Discussion
Most often, diverticula are found in the jejunum, 15% are found in the ileum, and 5% are distributed in both. Jejunal Diverticulosis is mostly a silent disease, and only 29% of patients are symptomatic, whilst only 10% of patients proceed to develop complications including, obstruction, fistula formation, peritonitis, lower gastrointestinal bleeding, and perforation6. Malabsorption and mesenteric abscess are other complications1. Intestinal obstruction is mainly attributed to adhesions or stenosis, as a result of diverticulitis, as well as intussusception and volvulus associated with the segment containing the diverticulum. Additionally, large stones that are trapped in the diverticula have the tendency to escape or exert stress on local gut wall, resulting in intestinal occlusion4. Perforation of the jejunal diverticula can be caused by diverticulitis, foreign materials and abdominal trauma4. Malabsorption may be explained by irregular bowel movements caused by peristalsis, diverticula enlargement, intestinal stagnation, and bacterial overgrowth4. Acute diverticulitis might result in bleeding because of the erosive effects of the infection. As a result, mesenteric vessels are compromised by mucosal ulcerations, which results in bleeding4.
Krishnamurthy et al . reported intestinal obstruction to be the major clinical presentation of jejunal diverticulosis, with patients presenting with vomiting, abdominal pain, and abdominal distention, which in its most severe form can present with perforation and peritonitis, as did occur in our case7 A classical triad consisting of clinical and radiological findings has been described, which includes abdominal pain, anemia, and segmental dilatation in the left upper abdomen or epigastrium visualized on a plain abdominal X-Ray8. The anemia is attributed to megaloblastic anemia and anemia caused by iron deficiency have both been observed frequently and are frequently related to malabsorptive disorders, steatorrhea, and vitamin deficiencies4. Signs of complications include distention of jejunal bowel loops, multiple air-fluid levels, and pneumoperitoneum8 due to recurrent micro perforations of the diverticula4. Whilst enteroclysis and barium follow-through are more specific than a plain abdominal X-ray, there are doubts over their utility in emergency situations4. Computed Tomography Scan (CT) is a more specific investigation, which demonstrates focal outpouchings on the mesenteric side of the bowel4. For complex instances, laparoscopy becomes a reliable diagnostic method. It also quickly transforms into laparotomy and can serve as a guide to prevent necessary laparotomies. Additionally, by pinpointing the location of the intestinal complication, laparoscopy helps the surgeon choose the best location to make an incision on the abdominal wall, reducing overall on the length of the procedure, the pain encountered thereafter, and the morbidity associated with a larger abdominal incision4. A promising new method for finding small bowel illnesses, wireless capsule endoscopy is mostly employed when there is concealed intestinal bleeding. Despite the relative caution that should be exercised when using capsule endoscopy in patients with isolated small bowel diverticulosis and occult intestinal bleeding, the presence of large diverticula is a relative contraindication because there is a chance that the capsule could become strangulated in small bowel diverticula.4
Some patients respond to the brief cessation of enteral nourishment, alleviation of gastrointestinal symptoms provided by a nasogastric tube, and the use of empirical, broad-spectrum antibiotics, although 8–30% of patients experience problems necessitating surgical intervention.. In the event of a perforation, exploratory laparotomy with resection of the affected intestinal segments and primary anastomosis is necessary. The extent of the intestinal resection depends on the length of the bowel affected, with a more conservative resection of only perforated intestinal segments preferred in cases of involvement of long sections of the bowel, which was the situation in our case1. Other surgical procedures such as invagination of diverticula, closure of perforation with omental patch and diverticulectomy have also been proposed, but they have been associated with high mortality rates9. An operated diverticulum generally has good outcomes, and the postoperative mortality rate is influenced by the time interval between presentation and intervention, the age of the patient, and the type of complications10. If the cause of obstruction was an enterolith, then the stone must be removed by an enterotomy4. Recurrence of diverticula can occur despite intestinal resection as the mechanism of diverticula formation is still patent4
Acquired jejunoileal diverticulosis has a wide range of clinical manifestations. As a result, it may be challenging to diagnose the illness. Up to 90% of patients have been shown to present with symptoms similar to those of irritable bowel syndrome, including intermittent abdominal pain, constipation, and diarrhea. Imaging tests primarily have an atypical appearance without essential diagnostic features and may not correspond with the clinical symptoms1. Contrarily, it can be more challenging to distinguish the diverticula from overlapping loops of small bowel in patients with severe jejunal diverticulosis3. Although a thorough examination of the small bowel is required, it may be challenging to identify jejunal or ileal diverticula during surgery since they are typically concealed in the mesenteric fat9. As a result, the diagnosis is frequently found accidentally after a laparotomy due to difficulties or during a radiographic examination. During a barium swallow, laparotomy, or autopsy, 75% of jejuno-ileal diverticula are unintentionally detected5. Thus, knowledge of the condition and the numerous forms in which it may manifest is crucial for clinical diagnosis of the disease1. Because perforation is linked to a high mortality rate in up to 40% of patients, a delayed diagnosis can be catastrophic5. Hence, when discovered it shouldn’t be discounted as a minor discovery in older individuals who present with unexplained stomach complaints1. In fact, according to some writers, jejunal diverticulosis need to be routinely taken into account as a potential cause in any patient who presents with inexplicable diarrhoea3. The presence of perforated Jejunal diverticulosis should not be discounted in the differential diagnosis of any elderly patient, especially when they present with the classical triad of clinical and radiological findings especially when they have a prior history of constipation, or any pathology that causes chronic raised intra-abdominal pressure. In such cases of high suspicion and impending peritonitis, a laparoscopy can be a reliable method of diagnosis. However, when presented with symptoms, it is also crucial to include differential diagnosis like neoplasms (with or without perforation), foreign body perforation, traumatic hematoma, medication-induced ulceration (non-steroidal anti-inflammatory drug), and Crohn’s disease in our investigation5.