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Jejunal diverticula: a rare cause of life-threatening gastrointestinal bleeding

Jejunal diverticula: a rare cause of life-threatening gastrointestinal bleeding Jejunal diverticula are rare and the condition remains mostly asymptomatic. However, they can present with vague chronic abdominal symptoms and, in some cases, acute life-threatening complications, such as gastrointestinal (GI) bleeding, bowel obstruction and perforation. We present a case of an adult male who presented with life-threatening GI bleeding secondary to jejunal diverticular disease. Whilst there are undoubtedly more common causes of GI bleeding, this case demonstrates that jejunal diverticular disease should remain on the differential diagnosis and investigations to confirm the diagnosis should be considered. However, despite investigations, the diagnosis may remain elusive and in patients with on-going bleeding, laparotomy and surgical resection is currently the treatment of choice. INTRODUCTION disease, presented to the emergency department after a sudden collapse at home. His medications included aspirin and clopidogrel. Jejunal diverticular disease is a rare clinical entity with an inci- Whilst in the department, he experienced a further syncopal dence of between 0.06 and 1.5% [1]. The true incidence however event with two episodes of large-volume melaena. He was pale, may be higher as the majority of jejunal diverticula are asymp- clammy and haemodynamically unstable with a systolic blood tomatic, and thereby remain undiagnosed. pressure of 75 mmHg. His blood results showed a haemoglobin In symptomatic cases, non-specific epigastric pain and bloat- (Hb) of 66 g/l and a urea of 32.7 mmol/l. There were no reports ing are the most common complaints [2, 3]. However, life-threa- of melaena or haematemesis prior to admission. He was initially tening complications such as gastrointestinal (GI) bleeding, resuscitated with intravenous fluids, red blood cells (RBCs), plate- bowel perforation and obstruction have been reported in up to lets, fresh frozen plasma (FFP) and cryoprecipitate. 18% of cases [4]. It is therefore vital that the diagnosis of the con- The patient proceeded to urgent upper GI endoscopy (OGD) dition can be made promptly to ensure optimal and timely man- but the procedure failed to identify any evidence of recent or ac- agement for the patient. tive bleeding. Colonoscopy showed large amounts of altered We present a case of a 78-year-old male with massive GI blood in the colon as well as the presence of sigmoid diverticula bleeding secondary to jejunal diverticular disease who was surgi- but without evidence of active bleeding. Segmental CT-angio- cally managed with good post-operative outcome. gram was contraindicated given patient’s poor renal function. Despite vasopressor support and a proton-pump-inhibitor in- CASE REPORT fusion, with on-going melaena, the patient’s Hb and blood pres- A 78-year-old male with a history of ischaemic heart disease, sure remained low, requiring 19 units of RBCs in the first 48 h of stage IV chronic kidney disease and chronic obstructive pulmonary admission. Over the subsequent 36 h, the patient’scondition Received: October 14, 2014. Accepted: December 23, 2014 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 | Jejunal diverticula: a rare cause of life-threatening gastrointestinal bleeding stabilized with an Hb consistently over 90 g/l. However, on Day 4 DISCUSSION of admission, he produced five further episodes of melaena, and Jejunal diverticular disease is an uncommon condition that is became acutely tachycardic and hypotensive. His repeat Hb was usually asymptomatic but may rarely present with life-threaten- 78 g/l. A repeat OGD revealed no evidence of gastric or duodenal ing complications including massive GI bleeding [2, 3]. Other bleeding. complications such as chronic malabsorption, volvulus, diver- The decision was then made to proceed to exploratory lapar- ticulitis with or without perforation or abscess occur in 10–30% otomy with a pre-operative plan of performing a subtotal colec- of patients [1, 5]. The majority of patients who present with GI tomy. The presumptive diagnosis was that the bleeding was bleeding do not display previous GI symptoms and are reported likely secondary to his known colonic diverticulosis. Intra-opera- to develop an acute onset haemorrhage per rectum [6]. tively however, we found multiple diverticula clustered along the Jejunal diverticulosis is often difficult to locate endoscopic- proximal and mid jejunum at the mesenteric edge. Partially di- ally and diagnosing jejunal diverticular bleeding remains prob- gested blood was seen in the portion of small bowel distal to lematic, with current imaging techniques continuing to be these diverticula. We performed a small bowel resection of unreliable [7]. Whilst jejunal diverticulosis can be identi- ∼80 cm length of diseased jejunum and an end-to-end anasto- fied by abdominal CT and barium follow-through studies [8], mosis (Figs 1 and 2). Histology confirmed numerous true divertic- enteroclysis remains the investigation of choice [3]. Although ula, with no evidence of malignancy. In total, since admission, some reports demonstrate success with capsule endoscopy the patient received 23 units of RBCs, 16 units of FFP, 4 units of and double balloon endoscopy [9, 10] such investigations are platelets and 3 units of cryoprecipitate. of limited use in emergency settings. In cases of jejunal diver- Post-operatively, the patient made a slow but steady recovery. ticular bleeding, selective mesenteric angiography or CT angio- There were no further drops in Hb or episodes of GI bleeding. The gram can be used to localize active bleeding [6]but may be patient was discharged on Day 7 post-operation and followed-up contraindicated in patients’ with severe kidney impairment in outpatients clinic 2 weeks later. There were no further reports as with our patient. of bleeding and he was discharged from surgical follow-up. Urgent laparotomy is indicated in the presence of acute com- plications of jejunal diverticula including diverticulitis, massive bleeding or bowel perforation both as a diagnostic and therapeut- ic measure [3, 6, 7]. Several successful cases with complete small bowel resection with primary entero-entero anastomosis have been reported [6]. Due to low incidence, low clinical index of suspicion and un- reliable diagnostic imaging in emergency situations, diagnosis of jejunal diverticular disease is challenging and therefore often de- layed several days after initial presentation. This has major im- plications with regard to prompt and timely management, and can lead to significantly increased morbidity and mortality. Whilst there are undoubtedly more common causes of GI bleed- ing, this case demonstrates that jejunal diverticular disease should remain on the differential diagnosis and investigations to confirm the diagnosis should be considered. However, despite investigations, the diagnosis may remain elusive and in patients with on-going bleeding, laparotomy and surgical resection is cur- rently the treatment of choice [3, 6, 7]. Figure 1: Intra-operative photography demonstrating multiple jejunal diverticula. Note that the diverticula arise at the mesenteric border and are clustered around proximal jejunum. REFERENCES 1. Kassahun WT, Fangmann J, Harms J, Bartels M, Hauss J. Com- plicated small bowel diverticulosis: a case report and review of the literature. World J Gastroenterol 2007;13:2240–2. 2. Ferreira-Aparicio FE, Gutiérrez-Vega R, Gálvez-Molina Y, Onti- veros-Nevares P, Athie-Gútierrez C, Montalvo-Javé EE. Diver- ticular disease of the small bowel. Case Rep Gastroenterol 2012;6:668–76. 3. Nejmeddine A, Bassem A, Mohamed H, Hazem BA, Ramez B, Issam BM. Complicated jejunal diverticulosis: a case report with literature review. North Am J Med Sci 2009;1:196–9. 4. Krishnamurthy S, Kelly MM, Rohrmann CA, Schuffler MD. Jejunal diverticulosis. A heterogenous disorder caused by a variety of abnormalities of smooth muscle or myenteric plexus. Gastroenterology 1983;85:538–47. 5. Woods K, Williams E, Melvin W, Sharp K. Acquired jejunoileal diverticulosis and its complications: a review of the literature. Am Surg 2008;74:849–54. Figure 2: Intra-operative photography demonstrating jejunal diveritcula 6. Yaqub S, Evensen BV, Kjellevold K. Massive rectal bleeding proximally and presence of altered blood in the small bowel distal to these diverticula. from acquiredjejunal diverticula. World J Emerg Surg 2011;6:17. B.J. Lee et al. | 3 7. Butler JS, Collins CG, McEntee GP. Perforated jejunal divertic- endoscopy with push enteroscopy in chronic gastrointestinal ula: a case report. J Med Case Reports 2010;4:172. bleeding. Endoscopy 2002;34:685–9. 8. Fintelmann F, Levine MS, Rubesin SE. Jejunal diverticulosis: find- 10.Yang CW, Chen YY, Yen HH, Soon MS. Successful double bal- ings on CT in 28 patients. AJR Am J Roentgenol 2008;190:1286–90. loon enteroscopy treatment for bleeding jejunal diverticulum: 9. Ell C, Remke S, May A, Helou L, Henrich R, Mayer G. The first a case report and review of the literature. J Laparoendosc Adv prospective controlled trial comparing wireless capsule Surg Tech A 2009;19:637–40. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Jejunal diverticula: a rare cause of life-threatening gastrointestinal bleeding

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015.
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2042-8812
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10.1093/jscr/rju150
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25600131
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Abstract

Jejunal diverticula are rare and the condition remains mostly asymptomatic. However, they can present with vague chronic abdominal symptoms and, in some cases, acute life-threatening complications, such as gastrointestinal (GI) bleeding, bowel obstruction and perforation. We present a case of an adult male who presented with life-threatening GI bleeding secondary to jejunal diverticular disease. Whilst there are undoubtedly more common causes of GI bleeding, this case demonstrates that jejunal diverticular disease should remain on the differential diagnosis and investigations to confirm the diagnosis should be considered. However, despite investigations, the diagnosis may remain elusive and in patients with on-going bleeding, laparotomy and surgical resection is currently the treatment of choice. INTRODUCTION disease, presented to the emergency department after a sudden collapse at home. His medications included aspirin and clopidogrel. Jejunal diverticular disease is a rare clinical entity with an inci- Whilst in the department, he experienced a further syncopal dence of between 0.06 and 1.5% [1]. The true incidence however event with two episodes of large-volume melaena. He was pale, may be higher as the majority of jejunal diverticula are asymp- clammy and haemodynamically unstable with a systolic blood tomatic, and thereby remain undiagnosed. pressure of 75 mmHg. His blood results showed a haemoglobin In symptomatic cases, non-specific epigastric pain and bloat- (Hb) of 66 g/l and a urea of 32.7 mmol/l. There were no reports ing are the most common complaints [2, 3]. However, life-threa- of melaena or haematemesis prior to admission. He was initially tening complications such as gastrointestinal (GI) bleeding, resuscitated with intravenous fluids, red blood cells (RBCs), plate- bowel perforation and obstruction have been reported in up to lets, fresh frozen plasma (FFP) and cryoprecipitate. 18% of cases [4]. It is therefore vital that the diagnosis of the con- The patient proceeded to urgent upper GI endoscopy (OGD) dition can be made promptly to ensure optimal and timely man- but the procedure failed to identify any evidence of recent or ac- agement for the patient. tive bleeding. Colonoscopy showed large amounts of altered We present a case of a 78-year-old male with massive GI blood in the colon as well as the presence of sigmoid diverticula bleeding secondary to jejunal diverticular disease who was surgi- but without evidence of active bleeding. Segmental CT-angio- cally managed with good post-operative outcome. gram was contraindicated given patient’s poor renal function. Despite vasopressor support and a proton-pump-inhibitor in- CASE REPORT fusion, with on-going melaena, the patient’s Hb and blood pres- A 78-year-old male with a history of ischaemic heart disease, sure remained low, requiring 19 units of RBCs in the first 48 h of stage IV chronic kidney disease and chronic obstructive pulmonary admission. Over the subsequent 36 h, the patient’scondition Received: October 14, 2014. Accepted: December 23, 2014 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 | Jejunal diverticula: a rare cause of life-threatening gastrointestinal bleeding stabilized with an Hb consistently over 90 g/l. However, on Day 4 DISCUSSION of admission, he produced five further episodes of melaena, and Jejunal diverticular disease is an uncommon condition that is became acutely tachycardic and hypotensive. His repeat Hb was usually asymptomatic but may rarely present with life-threaten- 78 g/l. A repeat OGD revealed no evidence of gastric or duodenal ing complications including massive GI bleeding [2, 3]. Other bleeding. complications such as chronic malabsorption, volvulus, diver- The decision was then made to proceed to exploratory lapar- ticulitis with or without perforation or abscess occur in 10–30% otomy with a pre-operative plan of performing a subtotal colec- of patients [1, 5]. The majority of patients who present with GI tomy. The presumptive diagnosis was that the bleeding was bleeding do not display previous GI symptoms and are reported likely secondary to his known colonic diverticulosis. Intra-opera- to develop an acute onset haemorrhage per rectum [6]. tively however, we found multiple diverticula clustered along the Jejunal diverticulosis is often difficult to locate endoscopic- proximal and mid jejunum at the mesenteric edge. Partially di- ally and diagnosing jejunal diverticular bleeding remains prob- gested blood was seen in the portion of small bowel distal to lematic, with current imaging techniques continuing to be these diverticula. We performed a small bowel resection of unreliable [7]. Whilst jejunal diverticulosis can be identi- ∼80 cm length of diseased jejunum and an end-to-end anasto- fied by abdominal CT and barium follow-through studies [8], mosis (Figs 1 and 2). Histology confirmed numerous true divertic- enteroclysis remains the investigation of choice [3]. Although ula, with no evidence of malignancy. In total, since admission, some reports demonstrate success with capsule endoscopy the patient received 23 units of RBCs, 16 units of FFP, 4 units of and double balloon endoscopy [9, 10] such investigations are platelets and 3 units of cryoprecipitate. of limited use in emergency settings. In cases of jejunal diver- Post-operatively, the patient made a slow but steady recovery. ticular bleeding, selective mesenteric angiography or CT angio- There were no further drops in Hb or episodes of GI bleeding. The gram can be used to localize active bleeding [6]but may be patient was discharged on Day 7 post-operation and followed-up contraindicated in patients’ with severe kidney impairment in outpatients clinic 2 weeks later. There were no further reports as with our patient. of bleeding and he was discharged from surgical follow-up. Urgent laparotomy is indicated in the presence of acute com- plications of jejunal diverticula including diverticulitis, massive bleeding or bowel perforation both as a diagnostic and therapeut- ic measure [3, 6, 7]. Several successful cases with complete small bowel resection with primary entero-entero anastomosis have been reported [6]. Due to low incidence, low clinical index of suspicion and un- reliable diagnostic imaging in emergency situations, diagnosis of jejunal diverticular disease is challenging and therefore often de- layed several days after initial presentation. This has major im- plications with regard to prompt and timely management, and can lead to significantly increased morbidity and mortality. Whilst there are undoubtedly more common causes of GI bleed- ing, this case demonstrates that jejunal diverticular disease should remain on the differential diagnosis and investigations to confirm the diagnosis should be considered. However, despite investigations, the diagnosis may remain elusive and in patients with on-going bleeding, laparotomy and surgical resection is cur- rently the treatment of choice [3, 6, 7]. Figure 1: Intra-operative photography demonstrating multiple jejunal diverticula. Note that the diverticula arise at the mesenteric border and are clustered around proximal jejunum. REFERENCES 1. Kassahun WT, Fangmann J, Harms J, Bartels M, Hauss J. Com- plicated small bowel diverticulosis: a case report and review of the literature. World J Gastroenterol 2007;13:2240–2. 2. Ferreira-Aparicio FE, Gutiérrez-Vega R, Gálvez-Molina Y, Onti- veros-Nevares P, Athie-Gútierrez C, Montalvo-Javé EE. Diver- ticular disease of the small bowel. Case Rep Gastroenterol 2012;6:668–76. 3. Nejmeddine A, Bassem A, Mohamed H, Hazem BA, Ramez B, Issam BM. Complicated jejunal diverticulosis: a case report with literature review. North Am J Med Sci 2009;1:196–9. 4. Krishnamurthy S, Kelly MM, Rohrmann CA, Schuffler MD. Jejunal diverticulosis. A heterogenous disorder caused by a variety of abnormalities of smooth muscle or myenteric plexus. Gastroenterology 1983;85:538–47. 5. Woods K, Williams E, Melvin W, Sharp K. Acquired jejunoileal diverticulosis and its complications: a review of the literature. Am Surg 2008;74:849–54. Figure 2: Intra-operative photography demonstrating jejunal diveritcula 6. Yaqub S, Evensen BV, Kjellevold K. Massive rectal bleeding proximally and presence of altered blood in the small bowel distal to these diverticula. from acquiredjejunal diverticula. World J Emerg Surg 2011;6:17. B.J. Lee et al. | 3 7. Butler JS, Collins CG, McEntee GP. Perforated jejunal divertic- endoscopy with push enteroscopy in chronic gastrointestinal ula: a case report. J Med Case Reports 2010;4:172. bleeding. Endoscopy 2002;34:685–9. 8. Fintelmann F, Levine MS, Rubesin SE. Jejunal diverticulosis: find- 10.Yang CW, Chen YY, Yen HH, Soon MS. Successful double bal- ings on CT in 28 patients. AJR Am J Roentgenol 2008;190:1286–90. loon enteroscopy treatment for bleeding jejunal diverticulum: 9. Ell C, Remke S, May A, Helou L, Henrich R, Mayer G. The first a case report and review of the literature. J Laparoendosc Adv prospective controlled trial comparing wireless capsule Surg Tech A 2009;19:637–40.

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Published: Jan 17, 2015

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