radiologic findings of perforated jejunal diverticulitis: a ......perforated jejunal diverticulitis....

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Jejunal diverticulosis has been reported to occur in less than 0.2- 2% of autopsied patients (1). Acute com- plications from diverticulitis are relatively rare, occur- ring in 10% of patients. Reported mortality from perfo- ration was 21- 40% (2), but the recent mortality rate of complicated diverticulitis is very low (3). Because of the rarity of jejunal diverticulitis, it is rarely considered as the etiology for patient’s abdominal pain, and this con- tributes to the delayed diagnosis and ineffective treat- ment (4). We experienced a case of jejunal diverticulitis that was correctly diagnosed preoperatively by ultra- sonography (U/S) and computed tomography (CT) and treated by surgical resection. We present a case of perfo- rated jejunal diverticulitis including characteristic im- ages. Case Report A 68-year-old man, who had a long history of xerotic eczema and had been managed with prednisone for 53 years, was admitted with abdominal pain lasting for 3 days. On abdominal examination, the right upper quad- rant was severely tender. The laboratory values showed an increased white blood cell count (13,600 /mm 3 ) and the body temperature was high (38.6). The supine and erect radiographs of the abdomen showed the presence of dilated colon and small bowel loops without an evidence of free air. Acute cholecystitis was suggested and abdominal ultrasonography was rec- ommended. The U/S examination (Fig. 1A) showed a hypoechoic structure, connected to a small bowel loop, highly suggestive of diverticulum. The presence of hy- perechogenic tissue around the diverticulum was sug- gestive of inflamed fat. CT images of the abdomen and pelvis showed multiple diverticula, misty mesentery, and free air localized within the mesenteric leaf in a proximal jejunal loop (Fig. 1B). The patient underwent J Korean Radiol Soc 2006;54:289-292 289 Radiologic Findings of Perforated Jejunal Diverticulitis: A Case Report 1 Jeong-Hwa Kong, M.D., Dong Ho Lee, M.D., Hyoung Jung Kim, M.D., Joo Won Lim, M.D., Young Tae Ko, M.D., Yong Koo Park, M.D. 2 1 Department of Diagnostic Radiology, Kyung Hee University Hospital 2 Department of Pathology, Kyung Hee University Hospital Received July 16, 2005 ; Accepted October 27, 2005 Address reprint requests to : Dong Ho Lee, M.D., Department of Diagnostic Radiology, Kyung Hee University Hospital, 1, Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea. Tel. 82-2-958-8615 Fax. 82-2-968-0787 E-mail: [email protected] We report a case of perforated jejunal diverticulitis in a 68-year-old man with iatro- genic Cushing’s syndrome. The patient presented with right upper abdominal pain. Ultrasonography showed a hypoechoic structure connected to a small bowel loop, and subsequent CT examination showed multiple diverticula in proximal jejunal loops with free air trapped within the mesenteric leaf. Segmental resection of the jejunal loop confirmed jejunal diverticulitis with perforation. Index words : Intestines, diverticula Intestines, inflammation Mesentery, diseases Mesentery, CT

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  • Jejunal diverticulosis has been reported to occur inless than 0.2-2% of autopsied patients (1). Acute com-plications from diverticulitis are relatively rare, occur-ring in 10% of patients. Reported mortality from perfo-ration was 21-40% (2), but the recent mortality rate ofcomplicated diverticulitis is very low (3). Because of therarity of jejunal diverticulitis, it is rarely considered asthe etiology for patient’s abdominal pain, and this con-tributes to the delayed diagnosis and ineffective treat-ment (4). We experienced a case of jejunal diverticulitisthat was correctly diagnosed preoperatively by ultra-sonography (U/S) and computed tomography (CT) andtreated by surgical resection. We present a case of perfo-rated jejunal diverticulitis including characteristic im-ages.

    Case Report

    A 68-year-old man, who had a long history of xeroticeczema and had been managed with prednisone for 53years, was admitted with abdominal pain lasting for 3days. On abdominal examination, the right upper quad-rant was severely tender. The laboratory values showedan increased white blood cell count (13,600 /mm3) andthe body temperature was high (38.6℃).

    The supine and erect radiographs of the abdomenshowed the presence of dilated colon and small bowelloops without an evidence of free air. Acute cholecystitiswas suggested and abdominal ultrasonography was rec-ommended. The U/S examination (Fig. 1A) showed ahypoechoic structure, connected to a small bowel loop,highly suggestive of diverticulum. The presence of hy-perechogenic tissue around the diverticulum was sug-gestive of inflamed fat. CT images of the abdomen andpelvis showed multiple diverticula, misty mesentery,and free air localized within the mesenteric leaf in aproximal jejunal loop (Fig. 1B). The patient underwent

    J Korean Radiol Soc 2006;54:289-292

    ─ 289 ─

    Radiologic Findings of Perforated Jejunal Diverticulitis: A Case Report1

    Jeong-Hwa Kong, M.D., Dong Ho Lee, M.D., Hyoung Jung Kim, M.D., Joo Won Lim, M.D., Young Tae Ko, M.D., Yong Koo Park, M.D.2

    1Department of Diagnostic Radiology, Kyung Hee University Hospital2Department of Pathology, Kyung Hee University HospitalReceived July 16, 2005 ; Accepted October 27, 2005Address reprint requests to : Dong Ho Lee, M.D., Department ofDiagnostic Radiology, Kyung Hee University Hospital, 1, Hoegi-dong,Dongdaemun-gu, Seoul 130-702, Korea.Tel. 82-2-958-8615 Fax. 82-2-968-0787 E-mail: [email protected]

    We report a case of perforated jejunal diverticulitis in a 68-year-old man with iatro-genic Cushing’s syndrome. The patient presented with right upper abdominal pain.Ultrasonography showed a hypoechoic structure connected to a small bowel loop, andsubsequent CT examination showed multiple diverticula in proximal jejunal loopswith free air trapped within the mesenteric leaf. Segmental resection of the jejunalloop confirmed jejunal diverticulitis with perforation.

    Index words : Intestines, diverticulaIntestines, inflammationMesentery, diseasesMesentery, CT

  • segmental resection of the jejunum, which containedperforated diverticula. Histopathologic findings con-firmed jejunal diverticula at the site of mesenteric at-tachment and diffuse inflammatory cell infiltration inmesentery (Figs. 1C and 1D). The patient was dis-charged on postoperative day (POD) 11.

    Discussion

    Jejunal diverticulosis is a rare clinical entity and de-tected in 0.2-2% of patients (1). In contrast to true di-verticula such as Meckel’s diverticula, which are fairlycommon, acquired diverticula consist only of mucosa,

    submucosa and serosa without muscularis propria.Thus they are termed pseudodiverticula. The pathogen-esis of acquired diverticula of the small bowel is un-clear, although it may be ascribed to a pulsion phenome-non (5). It explains that small bowel has natural weakpoints along the mesentery side where blood vesselspenetrate the intestinal wall, and that locally increasedintraluminal pressure with abnormal peristalsis causesthe protrusion of mucosa and submucosa. Jejunal diver-ticula occur most frequently in the proximal jejunum,possibly due to the larger size of the vasa recta at this lo-cation (6). Jejunal diverticulosis in younger patients waspreviously reported, however, the incidence of jejunal

    Jeong-Hwa Kong, et al : Radiologic Findings of Perforated Jejunal Diverticulitis

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    A B

    C DFig. 1. Perforated jejunal diverticulitis in a 68-year-old man. A. On transabdominal US image, a hypoechoic structure (arrows) projecting beyond the contour of the small bowel, suggestive of adiverticulum, is visualized. Heterogeneous hyperechogenecity around the diverticulum, suggestive of inflamed mesenteric fat, isalso seen. B. Transverse CT scan shows several air containing diverticula (arrow) along the mesenteric fat. Extraluminal air pockets (arrow-heads) trapped within the mesenteric leaf, and misty mesentery representing inflammation of the adjacent mesenteric fat is seen.C. Photograph of gross specimen shows a cross sectioned jejunal diverticulum (arrow) at the mesentery border. D. On photomicrograph, there is herniated jejunal mucosa (arrows) through the defect of the muscle coat (H & E staining, × 15).

  • diverticulosis increases with age, especially during thesixth and seventh decades (1).

    Small bowel diverticulosis usually remains asympto-matic and complications related to the diverticula areuncommon. Perhaps the most frequent acute complica-tion of a jejunal diverticula is diverticulitis with or with-out perforation, occurring in 2.3-6.4% of cases (1, 7).Jejunal diverticulitis with perforation is a very uncom-mon complication of jejunal diverticulitis. To ourknowledge, this is the first case report within the coun-try. Mortality of complicated diverticulitis of up to 21%in cases of perforations was reported in 1962 (2), but ithas decreased dramatically due to improved diagnosticand surgical techniques, and a recent series reported amortality rate of 0% (3). Jejunal diverticular perforationis very difficult to diagnose because of its rarity and non-specific symptoms such as acute abdomen, abdominalpain and tenderness with leukocytosis, so that perfora-tion is often misdiagnosed as cholecystitis, colonic diver-ticulitis, peptic ulcer disease or appendicitis (4). In ourcase, the symptom of the perforated jejunal diverticu-lum was similar to acute cholecystitis, showing pain inthe right upper quadrant of the abdomen with leukocy-tosis and fever.

    There was a case report of multiple jejunal diverticuli-tis with perforation in a patient with systemic lupus ery-thematosus (SLE) who had been treated with pred-nisone (8). They speculated that systemic lupus erythe-matosus (SLE) patient could have acquired multiple jeju-nal diverticulosis due to intraperitoneal adhesion, recur-rent peritonitis and vasculitis. Our patient had xeroticdermatitis which had been managed with steroid thera-py for a long time. He was diagnosed with iatrogenicCushing’s syndrome and had prominent mesenteric fatpossibly due to steroid therapy. As far as we know,there has been no report on the relationship of steroiduse and jejunal diverticulitis.

    The radiologic diagnosis of jejunal diverticula is diffi-cult. Plain abdominal radiograph as a routine procedurefor acute abdominal pain is not usually sufficient tomake the diagnosis of jejunal diverticulosis or divertic-ulitis (4), unless there is pneumoperitoneum due to per-foration of jejunal diverticulitis. U/S is a readily avail-able method and can demonstrate the inflamed divertic-

    ulum and perforation (9). Kelekis et al (9) reported thatCT imaging was superior to U/S, demonstrating the pre-cise localization of the lesion and defining its bordersand extent of the inflammatory reaction. CT scan typi-cally shows an inflammatory mass containing gas, wallthickening in the involved segment, and edema of thesurrounding tissues including fat or fascial planes.However, there has been only a single case report re-garding perforated jejunal diverticulum which was pre-operatively made by CT (4). In our case, U/S examina-tion showed a diverticular sac with inflamed mesentericfat and CT scan demonstrated multiple diverticular sacsand free air trapped within mesenteric leaves of je-junum with adjacent misty mesentery, thus confirmingperforated jejunal diverticulitis.

    In conclusion, jejunal diverticulitis with perforation isa rare entity and correct diagnosis can be difficult. TheU/S can demonstrate the inflamed diverticulum itself.The CT scan can confirm the U/S diagnosis and further-more can localize the inflamed diverticulum with perfo-ration.

    References

    1. Sibille A, Willocx R. Jejunal diverticulitis. Am J Gastroenterol 1992;87:655-658

    2. Herrington JL Jr. Perforation of acquired diverticula of the je-junum and ileum. Analysis of reported cases. Surgery 1962;51:426-433

    3. Tsiotos GG, Farnell MB, Ilstrup DM. Nonmeckelian jejunal orileal diverticulosis: an analysis of 112 cases. Surgery 1994;116: 726-731

    4. Greenstein S, Jones B, Fishman EK, Cameron JL, Siegelman SS.Small bowel diverticulitis: CT findings. AJR Am J Roentgenol1986;147:271-274

    5. Krishnamurthy S, Kelly MM, Rohrmann CA, Schuffler MD.Jejunal diverticulosis. A heterogenous disorder caused by a varietyof abnormalities of smooth muscle or myenteric plexus.Gastroenterology 1983;85:538-547

    6. Tuszynski TR, Aryanpur JJ, Buchman TG. Perforated ileal diverti-culitis. Contemp Surg 1986;28:89-93

    7. Wilcox RD, Shatney CH. Surgical implications of jejunal diverticu-la. South Med J 1988;81:1386-1391

    8. Yagmur Y, Aldemir M, Buyukbayram H, Tacyildiz I. Multiple je-junal diverticulitis with perforation in a patient with systemic lu-pus erythematosus: report of a case. Surg Today 2004;34:163-166

    9. Kelekis AD, Poletti PA. Jejunal diverticulitis with localized perfora-tion diagnosed by ultrasound: a case report. Eur Radiol 2002;12Suppl 3:S78-81

    J Korean Radiol Soc 2006;54:289-292

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  • Jeong-Hwa Kong, et al : Radiologic Findings of Perforated Jejunal Diverticulitis

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    대한영상의학회지 2006;54:289-292

    천공된 공장 게실염의 방사선학적 소견: 증례 보고1

    1경희의료원진단방사선과2경희의료원병리과

    공정화·이동호·김형중· 임주원·고영태·박용구2

    저자들은 의인성 쿠싱증후군을 가진 68세 남자 환자에게서 천공을 일으킨 공장 게실염을 보고 한다. 환자는 우상복

    부 통증을 주소로 내원하였다. 초음파 상 소장과 연결된 저에코의 구조물이 보였으며, 이어서 시행한 CT 상 상부 공장

    에 다발성 게실과 장간막 소엽 내에 포획된 유리 공기가 보였다. 공장을 부분 절제하였고 천공된 공장 게실염을 확인하

    였다.