman with perforated jejunal diverticulitis. (A) The ultrasound examination shows several jejunum diverlicula (arrowheads). In contiguity with one of them there is a collection containing small extraluminal air bubbles (arrow). (B) The abdominal CT, performed with intravenous contrast, demostrates an inflammatory mass containing air bubbles (white arrows) adjacent to a jejunal loop. (C) It shows several diverticula in the small bowel loop with thickening of its wall (arrowheads).
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other uncomplicated small bowel diverticula (Fig. 5C). The radiological diagnosis of an abscess secondary to a covered perforation of an inflamed jejunal diverticulum was made. The patient was initially treated conservatively with antibiotics; but eight days after, she was taken to the operating room due to clinical worsening and acute abdominal pain. The surgical examination showed multiple jejunum diverticula and a 10 cm long segment of the jejunum having inflammatory changes. A 40 cm long segment of jejunum was resected. Pathological analysis demonstrated multiple thin walled jejunal diverticula; one of them showing chronic inflammation and fibrosis and microabscesses within the surrounding fat. 4. Discussion Small bowel diverticula are usually acquired and “false,” with only mucosa and submucosa [6,7] layers that herniate through the muscular and serosa. The inflamed diverticula of our cases were all pseudodiverticula, except for one. The small bowel diverticula are more frequently placed along the mesenteric border at the sites where penetrating vessels pass through the bowel wall [6,7]. They may be primary, resulting from either raised intraluminal pressure or an underlying visceral myopathy [8,9], or secondary to conditions such as abdominal surgery, tuberculosis, and Crohn’s disease [7,9]. Reported incidence at autopsy varies between 0.5 and 2.3% [2,8,9]. Jejuno–ileal diverticula are observed four times less often than duodenal diverticula [9]. They are found almost exclusively in individuals older than 40 [7–9], most patients being in the seventh decade of life or older [7,9], and they are twice more frequent in men than in women [2,7,8]. The diverticula are usually multiple [3,4,7,9] and they have a tendency to be larger and higher in number in the proximal jejunum and smaller and fewer as one progresses distally in the small bowel [2,6,8,9]. An exception is the terminal ileum, where the diverticula are often multiple [9]. Associated diverticula are found in the colon in 35–75%, of patients; in the duodenum in 15–42%, in the oesophagus in 2%, in the stomach in 2%, and in the urinary bladder in 12% of cases [9]. Sixty to seventy percent of small bowel diverticula are asymptomatic and are incidentally discovered during autopsy, laparotomy, or barium studies [7,9]. Acute diverticulitis is one of the more common complications of jejuno–ileal diverticulosis (2.3–6.4% of the cases), but free perforation, intestinal obstruction, and haemorrhage also have been reported. Acute necrotizing inflammatory reaction is the most common cause of diverticular perforation (82%), however it may also result from penetration of the intestinal wall by a foreign body (6%) or from blunt trauma to the abdominal wall (12%) [6]. Usually a localized peritonitis results, because the diverticulum is walled off by adjacent small bowel mesentery [9]. Gangrene is the most serious complication, with a reported mortality up to 40%, mainly attributed to a delay in the correct diagnosis and the advanced age of most of the patients [8,9]. No pathognomonic features or clinical symptoms indicating small bowel diverticulitis have been reported. The spectrum of complaints varies from intermittent abdominal pain to an
Table 1 Radiological findings of small bowel diverticulitis with localized perforation Ultrasound findings Thickening of the intestinal wall (4 patients) Diverticula (hypoechoic irregular formations with hyperechoic centre connected to the intestine) (3 patients) Inflamed fat (hyperechoic tissue around the diverticula) (4 patients) Extraluminal fluid collections with air bubbles (tiny hyperechoic reverberating dots) (4 patients) Computed tomography findings Dilated small bowel loop with thickened and hyperenhancing wall (3 patients) Inflammation of the mesenteric fat (hyperdense appearance) (4 patients) Mass lesion containing extraluminal air bubbles or air fluid levels (5 patients) Uncomplicated diverticula elsewhere in the small bowel (4 patients)
acute abdomen with leukocytosis and fever [2,4]. The presentation commonly mimics acute appendicitis, a perforated cancer, Crohn’s disease of the ileocecal region [2,6,9]. Since the symptoms are non-specific, the diagnosis is performed mainly by imaging studies or at an exploratory laparotomy. Ultrasound is an inexpensive and available imaging test that can be used as a first screening method for acute abdominal pain. It can reveal thickening of the intestinal wall; hypoechoic irregular formations with hyperechoic centre connected to the intestine suggestive of diverticula; hyperechoic tissue around the diverticula indicating inflamed fat and extraluminal fluid collections with air bubbles (small tiny hyperechoic reverberating dots) (Table 1). Computed tomography can show a mass lesion containing extraluminal air bubbles or air fluid levels in contiguity with an adjacent dilated small bowel loop with thickened and hyperenhancing wall; hyperdense appearance of the mesenteric fat suggesting inflammation and uncomplicated diverticula elsewhere in the small bowel (Table 1). All CT examinations in the five patients were performed in a single detector CT scanner using 7 mm slice thickness. With multidetector CT thinner slices will increase spatial resolution, and could facilitate an accurate diagnosis. Although diagnosis can be made on CT without oral or intravenous contrast, as in two of our cases, the, administration of oral and intravenous contrast is recommended for most patients. The injection of an intravenous bolus of contrast material is helpful to detect the inflammatory changes showing the enhancement of the bowel wall and the rim enhancement of the collections, often associated with perforated diverticulitis. With the distension and opacification of the bowel with positive oral contrast it is easier to assess the thickening of the bowel wall and to differentiate between intra- and extraluminal structures. Most authors recommend the administration of 750–1000 ml of oral contrast material and 100–120 ml of iodinated intravenous contrast at a rate of 2–3 ml/s with an imaging delay of 60–90 s [10]. Patient condition can prevent for the administration of oral or iv contrast.
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Although similar findings can be seen on CT or US images in other intestinal diseases, such as, a perforated neoplasm, Crohn’s disease, Meckel’s diverticulitis or in foreign body perforation [2,6,9,11,12], there are some clues that can suggest the diagnosis. In our report, in four of the five patients, uncomplicated small bowel and colon diverticula were also found, being an important feature in order to make the diagnosis. A precise diagnosis of small bowel diverticulitis was made preoperatively, based on CT and US findings, in three out of these five cases. In the patients presented, CT imaging was useful to confirm the US findings, to localize the inflammatory process near to the small bowel and to assess the extension of the inflammatory reaction. Although making the correct diagnosis has allowed successful medical management in some reported cases [13,14], surgery in the acute setting, with or without a period of preoperative antibiotic therapy, is the most common treatment approach [11]. 5. Conclusion Jejuno–ileal diverticulitis is frequently overlooked as a cause of acute abdominal pain in the elderly patient. A delayed diagnosis can be fatal, because perforation is associated with a high mortality and complication rate. The CT and US findings are useful to suggest this diagnosis and to exclude other causes of acute abdominal pain, so it is important to recognise these imaging findings and to include this entity in the differential diagnosis of patients with acute abdomen, because clinical symptoms are not specific.
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