0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Diagnosis FREE

[+] Author Affiliations

SECTION EDITOR: CARL E. BREDENBERG, MD

More Author Information
JAMA Surg. 2013;148(6):578. doi:10.1001/jamasurg.2013.303b.
Text Size: A A A
Published online

ANSWER: PERFORATED SMALL-BOWEL DIVERTICULUM WITH CALCIFIED FECALITH

Examination of the bowel revealed numerous proximal jejunal diverticula, including one that had obviously perforated and was associated with an abscess cavity (Figure 2A). After washout of the abdomen, a 90-cm segment of small bowel that contained 11 diverticula was resected, and the 2 ends were joined with a side-to-side functional end-to-end anastomosis. Pathologic examination of the small-bowel specimen revealed a calcified fecalith in the perforated diverticulum and partially digested food particles (Figure 2B).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Eleven small-bowel diverticula found in proximal small bowel, one of which was firm and grossly perforated (A). White arrow shows perforated diverticulum, whereas black arrows denote nonperforated diverticula in same small-bowel segment. Pathologic examination revealed calcified fecalith in perforated diverticulum (B).

Small-bowel diverticula are very rare, although the medical literature is scattered with case reports and small case series. The prevalence of these non-Meckelian small-bowel diverticula increases with age because they are considered to be acquired pulsion diverticula, and nonmechanical obstructive symptoms can be related to dyskinesia.1 In nearly every case in the literature in which patients presented with perforated jejunal diverticula, they were unaware of the presence of diverticular disease and were previously asymptomatic. Although the management of perforated jejunal diverticula is nearly always surgical, there are reported cases of successful nonoperative management when patients presented with only localized abdominal pain.2

The diagnosis of perforated jejunal diverticula is often made in the operating room, as in the present case, because the diagnosis can be elusive, even with high-quality cross-sectional imaging that often accompanies a preoperative diagnosis of other intra-abdominal acute processes such as perforated appendicitis.1,3 However, complications other than perforation can result from jejunal diverticular disease such as massive lower gastrointestinal bleeding, obstruction, or vague nonspecific symptoms.4,5

Small-bowel pulsion diverticular disease usually occurs in the jejunum and usually in multiple numbers.1,3,6 Although there are reports of primary repair and closure of perforated jejunal diverticula,6 resection of the involved segment seems to be the norm. In the present case, the diverticula were quite large (5-8 cm in diameter), pedunculated, and all contiguous in the proximal jejunum. Presentation with perforation secondary to enterolith has also been reported in several instances7,8 and has also been associated with multiple diverticula in the proximal jejunum.

This case demonstrates the difficulty in diagnosing small-bowel diverticula even with advanced imaging. The presentation of non-Meckelian jejunal diverticula ranges from generalized peritonitis secondary to perforation to massive lower gastrointestinal bleeding or may present with obstructive symptoms. Although rare, the general surgeon should have some familiarity with small-bowel diverticular disease and its role in both acute and chronic abdominal pathology.

Return to Quiz Case.

Correspondence: Antonio D. Lassaletta, MD, Department of Surgery, Beth Israel Deaconess Medical Center, 110 Francis St, Ste 9B, Boston, MA 02215 (alassale@bidmc.harvard.edu).

Accepted for Publication: February 25, 2012.

Author Contributions:Study concept and design: All authors. Acquisition of data: Lassaletta and Sheth. Analysis and interpretation of data: Lassaletta and Sheth. Drafting of the manuscript: Lassaletta. Critical revision of the manuscript for important intellectual content: All authors. Administrative, technical, and material support: All authors. Study supervision: Sheth.

Conflict of Interest Disclosures: None reported.

Garg N, Khullar R, Sharma A, Soni V, Baijal M, Chowbey P. Total laparoscopic management of large complicated jejunal diverticulum.  J Minim Access Surg. 2009;5(4):115-117
PubMed   |  Link to Article
Prost A La Denise J, Douard R, Berger A, Cugnenc PH. Small bowel diverticulosis complicated by perforated jejunal diverticula.  Hepatogastroenterology. 2008;55(86-87):1657-1659
PubMed
Tankova L, Berberova M, Purvanov P, Tsankov Ts, Gegova A. Complicated small bowel diverticulosis.  Chirurgia (Bucur). 2007;102(5):603-606
PubMed
Assenza M, Ricci G, Antoniozzi A, Clementi I, Simonelli L, Modini C. Perforated jejuneal diverticulosis.  Ann Ital Chir. 2007;78(3):247-250
PubMed
Tan KK, Liu JZ, Ho CK. Emergency surgery for jejunal diverticulosis.  ANZ J Surg. 2011;81(5):358-361
PubMed   |  Link to Article
Butler JS, Collins CG, McEntee GP. Perforated jejunal diverticula.  J Med Case Rep. 2010;4:172
PubMed   |  Link to Article
Nonose R, Valenciano JS, de Souza Lima JS, Nascimento EF, Silva CM, Martinez CA. Jejunal diverticular perforation due to enterolith.  Case Rep Gastroenterol. 2011;5(2):445-451
PubMed   |  Link to Article
Chugay P, Choi J, Dong XD. Jejunal diverticular disease complicated by enteroliths.  World J Gastrointest Surg. 2010;2(1):26-29
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Eleven small-bowel diverticula found in proximal small bowel, one of which was firm and grossly perforated (A). White arrow shows perforated diverticulum, whereas black arrows denote nonperforated diverticula in same small-bowel segment. Pathologic examination revealed calcified fecalith in perforated diverticulum (B).

Tables

References

Garg N, Khullar R, Sharma A, Soni V, Baijal M, Chowbey P. Total laparoscopic management of large complicated jejunal diverticulum.  J Minim Access Surg. 2009;5(4):115-117
PubMed   |  Link to Article
Prost A La Denise J, Douard R, Berger A, Cugnenc PH. Small bowel diverticulosis complicated by perforated jejunal diverticula.  Hepatogastroenterology. 2008;55(86-87):1657-1659
PubMed
Tankova L, Berberova M, Purvanov P, Tsankov Ts, Gegova A. Complicated small bowel diverticulosis.  Chirurgia (Bucur). 2007;102(5):603-606
PubMed
Assenza M, Ricci G, Antoniozzi A, Clementi I, Simonelli L, Modini C. Perforated jejuneal diverticulosis.  Ann Ital Chir. 2007;78(3):247-250
PubMed
Tan KK, Liu JZ, Ho CK. Emergency surgery for jejunal diverticulosis.  ANZ J Surg. 2011;81(5):358-361
PubMed   |  Link to Article
Butler JS, Collins CG, McEntee GP. Perforated jejunal diverticula.  J Med Case Rep. 2010;4:172
PubMed   |  Link to Article
Nonose R, Valenciano JS, de Souza Lima JS, Nascimento EF, Silva CM, Martinez CA. Jejunal diverticular perforation due to enterolith.  Case Rep Gastroenterol. 2011;5(2):445-451
PubMed   |  Link to Article
Chugay P, Choi J, Dong XD. Jejunal diverticular disease complicated by enteroliths.  World J Gastrointest Surg. 2010;2(1):26-29
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles