Complicated jejunal diverticulitis with small bowel obstruction due to enterolith: A case report

Abstract

Introduction and importance

Small bowel diverticular disease (DD) is encountered and managed much less frequently than colonic DD, leading to a significantly less developed body of evidence for managing small bowel diverticulum and its associated complications.

Case presentation

This case report discusses a rare occurrence of simultaneous perforated jejunal diverticulitis and mechanical small bowel obstruction (SBO) due to a migrating diverticular enterolith. The patient's condition was ultimately managed operatively through laparoscopically assisted small bowel resection.

Clinical discussion

A review of the literature reveals only eight reported cases of jejunal diverticulitis with simultaneous enterolith obstruction. All cases were managed operatively, with approaches including small bowel resection encompassing both pathologies, milking the enterolith back to the diverticulitis site and resecting en bloc to avoid extensive resection, or enterotomy and enterolith retrieval.

Conclusion

The prevalence of small bowel diverticular disease is increasing, and as a result, clinicians may encounter more complications associated with this condition in the future. This case highlights the importance of considering alternate complications of small bowel DD.

Highlights

• •Rare case presentation: jejunal diverticulitis with mechanical enterolith SBO
• •Only a limited number of cases (8) have been reported in the literature.
• •All cases in the literature presenting with dual complications required operative management.
• •Case contributes to limited literature on this topic, highlights the need for more research.
• •Growing prevalence of small bowel diverticular disease, may lead to increasing complications.

1. Introduction

Colonic diverticular disease (DD) is highly prevalent in Western society, with the disease's incidence increasing exponentially with age, affecting up to 60–80 % of individuals by the age of 80 [[1], [2], [3]]. DD ranks among the top five most common and costly gastrointestinal disorders, with well-established management guidelines [3,4]. In contrast, small bowel diverticular disease is much rarer, and the associated complications are less frequently encountered. The reported prevalence of small bowel DD varies between radiographic, endoscopic, and autopsy studies [[5], [6], [7], [8], [9], [10], [11]]. Duodenal diverticula are the most common among small bowel diverticula, with jejunoileal diverticula being less common [[12], [13], [14], [15], [16], [17]]. Due to its rarity, there is limited evidence available for managing small bowel diverticula and their complications, which can include bleeding, small bowel obstruction (SBO), obstructive jaundice, and diverticulitis with or without abscess formation, fistulation, or perforation [18,19].

The pathogenesis of small bowel DD is believed to share similarities with large bowel DD. Rates of coexistent colonic DD in patients with small bowel DD have been reported at 30–40 % suggesting an associated or common aetiology [16,17,20]. Factors contributing to small bowel diverticulosis include genetics, environmental factors, altered bowel wall structure, atrophy of the bowel wall, dysmotility, visceral myopathy, and increased intraluminal pressures, leading to mucosal herniation along the mesenteric border of the bowel [18,19,21,22]. Neuromuscular disorders have also been associated with small bowel diverticulosis [22] With respect to the location of the diverticula, the mesenteric border of the bowel is more susceptible because of an innate weakening of the wall due to entry of mesenteric blood vessels [23]. Small bowel diverticula can be true or false diverticula and may be congenital or acquired, with the acquired form primarily being false diverticula due to the absence of muscularis involvement. The pathophysiology of diverticulitis involves the obstruction of the diverticular sac by faecoliths/enteroliths, leading to mucosal irritation, inflammation, congestion, and pressure necrosis, potentially resulting in perforation or abscess formation [24]. Enteroliths form from bile precipitation as a result of pH changes, dysmotility within diverticulum or as a result of undigested food [25].

Methodology: Please note that this body of work has been reported in line with the SCARE criteria [26].

2. Case presentation

An elderly man in his 80s presented to the emergency department with a 48-hour history of acute central abdominal pain. His medical history included T2DM managed with metformin and hypertension treated with amlodipine. He was a non-smoker, consumed a balanced diet with reasonable dietary fibre intake, and had no significant family history particularly of neuromuscular disorders or bowel disease. The patient had no history of prior abdominal surgeries but had undergone a colonoscopy three years earlier which showed sigmoid diverticular disease. On arrival to hospital, he was borderline tachycardic with a HR of 95, but had otherwise normal observations On examination, he exhibited central abdominal tenderness without signs of peritonism. A CT scan of the abdomen and pelvis demonstrated active jejunal diverticulitis without evidence of perforation or collection. Given his relatively stable clinical condition and reassuring examination findings, the initial approach was for conservative management with intravenous antibiotics. However, over the following two days, the patient's symptoms worsened, with the development of vomiting, abdominal distension and fever. A repeat CT scan showed a new SBO with an ovoid structure at the transition point, queried to be a bezoar, faecolith, or gallstone (Fig. 1.0).

Fig. 1.0.

CT scan showing SBO with an ovoid structure at the transition point.

The patient proceeded to operation which was achieved laparoscopically with a midline incision to deliver the bowel. Operative findings included two interloop abscesses centred around two separate perforated jejunal diverticula with associated four quadrant pus. Multiple large, non-inflamed diverticula were found in the proximal-mid jejunum, some containing faecoliths. A 4 cm faecolith obstructed the bowel just distal to the second perforation (Fig. 2.0). One meter of small bowel was resected to include both sites of perforation, the more distal obstructing faecolith, as well as the intermediate segment of jejunum with severe diverticulosis and further faecoliths (Fig. 3.0, Fig. 4.0). The patient had a slow recovery over the coming weeks complicated by pneumonia, delirium, poor glycaemic control and functional decline necessitating a rehabilitation admission. There were no significant surgical complications. Ultimately, he recovered well and was discharged home after a six week stay in hospital. Histopathology from the operation returned confirming acute diverticulitis with ulceration, perforation, and abscess formation.

Fig. 2.0.

Empty diverticulum on the left, similar in size and shape to the obstructing enterolith seen on the right (retrieved via enterotomy of specimen post resection).

Fig. 3.0.

Diverticular perforation, secondary to obstructing enterolith causing inflammation, congestion, and pressure necrosis.

Fig. 4.0.

Small bowel resection including both sites of perforation, the obstructing enterolith, as well as the intermediate segment of jejunum with severe diverticulosis and further enteroliths.

3. Discussion

Small bowel diverticula are rare and as such the complications of this condition are less frequently encountered and managed. While known complications include acute diverticulitis and SBO secondary to enterolith impaction, cases with both complications concurrently are infrequently reported in the literature. A review of existing literature uncovered only eight reported cases of jejunal diverticulitis with simultaneous enterolith obstruction [25,[27], [28], [29], [30], [31], [32], [33]], of which three involved bowel perforation (Table 1.0) [25,27,28]. To the best of our knowledge, this case is unique in presenting with two sites of perforation and an obstructing enterolith. All reviewed cases required operative management, with various surgical approaches employed [25,[27], [28], [29], [30], [31], [32], [33]].

Table 1.0.

Literature review.

Case report	Concomitant jejunal diverticulitis & enterolith SBO	Presence of perforated diverticulitis	Enterolith milked to site of active diverticulitis	SB resection to include both pathologies	Enterotomy retrieval of enterolith	Attempts to include adjacent diverticulum in resection
Garnet DJ, Scalcione LR, Barkan A, et al. 2011 [27]	√	√	√			√
Chugay P, Choi J, Da Dong X 2009 Case 1 [25]	√	√		√		√
Hubbard THE, Balasubramanian R, Smith J 2015 [28]	√	√		√		√
Fournea H, Coulier B, Rezazadeh AA 2018 [29]	√		√			√
Malghan L, Uttley A, Scullion D 2017 [30]	√			√
Aipuro IO, Yazzie PN 2019 [31]	√		√			√
Harris LM, Volpe CM, Doerr RJ 1997 [32]	√
Patel C, Balasubramaniam R, Adler JR 2020 [33]	√				√

In most cases, surgical intervention involved small bowel resection to address both pathologies. Some cases described milking the enterolith back to the site of active diverticulitis and resecting en bloc to minimize resection length [27,29,31]. In one case, where the diverticulitis was uncomplicated, the obstructing enterolith was retrieved via enterotomy without resection [33]. In cases where resection was necessary, efforts were made to include adjacent diverticular disease to prevent future complications [25,[27], [28], [29],31]. In cases of sole enterolith obstruction without active diverticulitis, surgical approaches described in the literature included crushing and milking the enterolith into the colon, bowel resection, and enterolith retrieval via enterotomy [24,32]. Successful conservative management was also reported in cases of partial obstruction or small enteroliths [32,34]. Given the aforementioned, conservative management in select cases with dual complications were the diverticulitis is uncomplicated could be appropriate. Some patients will ultimately fail this management, but it may not be an unreasonable initial approach in the right case.

Ultimately, in the case described the patient required laparoscopic operative management with a mini laparotomy to deliver the bowel. One meter of small bowel was resected en bloc to include both perforation sites, the obstructing enterolith, and a further segment of proximal jejunum with significant diverticular disease. As described earlier, another approach that could be considered in cases with limited intervening diverticular disease is milking the stone back to the site of active diverticulitis or perforation or crushing and milking into the colon to reduce the length of resection required. However, in this case, this approach wasn't feasible due to the two sites of perforation with significant intervening diverticular disease. Crushing and milking the stone also carries the risk of iatrogenic bowel injury. It is also worth noting that the gallbladder was inspected during this case to exclude the differential diagnosis of a gallstone ileus.

4. Conclusion

We describe a rare case of small bowel DD with concurrent mechanical obstruction. All cases reviewed in the literature required operative management via either enterotomy, resection encompassing both pathologies, or limited resection by milking the enterolith. However, in select patients with subacute obstruction and uncomplicated diverticulitis, a trial of non-operative management may be appropriate. This case adds to the limited body of literature on this topic, highlighting the need for further research and understanding of small bowel diverticular disease. With the growing prevalence of small bowel DD, clinicians may expect to be encountering increasing complications of the disease (Table 1.0).

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

As per Metro North Health HREC (Human Resource Ethics Committee), this case report is exempt from ethical approval. Written informed consent has been obtained from the patient for publication of this case report.

Metro North Health HREC statement on case reports:

“Individual patient consent should be obtained for the publication of case reports; however, ethics review is not required. Case reports involving more than 2 individuals are classified as a case series and require ethics review.”

https://metronorth.health.qld.gov.au/research/ethics-and-governance/ethics-approval/request-exemption-hrec-review

Funding

None.

Author contribution

First Author: Paige Barnard – concept and design, writer literature review

Author/contributor: Katherine Wilson – surgeon, supervision, editing

Guarantor

Guarantor – Paige Barnard

Conflict of interest statement

None.