Acute Abdomen Secondary to Perforated Ileal Diverticulitis

May 25, 2007
Surgical Rounds®, March 2006, Volume 0, Issue 0

Ehab Elakkary, Resident in General Surgery, Department of Surgery, North Oakland Medical Centers, Wayne State University, Detroit, MI; Igor Sincos, Resident in General Surgery, University of Sao Paulo, Sao Paulo, Brazil; Steven Bolton, Staff Surgeon, Department of Surgery, North Oakland Medical Centers, Pontiac, MI

Ehab Elakkary, MD

Resident in General Surgery Department of Surgery North Oakland Medical Centers Wayne State University Detroit, MI

Igor Sincos, MD

Resident in General Surgery University of Sao Paulo Sao Paulo, Brazil

Steven Bolton, MD

Staff Surgeon Department of Surgery North Oakland Medical Centers Pontiac, MI

The incidence of small bowel diverticula ranges from 0.06% to 1.9%.1 Although these diverticula are usually asymptomatic, serious complications such as infection, bowel ob?struction, bleeding, or perforation can occur.2,3 Diagnosis of symptomatic small bowel diverticulosis is often delayed due to the rarity of the disease.4 We report the case of an elderly woman who presented to the emergency department with an acute abdomen sec?ondary to perforated ileal diverticulitis.

Case report

A 90-year-old white woman presented to the emergency department with lower abdominal pain, which began 1 week earlier and became diffuse the day before her admission to the hospital. The patient described the pain as dull, nonradiating, and without any specific exacerbating or relieving factors. Her medical history was significant for one incidence of sigmoid diverticulitis 10 years earlier, which was treated conservatively. Her surgical history was significant for laparoscopic Nissen fundoplication, hysterectomy, and appendectomy. The pa?tient was 5 ft 4 in, weighed 110 lb, and had a body mass index of 18.5.

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On admission, she was afebrile, alert, oriented, in no acute distress, and had stable vital signs. Significant findings during the physical examination included a soft, nondistended abdomen with a large, right hypochondrial, ventral hernia (12 cm in diameter). The hernia was reducible and there were no signs of in?carceration or strangulation. Infraum?bilical tenderness with rebound and involuntary guarding were elicited on palpation. The pa?tient's workup included a complete blood count, which revealed an elevated white blood cell count of 16,000/L. Pelvic, rectal, and hemoccult examinations were normal. An abdominal radiograph showed no bowel obstruction, and a chest radiograph and electrocardiogram were normal. An echocardiogram dem?onstrated no structural cardiac abnormalities and revealed an ejection fraction of 55%. A computed tomography (CT) scan of the abdomen showed gas droplets un?der the right hemidiaphragm and diverticulosis of the descending and sigmoid colon (Figure 1).

The patient was taken to the operating room for an exploratory laparotomy after receiving adequate intravenous fluid resuscitation. A transverse incision was made in the right upper quadrant over the hernia. Blunt dissection was performed to separate the hernial sac from the surrounding fascia. The fascial defect was about 10 cm in diameter. When the hernial sac was opened, it was found to contain multiple loops of viable small bowel. During lysis of the adhesions of the bowel loops, an interloop abscess was discovered, which was adequately drained and sent for cultures. The abdominal cavity was explored through this incision, and the small bowel was run from the ligament of Treitz to the ileocecal junction. Another interloop abscess was found near the ileum and was drained. Multiple ileal diverticula were identified on the mesenteric side along 1 ft of the ileum (Figure 2), one of which was perforated (Figure 3). Examination of the rest of the abdominal cavity revealed no other pathology other than left colon diverticulosis. The diseased bowel segment was resected using end-to-end anastomosis. The peritoneal cavity was copiously irrigated with normal saline, and a No. 10 French Jackson-Pratt drain was placed in the abscess cavity in the right upper quadrant. The hernia fascial defect was closed using retention sutures, and the skin and subcutaneous tissue were left open.

The patient's postoperative recovery was complicated by myocardial infarction, and she died on postoperative day 8. An autopsy was not performed as per the family's request. The final pathology re?port revealed findings of ischemic changes within a portion of the small bowel, soft tissue hemorrhage, marked inflammation, and necrosis consistent with abscess.

Discussion

Jejunal and ileal diverticula are rarely found in the small bowel (excluding Meckel's diverticulum), usually observed only in the elderly. Duodenal diverticula typically develop in the fifth decade of life compared with jejunal and ileal diverticula, which develop in the sixth and seventh decades.5 Autopsy studies show an incidence of 0.5% to 2.3%.1-3

Small bowel diverticula are classified as congenital (true) or acquired (false). Meckel's diverticulum represents the congenital variant and is present on the antimesenteric border of the small bowel approximately 2 ft from the ileocecal valve.6 Acquired diverticula are present on the mesenteric border and lack the tunica muscularis layer.7 Mesenteric ple?x?us ab?normalities in combination with uncoordinated activity of the smooth muscles cause localized areas of weakness in the small bowel wall, resulting in multiple diverticula.2

Although small bowel diverticulosis is usually asymptomatic (only 10% of pa?tients have symptoms), patients can present with chronic abdominal postprandial pain, nausea, emesis, and malabsorption.8,9 Serious complications may include infection, perforation, obstruction, and hemorrhage.2,3 A study by Kouraklis and colleagues showed the incidence of symp?toms to be as follows: abdominal pain, 64%; bowel obstruction, 10% to 25%; gastro?intestinal bleeding, 15%; malabsorption, 3.5% to 12%; and perforation, 2%.4

A second report by Kouraklis and colleagues revealed that small bowel diverticula are located in the jejunum in 61.9% of patients, in the ileum in 23.8% of patients, and in both the jejunum and ileum in 14.3% of patients.10 The true incidence of small bowel diverticula, however, is underestimated because they are difficult to detect radiographically and anatomically.11,12 A retrospective study of 208 patients by Akhrass and associates revealed most diverticula were located in the duodenum (79%) compared with 3% for combined involvement of the duodenum, jejunum, and ileum.13 Com?plica?tions occurred in 20% of patients in the form of bleeding diverticulitis with perforation, abscess, and malabsorption. Of the complications, 46% were due to je?jun?o?ileal diverticula and 13% were at?tributed to duodenal diverticula.

The diagnostic workup for the individual clinical presentations is shown in the Table.4,14,15 Exploratory laparotomy is indicated for complicated diverticula. Duo?denal diverticula can be managed using simple diverticulectomy, whereas jejunal and ileal diverticula require segmental resection with end-to-end anastomosis.16 Uncomplicated duodenal diverticula may be managed nonoperatively because of the low incidence of complications.13

References

1. Kraus M, Sampson D, Wilson SD. Perforation of diverticulum of terminal ileum presenting as acute appendicitis. Surgery. 1976;79(6): 724-725.

2. Longo WE, Vernava AM 3rd. Clinical implications of jejunoileal diverticular disease. Dis Colon Rectum. 1992;35(4):381-388.

3. Ross CB, Richards WO, Sharp KW, et al. Diverticular disease of the jejunum and its complications. Am Surg. 1990;56(5): 319-324.

4. Kouraklis G, Mantas D, Glivanou A, et al. Diverticular disease of the small bowel: report of 27 cases. Int Surg. 2001;86(4): 235-239.

Curr Pract Med

5. Taylor TV. Diverticulitis.. 1999;2:2423-2429.

6. Arnold JF, Pellicane JV. Meckel's diverticulum: a ten-year experience. Am Surg. 1997;63(4): 354-355.

7. Bokhari SR, Resnik AM, Nemir P Jr. Diverticulitis of the terminal ileum: report of a case and review of the literature. Dis Colon Rectum. 1982;25(7):660-663.

8. Chiu EJ, Shyr YM, Su CH, et al. Diverticular disease of the small bowel. Hepatogastroenterology. 2000;47(31):181-184.

9. Williams RA, Davidson DD, Serota AI, et al. Surgical problems of diverticula of the small intestine. Surg Gynecol Obstet. 1981;152(5):621-626.

10. Kouraklis G, Glinavou A, Mantas D, et al. Clinical implications of small bowel diverticula. Isr Med Assoc J. 2002;4(6):431-433.

11. Palder SB, Frey CB. Jejunal diverticulosis. Arch Surg. 1988;123(7): 889-894.

12. Mahorner H, Kisner W. Diverticula of the duodenum and jejunum. Surg Gynecol Obstet. 1947;85:607-622.

13. Akhrass R, Yaffe MB, Fischer C, et al. Small bowel diverticulosis: perceptions and reality. J Am Coll Surg. 1997;184(4):383-388.

14. Spiegel RM, Schultz RW, Casarella WJ, et al. Massive hemorrhage from jejunal diverticula. Radiology. 1982;143(2): 367-371.

15. Nobles ER Jr. Jejunal diverticula. Arch Surg. 1971;102(3): 172-174.

16. Eckhauser FE, Zelenock GB, Freier DT. Acute complications of jejunoileal pseudodiverticulosis: surgical implications and management. Am J Surg. 1979;138(2):320-323.

Diagnostic workup by presentation

Presentation

Diagnostic workup

Chronic abdominal pain

Enteroclysis4 (if endoscopic examination and CT scan are negative)

Bowel obstruction and/or perforation

Abdominal radiographs, CT scan, and operative exploration

Bleeding jejunal diverticula

Mesenteric angiography or red cell scan14

Malabsorption

Serum albumin, vitamin B12, Schilling test, and serum folic acid15