Jejunal diverticulosis is rare, reported in the literature to have a prevalence of approximately 2.3%,1 and it has a high male–female ratio and a tendency to present between 60 and 70 years of age.2–4 These are mainly pseudodiverticula5 that lack the muscular coat, but it is not always so. Reports have shown that up to 80% of the cases are asymptomatic,6,7 yet symptoms may present and can be chronic or acute, with vague abdominal pain being the most reported symptom. Complications are also rare but can be fatal if not suspected and treated accordingly.
A 66-year-old female with a total gastrectomy as a result of gastric cancer was admitted with septic shock, following severe diarrhoea, with associated pancytopenia and a drop in haemoglobin for which she received multiple blood transfusions. She started to have haematemesis and large melaenas mixed with fresh blood up to five times a day. Computed tomography (CT)8 showed dilatation of the proximal jejunal loops with a transitional zone in the upper right abdomen (Figure 1). Oesophagogastroduodenoscopy showed multiple small oozing erosions and ulcerations and two openings at 50 cm and 58 cm (Figure 2). Colonoscopy showed multiple oozing erosions reaching the ileum. The patient had three tagged red blood cell (RBC) scans, which came back negative. Angiography with embolization was then used twice prior to a subsequent tagged RBC scan which revealed a 3-cm filling defect with an enhanced wall. Three jejunal branches embolized with metallic coils helped surgeons to locate the lesion (Figures 3a and b). The patient eventually improved with supportive management.
Although debatable, most resources point to Soemmering and Baille’s9 autopsy studies in 1794 as the first description of jejunal diverticulosis, yet other references point to The anatomy and surgical treatment of crural and umbilical hernia, written by Sir A Cooper,10 as the first description of such cases. It might be because Soemmering and Baillie9 published their results in German that some authors have failed to give them credit for being the first to describe the case. However, the prevalence of jejunal diverticulosis varies between autopsies and radiological examination. Overall, the prevalence was found to be 0.02% to 2.3% on upper gastrointestinal (GI) radiographs, with an incidence of 1.3–4.6% at autopsy.2,11,12 Table 1 shows studies carried out between 1946 and 1986 comparing detection of jejunal diverticulosis using radiology and at autopsy.
|Method||Number of patients||Year||Prevalence (%)|
|Abdominal radiography and laparotomy||358||1989||1.1|
As previously stated, jejunal diverticulosis is often an asymptomatic incidental finding that rarely presents with complications.13–16 Vague abdominal discomfort, dyskinesia, chronic haemorrhage and malabsorption are the most reported chronic symptoms of the disease.6,16,17 Acute outcomes may present as massive haemorrhage, diverticulitis with or without perforation and intestinal obstruction.16
Clinical implications of our case
Haemorrhage, as a presenting symptom, occurs in 3.4–8.1% of patients with this disease.20,21 The mechanism of bleeding from jejunal diverticula is thought to be ulceration involving an artery, diverticulitis with or without ulceration, or irritation from a concretion or associated with drugs, such as warfarin and low-dose aspirin (rare).22,23 Such cases may present with massive per rectum bleeding17 and can be a challenge to diagnose requiring a great amount of conjecture and prompt action to save the patient’s life; however, most patients have had no previous GI bleeding or any other GI symptoms.22 Locating the source of the bleed in patients presenting with bleeding per rectum is challenging. Colonoscopy can aid in diagnosis when the source is in the colon. Nevertheless, if the source of the bleed is in the small intestine, as in our case, it is often impossible to find it endoscopically, yet there are some reports showing success with capsule endoscopy and double balloon endoscopy. However, those are expensive methods and are reserved for selected cases.24–26
Non-invasive imaging with technetium-99m (Tc-99)-labelled RBC scintigraphy can be used to locate GI bleeding. It has a sensitivity of 93% and a specificity of 95% for detecting a bleeding site with a bleed rate as low as 0.2 ml/minute.27 However, it has a false localization rate of approximately 22%.28
Mesenteric angiography can detect bleeding rates greater than 0.5 ml/minute with a sensitivity of 40–86%29,30 and has the advantage of therapeutic intervention through transcatheter embolization. The risk of ischaemia with embolization is always there.
In haemodynamically stable patients with lower GI haemorrhage, upper and lower GI endoscopy is recommended. Positive findings can be very helpful to localize the source of the bleed. If this is negative or inconclusive, the next step is abdominal CT angiography. Recent studies have showed that it can be a cost-efficient and time-efficient diagnostic tool.31 Active extravasation of contrast on arterial phase CT angiography is diagnostic of active bleeding. Some reports showed that CT angiography can be superior to angiography, yet conventional selective mesenteric angiography remains the main recommended diagnostic tool.31–33
Laparotomy is mainly suggested for haemodynamically unstable patients. Although bleeding is usually from the colon, the small bowel should never be excluded as a source, especially in those over 50 years of age. Intraoperative recognition can be facilitated by jejunal insufflation using manual compression. A subtotal colectomy is recommended, when small bowel diverticula are excluded.6 When jejunal diverticula are identified as the source of bleeding, partial resection of the involved segment of jejunum with primary anastomosis is recommended.6 In cases of multiple diverticula, an intraoperative endoscopy through an enterotomy is recommended to localize the source of the bleed.34 Preoperative CT angiography is recommended in cases of coexisting colonic diverticula, which is 50% of cases. Therefore, performance of colectomy alone, if a source is identified on CT angiography, can be avoided, as it will result in continued bleeding. In these cases, resection of jejunal diverticula during laparotomy is necessary.35
A study at the Department of Colorectal Surgery at the Royal Adelaide Hospital, Australia, reviewed 20 cases of jejunal diverticulosis treated over a period of 8 years.17 Table 2 shows the complications that were reported.
|Complication||Number of patients|
|Inflammation or perforation||9|
|Diarrhoea and malabsorption||5|
|Chronic abdominal pain||2|
In that study, at least 10 patients had more than one single complication, which was often missed, and eight patients more than that stated in Table 2 had chronic abdominal pain, yet this complication was missed until other complications supervened.
Twelve cases had resection, of which 11 were suitable for classification. Four cases had narrow-mouthed pulsion with no or only a thin muscle layer, which presented at the blood vessel penetration site. Four cases had a muscle layer and had wide-mouthed pulsion, two cases had features of both, one case was of Meckel’s type at the duodenal–jejunal flexure and seven cases had mucosal villous atrophy consistent with bacterial overgrowth.
Another study was conducted in the Department of Surgery at University Hospital, Jacksonville, FL, USA.17 It included four patients who presented during 10-year intervals to the hospital with the same complaint of bright red rectal bleeding. Patients were between 54 and 66 years of age. Three patients had jejunal resection, two of them had positive-tagged RBC scans, and the third patient was diagnosed intraoperatively. A fourth patient had positive mesenteric angiography findings, but did not receive surgical treatment as bleeding stopped after the angiography. This patient never experienced bleeding again and died 5 years later of myocardial infarction. The study implicates the possibility, although rare, of having no recurrence of rectal bleeding despite the fact that no surgical treatment is performed. Yet the study recommends surgical treatment whenever the source of bleeding is found to be jejunal diverticula.17
A 77-year-old female at Kaohsiung Veterans’ General Hospital in Taiwan, with a similar presentation to that of our patient, had resection of the involved part and primary anastomosis with no recurrence of bleeding.36
A 9-year study, from 1998 to 2006, conducted at the University Hospital of Pennsylvania,8 revealed 28 patients with jejunal diverticulosis on barium studies (24 follow through, four enemas) who also had an abdominal CT scan 6 months before diagnosis or afterwards with no limit, as jejunal diverticulosis is not known to regress. Eleven patients were male (39%) and 17 were female (61%). The age range was 36–87 years, with a mean age of 70.5 years. A total of 50% of patients underwent CT scanning before barium and 50% after barium. The study mainly concentrated on the CT findings of jejunal diverticulosis. Jejunal diverticula mainly appear as round structures outside the small bowel lumen and have a smooth wall lacking small bowel folds; however, they may connect to adjacent small bowel loops.8
Although there is a large amount of literature on jejunal diverticula online, there are few, if any, reported cases from the Middle East in general, and the United Arab Emirates specifically.
Our patient presented with all types of GI bleed, melaena, haematochezia and haematemesis. This case raised questions and caused a dilemma among physicians, until it was diagnosed by endoscopy and imaging. The delay in diagnosis might have cost the patient her life; therefore, the case is reported to increase the awareness of this diagnosis among physicians, residents and health-care professionals in the region.
Jejunal diverticulosis is a rare source of GI bleeding; however, it should be considered in all patients with acute bleeding in the lower part of the GI tract, especially in older age groups.17 If left undiagnosed, it may lead to severe complications and/or death.
Computed tomography angiography is a promising technique, showing even better results than angiography, but it still requires further study to establish its accuracy and prove its superiority to angiography.
For multiple jejunal diverticula, an intraoperative endoscopy is recommended via an enterotomy to localize the bleeding. Surgical resection of the involved intestine and primary anastomosis remains the main treatment choice.36,37 It is worth mentioning that diverticulitis with perforation and mechanical obstruction needs surgical intervention with segmental resection. Chronic complications such as malabsorption and bowel dyskinesia, caused by secondary bacterial overgrowth, can be treated with antibiotics and vitamin B12 substitution. Asymptomatic diverticula do not require treatment.