1981 A Case of Jejunal Diverticulum Causing Life-Threatening Hemorrhage

Abstract

INTRODUCTION: Diverticulosis seldom causes life threatening hemorrhage and is frequently found in the large bowel. Rare cases of small bowel diverticula are most notably known to appear in the duodenum. Even rarer are severe small bowel diverticulum bleeds in the jejunum with one study noting approximately 50 cases reported in the literature. Due to the difficult location, many have gone unidentified and ultimately resulted in small bowel resections. We present a 58-year-old man with a life threatening jejunal diverticular bleed that was diagnosed and treated conservatively. CASE DESCRIPTION/METHODS: A 58-year-old Hispanic male with past medical history significant for upper GI bleed requiring multiple transfusions, chronic pancreatitis, and SMA thrombosis presented to the ED for recurrent melena. He was previously admitted for suspected GI bleed with no identifiable source on colonoscopy, EGD, and outpatient capsule endoscopy. On this admission, vitals were hemodynamically stable but labs revealed a hemoglobin of 3.3. After appropriate resuscitation, push endoscopy revealed a bleeding proximal jejunal diverticulum which was tattooed, coagulated with epinephrine and clipped. CTA of abdomen showed a stable dissecting aneurysm in between the origin of the inferior pancreaticoduodenal arcade and jejunal branches. He was stabilized and discharged with follow up. DISCUSSION: Small bowel diverticulosis is usually found incidentally in asymptomatic patients. Because jejunal diverticuli are novelty differentials, often forgotten, diagnosis becomes delayed even with the use of standard endoscopy, resulting in significant morbidity and mortality. Several noninvasive studies can be done initially to assess for bleeding. With advances in technology such as small bowel enteroscopy, specifically push enteroscopy, jejunal diverticulum can be diagnosed earlier and treated with clipping as opposed to surgical resection which has been the mainstay treatment for refractory bleeding. This case brings to light a rare manifestation of small bowel diverticuli where future research could be dedicated. There has been another case with similar presentation in which the patient also had history of a SMA clot. This poses the question of whether there is a correlation and if it could be explained by the compromised integrity of the small bowel wall due to the lack of blood flow making it easier for diverticuli to arise there. It also raises the question as to why certain patients are more predisposed to developing these outpouchings.

Reporte de caso: diverticulitis yeyunal perforada, causa infrecuente de abdomen agudo

“…Esto se explica por el mayor diámetro de los vasos sanguíneos en el yeyuno proximal 23,24 . Suelen estar acompañados de divertículos en otros sitios hasta en un 90% 21,22 , como en colon (30-75%), duodeno (15-42%), vejiga (12%) y esófago (2%) 20,21,25 , por ello se deben buscar de forma intencional al observarlos en el transoperatorio. Predominan en el sexo masculino (1.5:1) y se observan con mayor frecuencia entre la sexta y séptima décadas de la vida 3,6,[8][9][10][11]13,14 .…”

“…El tratamiento suele ser quirúrgico, pero existen reportes que describen el manejo conservador con resultados exitosos 22,23 . Se han descrito otras complicaciones menos frecuentes, como resección hepática secundaria a la adherencia del divertículo al borde hepático y presencia de tejido pancreático ectópico en su interior 24,25 .…”

Diverticulitis yeyunal perforada: causa infrecuente de abdomen agudo

“…6,21,22 El tratamiento suele ser quirúrgico, pero existen reportes que describen el manejo conservador con resultados exitosos. 22,23 En la última década ha tomado relevancia el tratamiento endoscópico, cada vez con mejores resultados; éste se realiza mediante enteroscopia con un balón, doble balón o con espiral, con nuevas técnicas aún en estudio. 24 Se han reportado casos de tratamiento exitoso de sangrado activo de un divertículo, 25 mientras que, en otros, su utilidad resulta como diagnóstico preoperatorio.…”

“…27,28 El diagnóstico prequirúrgico se ha logrado establecer únicamente en 20% de los pacientes, debido a la localización mesentérica de los divertículos. 8 El estudio más útil hasta el momento es la tomografía computarizada, [1][2][3][4][5]14,23 Figura 5: Se observa divertículo yeyunal, sin pared muscular, únicamente mucosa.…”