Figure 1
Abdominal X-ray
No abnormalities were diagnosed at presentation.
Small bowel diverticulitis with abscess formation
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsSilva C, Palma S, Antunes D, Helena LS, Bruto da Costa F, Leitão J, Távora I
Connected authors
67 years, male
Clinical History
Patient presented at the emergency department complaining of acute onset of colicky abdominal pain in the left iliac fossa.
Imaging Findings
A 67-year-old male patient presented at the emergency department with a chief complaint of colicky pain in the left iliac fossa with 3 hours of onset. He did not have any other symptoms of gastrointestinal, urinary or musculoskeletal origin. Also fever was ruled out.
He had a past history of cholecystectomy, appendectomy and colonic polypectomy.
At physical examination, the left lower abdominal quadrant was tender, no masses were palpable and there was no rebound tenderness.
Laboratory investigations showed a C-reactive protein of 0.9 mg/dl and a white blood cell count of 14.3x109/l. A plain film of the abdomen was normal (Fig. 1).
Abdominal ultrasound was unremarkable, except for a slightly distended bowel loop with some hyperperistaltism.
The patient was admitted for further evaluation, and 12 hours later, after a little improvement with symptomatic therapy, his general condition declined.
An abdominopelvic CT scan was therefore requested putting into evidence a wall thickening of a distal jejunal loop, with increase in the attenuation of the perienteric fat, and a few extraluminal gas bubbles (Fig. 2, 3). There were no signs of free intraperitoneal fluid.
An acute small bowel process was diagnosed and at laparotomy surgeons found a perforated diverticulum in the jejunum contiguous to some other inflamed diverticula (Fig. 4, 5). Resection of 50 cm of jejunum was carried out.
Pathologist described some diverticula with aspects of inflammation and areas of wall necrosis, and the formation of abscesses with peritonitis, also with foci of steatonecrosis.
The post-operative recovery was uneventful.
He had a past history of cholecystectomy, appendectomy and colonic polypectomy.
At physical examination, the left lower abdominal quadrant was tender, no masses were palpable and there was no rebound tenderness.
Laboratory investigations showed a C-reactive protein of 0.9 mg/dl and a white blood cell count of 14.3x109/l. A plain film of the abdomen was normal (Fig. 1).
Abdominal ultrasound was unremarkable, except for a slightly distended bowel loop with some hyperperistaltism.
The patient was admitted for further evaluation, and 12 hours later, after a little improvement with symptomatic therapy, his general condition declined.
An abdominopelvic CT scan was therefore requested putting into evidence a wall thickening of a distal jejunal loop, with increase in the attenuation of the perienteric fat, and a few extraluminal gas bubbles (Fig. 2, 3). There were no signs of free intraperitoneal fluid.
An acute small bowel process was diagnosed and at laparotomy surgeons found a perforated diverticulum in the jejunum contiguous to some other inflamed diverticula (Fig. 4, 5). Resection of 50 cm of jejunum was carried out.
Pathologist described some diverticula with aspects of inflammation and areas of wall necrosis, and the formation of abscesses with peritonitis, also with foci of steatonecrosis.
The post-operative recovery was uneventful.
Discussion
Meckel's diverticulum is the most common true congenital diverticulum, whereas duodenal diverticula are considered the most common form of acquired diverticula of the small bowel.
Jejunal and ileal diverticula are uncommon with a reported prevalence ranging from 0.1% to 1.4% noted in some autopsy series and 0.1% to 1.5% noted in upper gastrointestinal studies. They are congenital or acquired, may present as either true or false diverticula, and are often multiple, usually protruding from the mesenteric border of the bowel. The aetiology of acquired jejunoileal diverticulosis is thought to be a motor dysfunction which causes pseudo-obstruction and high intraluminal pressures, after which diverticula form. The great majority remain asymptomatic and are usually found incidentally.
Acute complications such as acute diverticulitis, intestinal obstruction, haemorrhage, or perforation can occur; with acute necrotising inflammatory reaction being the most common cause of diverticular perforation (other causes include penetration of the intestinal wall by a foreign body or from blunt trauma).
Symptoms of abdominal pain, malabsorption (due to stasis of intestinal flow with bacterial overgrowth), functional pseudo-obstruction, and low-grade gastrointestinal haemorrhage can also occur on a chronic basis.
In the case of acute diverticulitis, abdominal radiograms may identify signs of perforation. Ultrasound can reveal thickening of the intestinal wall, aspects suggestive of diverticula, hyperechoic tissue around the diverticula indicating inflamed fat and extraluminal fluid collections with or without gas bubbles.
At CT, it may manifest as a focal area of asymmetric small bowel wall thickening, most prominent on the mesenteric side of the bowel, extraluminal gas bubbles or gas/fluid levels in contiguity, and hyperdense appearance of the mesenteric fat. An important feature in order to make the diagnosis is the presence of uncomplicated diverticula elsewhere in the small bowel (Fig. 3).
Most authors recommend administration of oral and intravenous contrast media to increase detection of inflammatory changes (enhancement of the bowel wall and rim enhancement of the collections; distension and opacification of the bowel with positive oral contrast makes it easier to assess the thickening of the bowel wall and to differentiate between intra- and extraluminal structures).
For incidentally noted, asymptomatic jejunoileal diverticula, no treatment is required. Treatment of complications such as bleeding, obstruction, and perforation is usually by intestinal resection and end-to-end anastomosis.
Antibiotics can usually be given to patients presenting with malabsorption secondary to bacterial overgrowth within the diverticula.
Jejunal and ileal diverticula are uncommon with a reported prevalence ranging from 0.1% to 1.4% noted in some autopsy series and 0.1% to 1.5% noted in upper gastrointestinal studies. They are congenital or acquired, may present as either true or false diverticula, and are often multiple, usually protruding from the mesenteric border of the bowel. The aetiology of acquired jejunoileal diverticulosis is thought to be a motor dysfunction which causes pseudo-obstruction and high intraluminal pressures, after which diverticula form. The great majority remain asymptomatic and are usually found incidentally.
Acute complications such as acute diverticulitis, intestinal obstruction, haemorrhage, or perforation can occur; with acute necrotising inflammatory reaction being the most common cause of diverticular perforation (other causes include penetration of the intestinal wall by a foreign body or from blunt trauma).
Symptoms of abdominal pain, malabsorption (due to stasis of intestinal flow with bacterial overgrowth), functional pseudo-obstruction, and low-grade gastrointestinal haemorrhage can also occur on a chronic basis.
In the case of acute diverticulitis, abdominal radiograms may identify signs of perforation. Ultrasound can reveal thickening of the intestinal wall, aspects suggestive of diverticula, hyperechoic tissue around the diverticula indicating inflamed fat and extraluminal fluid collections with or without gas bubbles.
At CT, it may manifest as a focal area of asymmetric small bowel wall thickening, most prominent on the mesenteric side of the bowel, extraluminal gas bubbles or gas/fluid levels in contiguity, and hyperdense appearance of the mesenteric fat. An important feature in order to make the diagnosis is the presence of uncomplicated diverticula elsewhere in the small bowel (Fig. 3).
Most authors recommend administration of oral and intravenous contrast media to increase detection of inflammatory changes (enhancement of the bowel wall and rim enhancement of the collections; distension and opacification of the bowel with positive oral contrast makes it easier to assess the thickening of the bowel wall and to differentiate between intra- and extraluminal structures).
For incidentally noted, asymptomatic jejunoileal diverticula, no treatment is required. Treatment of complications such as bleeding, obstruction, and perforation is usually by intestinal resection and end-to-end anastomosis.
Antibiotics can usually be given to patients presenting with malabsorption secondary to bacterial overgrowth within the diverticula.
Differential Diagnosis List
Small bowel diverticulitis with abscess formation.
Final Diagnosis
Small bowel diverticulitis with abscess formation.
References
[1] Graña L, Pedraja I, Mendez R, Rodríguez R (2009) Jejuno-ileal diverticulitis with localized perforation: CT and US findings. Eur J Radiol 71:318-23 (PMID: 18333632)
[2] Veen M, Hornstra BJ, Clemens CH, Stigter H, Vree R (2009) Small bowel diverticulitis as a cause of acute abdomen. Eur J Gastroenterol Hepatol 21:123-5 (PMID: 19011578)
[3] Macari M, Faust M, Liang H, Pachter HL (2007) CT of jejunal diverticulitis: imaging findings, differential diagnosis, and clinical management. Clin Radiol 62:73-7 (PMID: 17145267)
Case information
| URL: | https://eurorad.org/case/8859 |
| DOI: | 10.1594/EURORAD/CASE.8859 |
| ISSN: | 1563-4086 |
Figure 3
Intraoperative photograph
At laparotomy a perforated diverticulum in the jejunum contiguous to some other inflamed diverticula was found.
Figure 4
Intraoperative photograph
Diverticula with aspects of inflammation and areas of wall necrosis. Resection of 50 cm of jejunum was carried out.
Figure 5
Unenhanced CT scan - coronal view
Abdominal X-ray
No abnormalities were diagnosed at presentation.
Intraoperative photograph
At laparotomy a perforated diverticulum in the jejunum contiguous to some other inflamed diverticula was found.
Intraoperative photograph
Diverticula with aspects of inflammation and areas of wall necrosis. Resection of 50 cm of jejunum was carried out.
