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.