Introduction: Diverticular disease is one of the most common issues encountered by gastroenterologists. It is estimated that around one half of those above the age of 60 will have colonic diverticula and up to 25% of these individuals will experience a complication such as diverticulitis. In the small intestine, a majority of diverticula are found in the duodenum (79%). Diverticula of the jejunum and ileum are rather rare, affecting only 0.5%-2.3% of patients. In those with jejunoileal diverticula, their clinical course is largely asymptomatic but 10% of the time patients can develop complications. Here we present an interesting case of perforated jejunal diverticulitis with a coloenteric fistula that was misdiagnosed as gastroenteritis.
Case Description/Methods: A 74-year-old female presented to the hospital for 3 weeks of abdominal pain, diarrhea and fevers. Prior to this, she presented to an outside hospital on two separate occasions for her symptoms. During these admissions, she was told she had gastroenteritis and was subsequently discharged home on antibiotics. Eventually her pain became constant and she developed intractable vomiting therefore she presented to another hospital. Vitals were normal and the physical exam showed moderate tenderness of the epigastric area. White blood cell count was 21,000 uL and lactic acid was 2.1 mmol/L. CT scan without contrast showed nonspecific enteritis. Broad spectrum antibiotics were given. 24 hours later the abdominal pain worsened despite frequent narcotic administration. CT enterography was obtained, showing a 3.7cm x 2.8cm outpouching of the jejunum with significant thickening and stranding, that was inseparable from the transverse colon (Figure 1A). Exploratory laparotomy revealed ruptured jejunal diverticulitis that was fistulized to the mid transverse colon (Figure 1B). She then underwent a transverse colectomy and small bowel resection with anastomosis. Her postoperative course was uncomplicated and she was discharged 2 weeks later.
Discussion: Although jejunal diverticulitis may only occur in less than 2% of known diverticulosis, the occurrence can be fatal. Physical examination and the close evaluation of cross-sectional imaging are integral in its diagnosis. It is important to recognize that this disease may have an insidious presentation and may become a diagnostic challenge.
