Diverticulitis of the small bowel is rare. At this moment, there is no consensus concerning its treatment, although laparotomies are common in the acute setting. In this study, we present three patients in different stages of the disease and give a short overview of pathogenesis, symptoms, investigations and treatment of this seldom seen cause of acute abdomen. A case is made for conservative treatment in the absence of perforation.
A 69-year-old woman was transferred on account of an acute abdomen. The patient complained of abdominal pain, present for 45 min, located at the lower left quadrant and radiating to the back. No nausea or vomiting occurred. She had an unremarkable medical history, and was referred on suspicion of a ruptured abdominal aneurysm.
On examination, there was a painful, moderately sick patient. The abdomen was bloated and rebound-defense positive on palpitation of the left lower quadrant.
The laboratory investigations showed a C-reactive protein (CRP) of 24 mg/l and a white blood cell count (WBC) of 14.3 109/l. Computed tomography (CT) scan showed no aneurysm but a perforated jejunal diverticulum with free air (Fig. 1).
After diagnosis a laparotomy was performed. During operation there was a vast diverticulosis of jejunum and ileum. The perforated jejunal diverticulum was found, and a small bowel segment was resected (Fig. 2) with primary anastomosis. Postoperatively a 5-day course of antibiotics was administered. After 11 days the patient was discharged in good condition.
A 67-year-old woman, presented to our emergency department with an acute exacerbation of longer existing abdominal pain. A sudden worsening of preexisting pain was observed in the left lower quadrant, which had been present for a number of months, with anorexia and diarrhoea. She had a history of complicated diverticulitis for which a resection of the sigmoid was performed, an unrelated hemicolectomy and a conservatively treated subileus. Furthermore, there was a known diverticulosis of the entire remaining colon.
On physical examination, the abdomen was rebound-defense positive. Laboratory investigations showed a CRP of 46 mg/l and normal WBC. Supine radiograph of the abdomen showed an ileus with dilation of the small and large bowel, without signs of perforation (Fig. 3).
The patient was admitted and treated conservatively on suspicion of an obstructed ileus. One day after admission, there was no improvement and a laparotomy was performed. During surgery there was a vast diverticulosis of the small bowel with dozens of large diverticula along the mesentery. Halfway in the small bowel, one diverticulum was inflamed. A limited resection was performed, with primary anastomosis. Postoperatively, a 5-day course of antibiotics was administered.
Final pathology revealed several inflamed diverticula located in the mesentery with local peritonitis.
After 9 days the patient was discharged in good health. Resection of the innumerable remaining diverticula was considered impossible. The decision was made to treat similar future episodes with antibiotics alone, if dramatically elevated infection parameters or signs of perforation are absent.
A 79-year-old woman was referred to our emergency department on account of an acute abdomen. A history of frequent diverticulitis of the small and large bowel was present for which many conservative treatments, generally with antibiotics, on the outpatient clinic and several hospitalizations. Resections of the sigmoid, and a small bowel section had been performed, because of perforation.
On presentation, there was a continuous, familiar, abdominal pain existing for 5 days, with nausea, vomiting, diarrhoea and fever.
On physical examination, there was a mildly sick patient. The lower half of the abdomen was tender on palpitation. The temperature was 39.0°C.
The laboratory investigations showed a CRP of 144 mg/l and a normal WBC. Supine radiograph of the abdomen showed an ileus, without signs of free air.
As in the earlier episodes, she was managed nonoperatively with bowel rest, intravenous fluids and antibiotics.
After 7 days she was discharged with a course of oral antibiotics.
Diverticula of the small intestine are uncommon, with a reported prevalence ranging from 0.3 up to 23% [1–4]. They are congenital or acquired [3,4]. Small bowel diverticulitis (SBD) is rare, and before the advent of CT it was seldom diagnosed before surgery or autopsy [1,2,4,5]. Diverticulitis may occur in the duodenum, jejunum and ileum [1–6].
The major hypothesis focuses on dietary fibre deficiency, precipitating dysmotility, which causes pseudo-obstruction and high intraluminal pressures, after which diverticula form [6,7]. The main culprit in developing diverticulitis seems to be inspissated food, which leads to mucus secretion, bacterial overgrowth and eventual erosion of the luminal wall. This causes inflammation and focal necrosis of diverticula leading to microscopic or macroscopic perforation [7,8].
No pathognomonic signs or symptoms of SBD [1,2,5] are present. Earlier episodes may have been present (patient C) . Abdominal pain varies from intermittent to an acute abdomen [1,2,6]. On presentation, the pain may exist for several hours, or days [1,2,4–6]. It may be located in the entire abdomen and radiate to the back (patient A) [4,5].
Physical examination can reveal abdominal palpitory tenderness, to evident rebound tenderness [2,4–6]. Often there is fever [1,2,4,6].
Owing to the nonspecific symptoms, SBD should be considered in cases presenting as appendicitis, cholecystitis, pancreatitis, cancer, colitis, Crohn's disease, peptic ulcer, pyelonephritis, pelvic inflammatory disease, ovarian pathology and ectopic pregnancy [1,2,4–7,9]. Patient C was primarily suspected of a ruptured abdominal aneurysm.
The laboratory investigations may be normal, but usually there is leukocytosis or CRP elevation [1,2,4–9].
Chest and abdominal radiographs may identify signs of perforation [1,6,8]. However, CT is the test of choice to confirm suspected SBD [2,5–8].
No general guidelines exist for the treatment of SBD. Nevertheless, surgical management is recommended for complications, such as obstruction, perforation (patient A), sepsis, undrainable abcess and uncontrolled fistulas [2–4,6,9].
Continued medical advances have reduced the mortality from SBD complications, except perforation, which has a reported mortality of 21–40% [1,2,10].
Laparotomies are performed in cases of acute abdomen suspected of SBD, even without signs of perforation [1,2,4]. This was the case for patient B, where it was decided to apply nonoperative treatment in future episodes. Conservative treatment has been reported, but in case of perforation there are only a few successful known instances [4,5].
Diagnosing SBD is difficult (this seems to be the first recording of it initially suspected of being a ruptured abdominal aneurysm) and the diagnosis is rarely made preoperatively [1,2]. Even during surgery small bowel diverticula are difficult to recognize . As not to miss them, SBD should be included in the differential diagnosis of intraabdominal inflammatory processes . The importance is because of the high mortality in case of perforation [1,2].
No consensus is found for treatment of the condition. We refer to our successful experience with conservative therapy and plead for this possibility in the absence of perforation.
The authors acknowledge Dr L. Spaargaren, Department of Radiology, Diaconessenhuis Leiden, W. Zikkenheiner, C. Jongeling and A. van Eeden for their contributions to this article. There have been no sources of financial support in writing this article.
Conflict of interest: none declared.