Mid-jejunal Diverticulitis with Closed-loop Bowel Obstruction, Strangulation, and Contained Perforation

Overview

Journal Clin Case Rep

Date 2024 Oct 23

PMID 39440345

Authors

Tzu Han Huang

Madeline Marker

Torben Urdahl

Juan Manivel

Anthony T Rezcallah

Affiliations

Soon will be listed here.

Abstract

Key Clinical Message: Closed-loop bowel obstruction and contained perforation secondary to acute on chronic jejunal diverticulitis is rare and should be included in the differential diagnosis of acute abdomen. The association between polymyalgia rheumatica and diverticular disease requires further research but may prompt clinicians to consider appropriate therapies in patients with both diseases.

Abstract: Jejunal diverticulosis is a sac-like outpouching of the intestinal wall that can cause complications such as diverticulitis, obstruction, abscess, perforation, or fistula formation. Complicated jejunal diverticulosis may present with acute abdomen and nonspecific symptoms which can lead to misdiagnosis and delayed treatment. A 76-year-old male with a remote history of polymyalgia rheumatica (PMR) presented with sudden onset abdominal pain, fever, nausea, vomiting, and inability to pass flatus. Physical exam revealed a distended and diffusely tender abdomen with signs of peritonitis. Laboratory test results were significant for neutrophil-dominant leukocytosis and elevated inflammatory markers. CT scan of the abdomen with IV contrast revealed a contained perforation and a closed-loop small bowel obstruction in the mid-abdomen. The patient underwent emergent exploratory laparotomy and resection of 100 cm of mid-jejunum which was found to have numerous diverticula surrounding the closed-loop obstruction and contained perforation. Pathology findings showed evidence of acute on chronic jejunal diverticulitis. Jejunal diverticulosis with complications may present with an acute abdomen and peritonitis. Closed-loop bowel obstruction and contained perforation secondary to acute on chronic jejunal diverticulitis is uncommonly thought of and should be considered in the differential diagnosis. Additionally, the association between PMR and diverticular disease is notable. While the patient had a remote history but no active PMR on presentation, studies suggest a possible association between gut inflammation and rheumatologic disease. This association should prompt clinicians to consider appropriate therapies and bear in mind the potential risk for diverticular perforation if glucocorticoids are given to treat PMR. Jejunal diverticulosis with multiple complications such as closed-loop bowel obstruction and contained perforation secondary to acute on chronic jejunal diverticulitis is rare and may present with an acute abdomen and nonspecific symptoms. Including rare pathologies as such in the differential diagnosis may prevent misdiagnosis and delayed treatment. While further investigation is needed, the association between diverticulosis and PMR is noteworthy as patients who present with both diseases would require mindful management due to the potential risk of diverticular perforation after treatment with steroids.

References

Prough H, Jaffe S, Jones B . Jejunal diverticulitis. J Surg Case Rep. 2019; 2019(1):rjz005. PMC: 6354680. DOI: 10.1093/jscr/rjz005. View

Gracey E, Vereecke L, McGovern D, Frohling M, Schett G, Danese S . Revisiting the gut-joint axis: links between gut inflammation and spondyloarthritis. Nat Rev Rheumatol. 2020; 16(8):415-433. DOI: 10.1038/s41584-020-0454-9. View

Leigh N, Sullivan B, Anteby R, Talbert S . Perforated jejunal diverticulitis: a rare but important differential in the acute abdomen. Surg Case Rep. 2020; 6(1):162. PMC: 7338329. DOI: 10.1186/s40792-020-00929-3. View

Elling P, Olsson A, Elling H . Synchronous variations of the incidence of temporal arteritis and polymyalgia rheumatica in different regions of Denmark; association with epidemics of Mycoplasma pneumoniae infection. J Rheumatol. 1996; 23(1):112-9. View

Gerardi M, Rutigliano I, Scrivo R, Priori R, Riccieri V, Valesini G . "In sickness and in health": the peculiar occurrence of polymyalgia rheumatica in married cohabiting couples--a case series and review of the literature. Clin Rheumatol. 2014; 35(4):1111-5. DOI: 10.1007/s10067-014-2604-4. View

Rangan V, Lamont J . Small Bowel Diverticulosis: Pathogenesis, Clinical Management, and New Concepts. Curr Gastroenterol Rep. 2020; 22(1):4. DOI: 10.1007/s11894-019-0741-2. View

Elfanagely Y, Tse C, Patil P, Lueckel S . Jejunal Diverticulosis Complicated by Diverticulitis and Small Bowel Obstruction. Cureus. 2020; 12(5):e8347. PMC: 7263004. DOI: 10.7759/cureus.8347. View

Aljabri W, Hasosah M, Almehdar A, Bakhsh D, Alturkistany F . Duodenal Diverticulosis as an Unusual Cause of Severe Abdominal Pain. Cureus. 2020; 12(9):e10586. PMC: 7580970. DOI: 10.7759/cureus.10586. View

Hysa E, Sobrero A, Camellino D, Rumi F, Carrara G, Cutolo M . A seasonal pattern in the onset of polymyalgia rheumatica and giant cell arteritis? A systematic review and meta-analysis. Semin Arthritis Rheum. 2020; 50(5):1131-1139. DOI: 10.1016/j.semarthrit.2020.05.023. View

10.

Soriano A, Verrecchia E, Marinaro A, Giovinale M, Fonnesu C, Landolfi R . Giant cell arteritis and polymyalgia rheumatica after influenza vaccination: report of 10 cases and review of the literature. Lupus. 2012; 21(2):153-7. DOI: 10.1177/0961203311430222. View

11.

Cimmino M, Caporali R, Montecucco C, Rovida S, Baratelli E, Broggini M . A seasonal pattern in the onset of polymyalgia rheumatica. Ann Rheum Dis. 1990; 49(7):521-3. PMC: 1004141. DOI: 10.1136/ard.49.7.521. View

12.

Meekel J, Timmerman M, Hoeksema M, den Boer F . Jejunal closed-loop obstruction without prior abdominal surgery during COVID-19 ICU admittance: A case report. Ann Med Surg (Lond). 2021; 69:102729. PMC: 8373852. DOI: 10.1016/j.amsu.2021.102729. View

13.

Peris P . Polymyalgia rheumatica is not seasonal in pattern and is unrelated to parvovirus b19 infection. J Rheumatol. 2004; 30(12):2624-6. View

14.

Iwata K, Mizuno Y . A case of polymyalgia rheumatica following influenza B infection. Int J Gen Med. 2015; 8:345-7. PMC: 4621214. DOI: 10.2147/IJGM.S92435. View

15.

Zafouri E, Ben Ismail I, Sghaier M, Rebii S, Zoghlami A . Jejunal diverticulitis: A new case report and a review of the literature. Int J Surg Case Rep. 2022; 97:107395. PMC: 9403097. DOI: 10.1016/j.ijscr.2022.107395. View

16.

Alam S, Rana A, Pervez R . Jejunal diverticulitis: imaging to management. Ann Saudi Med. 2014; 34(1):87-90. PMC: 6074925. DOI: 10.5144/0256-4947.2014.87. View

17.

Matli V, Chandrasekar V, Campbell J, Karanam C, Jaganmohan S . Jejunal Diverticulitis: A Rare Diverticular Disease of the Bowel. Cureus. 2022; 14(1):e21386. PMC: 8766225. DOI: 10.7759/cureus.21386. View

18.

Barbaro M, Cremon C, Fuschi D, Marasco G, Palombo M, Stanghellini V . Pathophysiology of Diverticular Disease: From Diverticula Formation to Symptom Generation. Int J Mol Sci. 2022; 23(12). PMC: 9223421. DOI: 10.3390/ijms23126698. View

19.

Scrivo R, Gerardi M, Rutigliano I, Sessa P, Mipatrini D, Stricchiola G . Polymyalgia rheumatica and diverticular disease: just two distinct age-related disorders or more? Results from a case-control study. Clin Rheumatol. 2018; 37(9):2573-2577. DOI: 10.1007/s10067-018-4137-8. View

20.

Mohi Ms R, Moudgil Ms A, Bhatia Ms S, Seth Ms K, Kaur Ms T . Complicated Jejunal Diverticulosis: Small Bowel Volvulus with Obstruction. Iran J Med Sci. 2016; 41(6):548-551. PMC: 5106572. View