Complicated small bowel diverticulosis – a case report and literature review

Introduction
The original description of diverticular pathology might be revealed to 1700-ties, as J. B. Chomel describes a duodenal diverticulum in 1710. Sommering and Baillie reported jejunoileal diverticulum in 1794 (1). In 1920 J. T. Case presents the X-ray image of small bowel diverticula. One year later E. Hunt and P. Cook performed the first diverticular resection (2).
The rarest localization of gastrointestinal diverticula is the small bowel (3). The real frequency of small bowel diverticula is hard to be estimated, due to its accidental finding and frequent lack of documentation. The published frequency of small bowel diverticula is between 0,06 and 1,9% especially in people older than 60 years (4). Small bowel diverticula are found in 0,5 – 7,1% of X-ray contrast bowel imaging and in 0,3 – 4,5% at autopsy (5, 6).
The global increasing of diverticular frequency is associated with the diminished consumption of fibers, characteristic of west civilization and with the increased life expectancy. After the 5th decade of live the duodenal diverticula are found with equal frequency in men and women, which frequency is almost five times higher than the frequency of jejunoileal diverticula. The diverticula in jejunoileal gut area are described mainly in the 6th and 7th decade of live with weak predominance of male sex (1,5:1) (7).
Small bowel diverticulosis is asymptomatic in around 60% of cases. Temporary or constant dyspeptic symptoms are found in 25 to 30% of patients. Another 10 to 15% of patients demonstrate complications leading to surgical treatment. Often the importance of diverticular pathology is underestimated, concerning especially the potential risk of serious complications as infection, perforation, bleeding or obstruction.
In order to draw attention to jejunal diverticula and their complications we report a case of 79 years old woman with complicated diverticulosis.
Case presentation
A 79-years-old woman is admitted to the Gastroenterology Clinic because of recently detected by abdominal ultrasound liver changes, interpreted as advanced chronic liver disease with bigger regeneration nodules. In differential diagnosis liver metastases or multicentric hepatocellular carcinoma are discussed. The patient is hospitalized for fine needle biopsy and evaluation of liver lesions. A history of abdominal discomfort and long lasting tendency of constipation with periodic exacerbation of hemorrhoids is estimated on admission.
At presentation, patient's general condition is good. There`s no jaundice. Abdominal examination reveals weak to moderate pain on palpation in epigastria and sigma abdominal region, moderate hepatomegaly - liver on 2 cm under the ribs in medial clavicle line with hard consistency.
Laboratory data show increased ESR – 56 mm, lightly diminished prothrombin index 68%, albumin fraction of serum proteins 30g/l, cholestatic constellation – Alkaline Phosphatase – 677 U/l, GGT – 101U/l, total bilirubin – 32,1 mmol/l. The other findings of laboratory studies are in referral range.
Instrumental investigation shows ultrasound data of liver with heterogenic structure with more hypoechoic zones up to 1cm in size, interpreted as regeneration nodules of liver cirrhosis, less possibly in differential diagnosis–secondary lesions or primary multicentric hepatocellular carcinoma. Gall bladder calculs is also found. Fine needle biopsy of liver nodules under US guidance twice has shown no malignancy with normal hepatocytes in the aspirate. Fibrocolonoscopy finds diffuse noncomplicated large bowel diverticulosis, approximately 10 small polyps, less than 1cm in size, endoscopically removed. A soft polypoid like formation on the ileocecal valve is found on colonoscopy, interpreted as lipoma formation, biopsied and histologically verified as lipid tissue with arterial vessel and perivasal fibrosis.
During the hospital stay the patient suddenly complains of moderate abdominal pain without alteration in bowel habit and without blood or mucus in stools. On observation during the day the pain becomes deeper with signs of peritoneal irritation and positive Blumberg symptom in the ileocecal abdominal region. On control ultrasound examination there are edematous small bowel loops and a small quantity of free abdominal liquid retrocecally. All these clinical and instrumental data of acute abdominal problem lead to emergency surgery with suspicion for acute appendicitis.
At laparotomy a purulent exudates in the abdominal cavity is found with perforation of inflammated jejunal diverticulum, localized at 20 cm beyond lig.Treitz and concomitant liver cirrhosis. Multiple diverticula of various sizes between 5 mm and 2 cm are identified in the small and large intestine. In the ostium of jejunal perforation a sharp fish bone is found. A suture of the perforated intestine and abdominal lavage are done. During the surgery a resection biopsy of the liver is taken and consequently the diagnosis of weakly active mixed micro- macronodular cirrhosis is histologically confirmed.
The patient is discharged from hospital in good health with recommendation of high-fiber diet for regular defecation. On control ultrasound investigation one month later, knowing the operative finding of multiple diverticulosis, one of the larger diverticula – 2 cm in size is visualized (fig. 1). On follow-up six months later the patient is in good health any abdominal complaints.

Discussion
The only one congenital form of small bowel diverticula is the Meckel diverticulum, which is a true intestinal diverticulum. On the other side are the acquired intestinal diverticula, consisting of mucosis, submucosis and serosis without muscular layer. The reasons of their appearance are not entirely elucidated but the most popular pathogenetic theory is that of “locus minoris resistentiae”. Overactive or nonregular peristalsis causes herniation of mucosis and submucosis through the muscular layer in the places of vascular penetration of intestinal wall (8). Most common are the duodenal diverticula – 45%, followed by the Meckel diverticulum – 23%. The most frequent localization of jejunoileal diverticula is in the jejunum. This fact is explained by the larger size of penetrating jejunal arteries (5). In 35% to 75% of small bowel diverticula localization there is association with large bowel diverticulosis (9).
Jejunal diverticula are asymptomatic in most cases but their complications are serious and some times fatal (10, 11, 12, 13, 14).
When diverticular draining in the bowel lumen is inadequate or the neck of the diverticulum is very thin, food stasis develops in the pocket leading to possible inflammation. Complications of this stasis does not manifest until micro-perforation through the diverticular wall occurs with consequent abscess formation or generalized peritonitis. It is estimated that approximately 20% of all patients with diverticulosis develop inflammation or bleeding episodes (15).
The progression of diverticula from noncomplicated to complicated state might be prevented by early diagnosis and active conservative treatment (16). While noncomplicated diverticula are an incidental finding in barium enema studies, complicated form of the disease is usually diagnosed at laparotomy (17, 18, 19). Negative barium enema study does not exclude presence of intestinal diverticula, because small diverticular sacs might not be adequately filled with contrast. For investigation of ileum and jejunum, enteroclysis is the more specific procedure. In native abdominal X-ray, small bowel diverticula might be visualized through the presence of gas and liquid in them. That is the way of diagnosis in 44% of cases (5).
CT and ultrasound investigation might be useful in excluding other causes of abdominal pain such as acute appendicitis, abdominal abscess or inflamed large intestine. All of these disorders might mimic acute diverticulitis. In cases of peridiverticular abscess formation percutaneous drainage under CT or US guidance might be used (13, 16, 20). New diagnostic methods as capsule endoscopy are useful in identifying the cause of bleeding in small bowel diverticula.
Therapy is needed in cases of malabsorbtion, bleeding, obstruction ANDdiverticulitis with or without perforation. Malabsorbtion occurs in 3,5% to 12% of cases (4). Patients might have steatorrhea, megaloblastic anemia with or without neuropathy. Treatment consists of wide spectrum antibiotics and vitamin replacement. Relapsing or persisting bleeding requires surgical treatment (17). Enteroliths as a cause of duodenal obstruction are evacuated endoscopically, but jejunoileal obstruction requires surgical resection. Diverticulum perforation is seen in 2,3% of cases with small bowel diverticulosis; 82% of perforations are due to diverticulitis – necrotic inflammatory reaction. Other causes of perforation are abdominal trauma (19) and foreign body in the intestine as in our case (6%). Perforations themselves might be complicated with abscess or fistula formation between neighbor intestinal segments or ileocolonic and ileovesical communication. Free perforation may lead to diffuse peritonitis. Perforation and abscess are strong indications for surgery if percutaneous drainage is inapplicable (19). Perforations lead to death in 21% to 42% of cases (6).
This article presents a case of small bowel diverticular perforation, leading to peritonitis and surgical resection in 79-years-old woman, hospitalized for liver disease clarification. During the hospital stay of the patient a new abdominal pain and dyspeptic symptoms appear, primarily attributed to the coexisting gall bladder calculus. Worsening of complaints, the appearing clinical signs of peritoneal reaction and the ultrasound finding of liquid collection around the cecum lead to diagnosis acute appendicitis as a cause of peritonitis. Retrospectively, the advanced age and the previous endos-copic data of large bowel diverticulosis make the diagnosis of perforated diverticulum more appropriate. Intestinal diverticulosis is often underestimated in routine clinical practice and the preoperative diagnosis of its complications is missed. In this case report the patient has had known intestinal diverticulosis at the time the new abdominal pain appears. Preoperative ultrasound discloses the pericecal exudation but does not observe the possibility of complicated diverticular pathology, which is seen one month later on ultrasound evaluation. The reason for this discrepancy is the underestimation of the fact of existing bowel diverticula in the patient and the inadequate usage of sonography diagnostic potential in intestinal diverticula investigation and especially development of diverticulitis. It is not necessary to resect all of the diverticula The definitive treatment in cases of perforated diverticulum is surgical resection of intestinal segment. A number of factors should be taken into account in patients undergoing emergency laparotomy for diverticular disease. In our case extended intestinal resection was not appropriate due to the advanced age of the patient and the diffuse small and large bowel diverticulosis. This no radical and mainly symptomatic mode of resection requires future prophylaxis for possible diverticular complications.
In conclusion the presented case and the review of the literature demonstrate the different clinical manifestations of a relatively common pathology – intestinal diverticulosis in the elderly. Small intestinal diverticula should not be estimated as an innocent, clinically nonsignificant pathology. Patients with incidentally diagnosed small bowel diverticulosis should be strictly surveyed for the complications of this disease. The clinical manifestations of these possible complications have to be known and recognizable, especially in elderly patients with acute abdomen or intestinal hemorrhage of unknown etiology.

Acknowledgements
There are no conflicts of interest, neither in terms of financial, nor personal relations of any of the authors.

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