DISCUSSION:
Acquired small bowel diverticulum corresponds to a herniation of the
intestinal mucosa and submucosal through penetration sites of vasa
recta, which represent weak points of intestinal wall. Unlike congenital
Meckel’s diverticulum, there is no muscular layer in the diverticular
wall. It is a rare condition (1 to 4.6%) that occurs usually between 60
and 70 years[3].
The most frequent complication is diverticulitis. Two factors were
incriminated in its genesis: the stasis of the jejunum contents in the
diverticulum and the mucosal edema with subsequent obstruction of the
diverticular neck [3–5]. However, the diverticulitis is much less
common in the jejunum than in colonic diverticula probably because of
diverticulum larger size, better intra-luminal flow and lower
concentration of bacteria [3].
The perforation of jejunal diverticulum is rare (2.1 to 7% of
diverticulitis), probably because of intestinal intraluminal low
pressures [3,6].
Non complicated cases can be clinically silent or may mimic irritable
bowel syndrome symptoms: chronic abdominal pain, bloating sensation
after food intake, abdominal cramping of unexplained cause and diarrhea
[6]. In case of diverticulitis, symptoms are similar to an acute
peritonitis secondary to perforated duodenal ulcer.
On CT scan, jejunal diverticula are shown as round structures outside of
the small bowel lumen and containing some combination of contrast
material, air, and debris. The large jejunal diverticula can be
distinguished from adjacent small-bowel loops by their different
contents and by the absence of conniving valvulae [7]. Frequent
findings seen in diverticulitis are an inflammatory mass which may
contain gas, wall thickening of an involved segment, edema of the
surrounding tissues and fluid collection [1,5].
Non perforated jejunal diverticulitis is managed conservatively with
antibiotics, intravenous fluids, and bowel rest [8,9]. For
perforated jejunal diverticula, surgery is mandatory. The recommended
technique is resection of the involved intestinal segment. [3,7,10].
In case of multiple diverticulum (like our patient), resection should be
performed only for complicated one. The anastomosis can be performed
only in the absence of generalized peritonitis and septic shock, and it
should be done on intestinal segments without diverticula.