Case Rep Gastroenterol 2019;13:521–525

DOI: 10.1159/000503896 © 2019 The Author(s)

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Single Case

Perforated Jejunal Diverticulitis

Dhineshreddy Gurala a Pretty Sara Idiculla b Prateek Patibandla a
Jobin Philiposea Michael Krzyzak a Indraneil Mukherjeea

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a Internal
Medicine, Staten Island University Hospital, Northwell Health, Staten
Island, NY, USA; b Medicine, Sree Gokulam Medical College and Research Foundation,
Trivandrum, India

Keywords
Diverticulitis · Jejunum · Perforation

Abstract
Small intestinal diverticula are very rare; their incidence ranges from 0.06 to 1.3%, with a higher
prevalence after the 6th decade of life. Among these small intestinal diverticula, duodenal di-
verticula are more frequent, followed by diverticula of the jejunum and ileum. A jejunal diver-
ticulum is usually asymptomatic; sometimes patients complain of vague chronic symptoms like
malabsorption, pain, or nausea that easily lead to misdiagnosis. Complications are rarely re-
ported, only in 10% of patients. We report a unique case of a 70-year-old female who pre-
sented with confusion due to sepsis from perforated jejunal diverticulitis, which was success-
fully managed with initial resuscitation and definitive surgery.
© 2019 The Author(s)
Published by S. Karger AG, Basel

Introduction

Small intestinal diverticula are very rare; their incidence ranges from 0.06 to 1.3% [1].
Except for Meckel’s diverticulum, which is congenital, all diverticula are usually acquired.
Among these, duodenal diverticula are the most frequent (in 79% of patients), followed by
diverticula of the jejunum or ileum (18%) and diverticula in all segments together (3%) [2].
The prevalence of diverticula increases with age and peaks in the 6th–8th decades of life. A

Dhineshreddy Gurala
Internal Medicine, Staten Island University Hospital, Northwell Health
525 A Liberty Avenue
Staten Island, NY 10305 (USA)
E-Mail [email protected]
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DOI: 10.1159/000503896 © 2019 The Author(s). Published by S. Karger AG, Basel
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Gurala et al.: Perforated Jejunal Diverticulitis

jejunal diverticulum is usually asymptomatic; only 29% of the patients present with symp-
toms like nausea, abdominal pain, and malabsorption. Complications such as perforations, ad-
hesion, fistula, and peritonitis are more common than massive lower gastrointestinal bleed-
ing, and these complications are reported only in 10% of cases [1, 3]. Surgery is the definitive
treatment option in case of complicated diverticulitis with perforation like in our case.

Case Description

A 76-year-old female presented to our institution with abdominal pain and confusion 2
days prior to presentation. The abdominal pain was located in the epigastrium, crampy in na-

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ture, constant, nonradiating, 7/10 in intensity associated with nausea, vomiting, decreased
appetite, with no aggravating and relieving factors. The family reported that she was less in-
teractive, subjectively more withdrawn, and not oriented to her surroundings. Her vital signs
were stable with a temperature of 97.5°F, a heart rate of 65 bpm, blood pressure at 147/68
mm Hg, and saturation 98% on room air. A physical examination was positive for epigastric
tenderness with no abdominal distension, guarding, rigidity, or rebound tenderness. Bowel
sounds were present in all four quadrants. She was alert and oriented to persons and place
but not to time, but a neurological examination revealed no focal deficits. Laboratory studies
showed leukocytosis of 15,000 cells/μL with a left shift (predominant neutrophils), hemoglo-
bin at 13 g/dL (normal 12–16), a platelet count of 220,000 (130,000–400,000), blood urea
nitrogen at 15 mg/dL (10–20), creatinine at 0.9 mg/dL (0.7–1.5), calcium at 9.2 mg/dL (nor-
mal 8.5–10.1), lactate at 1.1 mmol/L (normal 0.5–1.6), lipase at 14 U/L (7–60), and amylase
at 25 U/L (normal 23–85).
A plain radiograph of the abdomen was negative for obstruction or perforation. Com-
puted tomography (CT) of the abdomen with oral and intravenous contrast showed a ring-
enhancing collection with an air-fluid level and extensive adjacent mesenteric inflammation
measuring 4.4 × 4.4 cm within the mesentery in the left hemiabdomen adjacent to the loop of
a thickened and edematous mid-jejunum and intraperitoneal free air consistent with perfo-
rated small bowel diverticulitis with abscess formation, and no evidence of bowel obstruction
or ascites (Fig. 1). The patient reported a past history of cholecystectomy and hysterectomy.
The diagnosis was considered to be contained perforation. The patient was initially re-
suscitated with intravenous fluids and was started on intravenous antibiotics. Her mentation
gradually improved, and her abdominal discomfort and tenderness resolved. On discussion
for the definitive treatment, she was taken to the operating room 2 days later after medical
and cardiac risk stratification. She was intubated because of an increased risk for surgery and
underwent diagnostic laparoscopy with extensive lysis of adhesion and drainage of multiple
small interloop abscesses. Two jejunal diverticula were found next to each other, one of which
was perforated. The segment of jejunum containing the two diverticula was resected. The
ends were primarily anastomosed. The procedure was completed without any complications,
and the patient was extubated and on the same day transferred to the critical care unit for
monitoring. She did well postoperatively. She was started on a liquid diet and advanced. She
was discharged after 6 days of hospital stay and recovered completely with no residual symp-
toms.
Pathology of the small bowel resection showed segments of the small bowel with diver-
ticular disease, one with perforation, acute and chronic diverticulitis, fistula formation with
abscess and extensive necrosis, and acute serositis with marked inflammation of the mesen-
tery; the rest of the small bowel showed congestion.
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DOI: 10.1159/000503896 © 2019 The Author(s). Published by S. Karger AG, Basel
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Gurala et al.: Perforated Jejunal Diverticulitis

Discussion

Sömmering and Baille first reported a case of jejunoileal diverticula in 1794 [4]. Jejunal
diverticula are usually multiple in number and localized in the proximal jejunum, and they
develop as a result of herniation of the mucosa, submucosa, and serosa through the muscular
layer of the bowel at the point where the vasa recta enter the muscularis propria. It is a pseu-
dodiverticulum, because it does not involve all layers of the bowel wall. The prevalence of
jejunoileal diverticulosis is about 2% in the population, slightly higher among men than
among women, and also slightly higher among elderly patients [5, 6]. These diverticula are
frequently associated with disorders of intestinal motility, such as progressive systemic scle-
rosis, visceral neuropathies, and myopathy. Their causes are unclear, but intestinal dyskinesia,

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abnormal peristalsis, and high intraluminal pressure are implicated in their pathogenesis.
Jejunal diverticulosis usually asymptomatic; only 29% of the patients develop signs and
symptoms [4], and 10% develop complications [3] such as perforation, obstruction, adhesion,
fistula, peritonitis, and lower gastrointestinal bleeding. Acute complications are related to the
inflammation of the mucosa, which leads to perforation and subsequent abscesses, as in our
patient. Perforation of jejunal diverticula is a severe complication that occurs in 2–6% of
cases [7].
Diagnosis is often challenging even with symptoms; therefore, a high degree of clinical
suspicion is required. A plain abdominal radiograph is the initial imaging modality of choice,
since it can show signs of perforation such as the presence of free air, or signs of intestinal
obstruction such as the presence of dilated intestinal loops and air-fluid levels. CT scanning or
magnetic resonance imaging can help recognize the condition, exposing signs of inflammation,
thickening of the bowel wall with outpouchings, lesions, free air, and air-fluid levels [8]. Mor-
tality from jejunal diverticulitis ranges from 0 to 5%, increasing to 40% in case of perfora-
tion [9].
Acute uncomplicated jejunal diverticulitis is managed with intravenous fluids, bowel rest,
and antibiotics [10]. Acute complicated diverticulitis causing perforation with localized peri-
tonitis with stable vital signs can be managed with conservative treatment as well as with
percutaneous CT-guided aspiration without the need for surgery [8, 11]. Perforation with gen-
eralized peritonitis needs surgical intervention such as laparotomy with segmental small
bowel resection with primary anastomosis. Overall mortality after general surgery is 24% be-
cause of poor prognostic factors such as advanced age and delays in diagnosis and treatment.

Conclusions

Even though colonic diverticulitis is almost always suspected in an elderly patient pre-
senting with abdominal pain and fever, jejunal diverticulitis should be considered as a differ-
ential diagnosis. It requires a high degree of clinical suspicion, given the low incidence of the
condition. Early diagnosis and prompt treatment are essential to prevent complications and
to improve the patient’s outcome.

Statement of Ethics

Consent was obtained from the patient. IRB approval was not needed.
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DOI: 10.1159/000503896 © 2019 The Author(s). Published by S. Karger AG, Basel
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Gurala et al.: Perforated Jejunal Diverticulitis

Disclosure Statements

The authors declare no financial disclosures or conflicts of interest.

Funding Sources

No funding was obtained for this case report.

Author Contributions

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D. Gurala, P. Patibandla, and J. Philipose wrote the Introduction, Case Description, and
Discussion; P.S. Idiculla drafted the Introduction; M. Krzyzak and I. Mukherjee reviewed and
edited the manuscript.

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Fig. 1. Computed tomography image of the abdomen with oral and intravenous contrast showing mesen-
teric inflammation and intraperitoneal free air consistent with perforated small bowel diverticulitis with
abscess formation.