A Rare Presentation of Small Bowel Diverticulosis Causing Chronic Obstruction and Malnutrition: A Case Study with Review of Literature

Mathangasinghe, Y.; Samaranayake, U. M. J. E.; Jayasinghe, J. D.; Banagala, A. S. K.

doi:https://doi.org/10.1155/2019/2548631

Case Reports in Surgery

On this page

Abstract Introduction Case Presentation Discussion Ethical Approval Consent Conflicts of Interest Authors’ Contributions Acknowledgments References Copyright Related Articles

Case Report | Open Access

Volume 2019 | Article ID 2548631 | https://doi.org/10.1155/2019/2548631

A Rare Presentation of Small Bowel Diverticulosis Causing Chronic Obstruction and Malnutrition: A Case Study with Review of Literature

Y. Mathangasinghe,¹U. M. J. E. Samaranayake,¹J. D. Jayasinghe,²and A. S. K. Banagala²

Academic Editor: Marcello Picchio

Received24 Jul 2018

Revised04 Dec 2018

Accepted26 Dec 2018

Published13 Jan 2019

Abstract

Small bowel diverticulosis is an uncommon entity. Clinical presentation of small intestinal diverticulosis is variable. A high mortality is associated with complications such as chronic malnutrition, haemorrhage, intestinal obstruction, and perforation. We report a case of a 63-year-old female with multiple small bowel diverticuli spanning from the first part of the duodenum to the proximal ileum presenting with chronic malnutrition and subacute intestinal obstruction. Although exploratory laparotomy was performed, we opted for a totally conservative treatment in order to avoid complications such as short gut syndrome and anastomotic leakage.

1. Introduction

Small bowel diverticulosis is an uncommon entity. Clinical presentation of small intestinal diverticulosis is variable. A high mortality is associated with complications such as chronic malnutrition, haemorrhage, intestinal obstruction, and perforation. We report a case of a 63-year-old female with multiple small bowel diverticuli spanning from the first part of the duodenum to the proximal ileum presenting with chronic malnutrition and subacute intestinal obstruction.

2. Case Presentation

A 63-year-old female presented with epigastric pain, loss of appetite, abdominal bloating, regurgitation, and episodic projectile vomiting of five-year duration. These symptoms were aggravated particularly after meals. Her bowel opening was normal. The patient had lost 20 kilograms over five years. The patient had a background history of hypothyroidism for which she was on thyroxine replacement therapy. She was clinically euthyroid. She had undergone a vaginal hysterectomy for uterovaginal prolapse at the age of 39 years. There was no significant family history for bowel disorders.

On physical examination, she had a body mass index of 13. She was pale. There were peripheral stigmata of chronic malnutrition and vitamin B12 deficiency. She had a distended abdomen, visible peristalsis, and hyperacute bowel sounds. There was no clinically demonstrable free fluid in the abdomen. She had anaemia (haemoglobin-8.9 g/dl, haematocrit-27.3%, mean corpuscular volume-97.4 fl, mean corpuscular haemoglobin-31.6 pg, mean corpuscular haemoglobin concentration-325 g/l, and red cell distribution width-58.4 fl), with normal platelet () and leucocyte () counts. Blood picture showed macrocytic red cells and hypersegmented neutrophils. Abnormal chemical pathological investigations comprised of elevated C-reactive protein (20.1 mg/l), hypoproteinaemia (59 g/dl), hypoalbuminaemia (25.3 g/l), hypovitaminosis B12 (160 pg/ml), and hypocholesterolaemia (total cholesterol-125.5 mg/dl, HDL-32 mg/dl, LDL-66.3 mg/dl, and triglycerides-136.4% with normal VLDL-27.2 mg/dl). Serum ionized calcium was 2.41 mmol/l. Serum iron studies favoured anaemia of chronic disease (serum iron-95 μg/dl, total iron binding capacity-138 μg/dl, iron saturation-40.8%, and ferritin-238 μg/l). She was biochemically euthyroid (TSH-4.65 mIU/l). Ultrasonography was suggestive of subacute small intestinal obstruction with distended first part of the duodenum filled with fluid. Multiple tortuous small bowel loops were noted around the pancreas with increased peristalsis. Large bowel was distended with gas. There was no bowel wall thickening, mass lesions, or free fluid in the abdomen. Computed tomography (CT) of dual slice contiguous axial sections of the abdomen obtained after intravenous, oral, and rectal contrast administrations demonstrated mild dilatation of the first and second parts of the duodenum with no evidence of significant obstruction to distal passage of oral contrast. The stomach was not distended. A focal calcification of the segment VII of the liver was noted, which was likely to be an incidental finding. There was no CT evidence of an annular pancreas or superior mesenteric artery syndrome. A spiral CT was repeated after one week. It showed markedly distended proximal bowel loops involving the duodenum and the proximal jejunum. No definite transition point was identified. There was a whirl appearance seen in the mesentery and superior mesenteric venous branches around the superior mesenteric artery raising the suspicion of a possible midgut volvulus. Mild mesenteric engorgement was also seen. No definite CT evidence of diverticuli was seen. Upper gastrointestinal (UGI) endoscopy revealed multiple duodenal diverticuli with a small hiatus hernia. Barium meal and follow-through study revealed a slightly distended duodenum without evidence of obstruction or persistent narrowing. Magnetic resonance enterography revealed multiple dilated small bowel loops with loss of valvulae in the right side of the abdomen (Figure 1). There were numerous outpouchings arising from the small bowel.

However, with unexplained weight loss, we wanted to exclude a gastrointestinal malignancy and intestinal tuberculosis. We opted for laparotomy out of diagnostic laparoscopy and laparotomy. Multiple large diverticuli were noted extending from the first part of the duodenum to the proximal ileum (Figure 2). Diverticuli were measuring from 0.5-12.0 cm. There was macroscopic evidence of diverticulitis. There was gross gastric dilatation. Proximal small bowel was dilated without a definitive transition point. The rest of the terminal ileum and colon were normal macroscopically. Small bowel was not surgically resected because she was not a suitable candidate for a primary anastomosis as she had nutritional deprivation and the risk of short gut syndrome. We closed the abdomen without any surgical interventions. Because of macroscopic evidence of diverticulitis, intravenous cefuroxime 750 mg 8 hourly and intravenous metronidazole 500 mg 8 hourly were administered for 7 days and were converted to oral cefuroxime 500 mg 12 hourly and oral metronidazole 400 mg 8 hourly for another 21 days. She had an uneventful postoperative period. She received complementary parenteral nutrition with amino acids, electrolytes, dextrose, and lipid injectable emulsions followed by standard polymeric formulae containing whole proteins. Soluble fibres were gradually introduced to her diet. She received a high-calorie diet, initially 125% of the daily calorie requirement followed by 150% of the daily calorie requirement after one month. Thousand international units of vitamin B12 was administered intramuscularly every other day for five days, and oral vitamin B complex 1 mg three times a day was continued for six months, with folate and micronutrient replacement. Iron-rich food and standard formulae were used to supplement micronutrients such as selenium and zinc for six months. She had a remarkable recovery with no recurrence of symptoms following 10 months follow-up.

3. Discussion

Multiple small intestinal diverticulosis is an uncommon entity. The jejunum is the commonest site to develop such diverticuli [1, 2]. According to Longo and Vernava, 80% of multiple diverticuli occur in the jejunum, followed by the ileum [3]. The incidence of jejunal diverticulosis is 2% as reported in enteroclysis studies, and it is 2-5% in autopsy studies [4, 5]. The incidence increases with age [4–6]. Up to 60% of patients with small intestinal diverticuli have concomitant colonic diverticula [7–10].

A true intestinal diverticulum is the herniation of mucosal and submucosal layers of the intestine through a defect in the muscular layer [11, 12]. There are discrete entities of small intestinal diverticuli such as Meckel’s diverticulum and isolated periampullary lesions [11]. In contrast to true diverticuli, multiple small intestinal diverticuli are considered as submucosal pulsion-type pseudodiverticuli [2, 13]. These are outpouchings at the sites where blood vessels pierce the intestinal wall [12]. Multiple small intestinal diverticuli are congenital or acquired [2]. Majority of the acquired ones are multifactorial. Multiple diverticuli may develop due to intestinal dysmotility. Irregular contractions cause increased intraluminal pressure in different segments of the intestine leading to multiple outpouchings from the sites where the intestinal wall is weak [14]. Multiple diverticuli are known to associate with Cronkhite-Canada syndrome [15], Fabry’s disease [16], mitochondrial neurogastrointestinal encephalomyopathy [17], Marfan and Ehlers Danlos syndromes [18, 19], and systemic lupus erythematosis [2]. In contrast to adults, patients with congenital multiple intestinal diverticuli present at a very early age; however, pathogenesis of congenital diverticuli is poorly understood [20].

Majority with multiple small intestinal diverticulosis are asymptomatic [10, 21]. They are known to present with features of malabsorption such as unexplained anaemia, macronutrient and micronutrient deficiencies [1, 22]. Bacterial overgrowth leading to blind loop syndrome is a postulated mechanism of malabsorption [2]. Patients present with chronic abdominal discomfort, which is often postprandial [1, 4, 5, 13]. These multiple diverticuli can get inflamed leading to diverticulitis. Clinical symptoms may mimic gastritis, pancreatitis, or cholelithiasis [11, 23, 24]. Terminal ileal diverticulitis may mimic acute appendicitis [8, 25, 26]. Leucocytosis and elevated inflammatory markers are seen in diverticulitis [8, 27]. Perforation, upper gastrointestinal bleeding, either haematochezia or melaena [10], and intestinal obstruction [1] are known complications of these patients. Intestinal obstruction may be due to dysmotility of the intestine itself or due to an obstructing enterolith [2]. These complications are associated with a high morbidity and mortality [1]. Perforation has a reported mortality between 30% and 40% [21, 26, 28, 29]. Rarely common bile duct obstruction, cholangitis, superior mesenteric vein thrombosis, and duodenal fistula formation are also reported [30].

Multiple small intestinal diverticulosis is often found incidentally in imaging studies [1, 9, 31, 32]. Plain X-rays may demonstrate segmental dilatation of the small intestine. But this sign is neither specific nor sensitive [1]. Pneumoperitoneum on plain X-rays are rarely seen [26, 33–35]. Ultrasonography is less sensitive than computed tomography (CT) in diagnosing this condition [33, 35]. Multislice CT is 81% sensitive and 99% specific [13, 35–37]. Magnetic resonance imaging (MRI) enteroclysis is specific and sensitive in the diagnosis of multiple small intestinal diverticuli presenting as nonemergency cases [13, 38–41]. They reduce the need of emergency laparotomies [13]. CT and MRI findings of small bowel diverticuli include multiple outpouching or air bubbles in the intestine with an inflammatory background [26, 42–44]. UGI contrast studies can be used in the absence of acute diverticulitis [45]. However, UGI barium follow-through studies cannot reliably exclude the presence of small bowel diverticuli as in our case. Maglinte et al. considered that, if the mouth of the diverticulum is large, it can rapidly empty, and therefore, barium will not stay inside the diverticulum to be visualized [46]. This is evident by the high prevalence of small intestinal diverticuli in autopsy series compared to the UGI contrast series [46, 47]. UGI endoscopy can be diagnostic or therapeutic. It can accurately diagnose lesions in the second part of the duodenum. But the diagnostic sensitivity is low since the rest of the bowel is difficult to visualize by UGI endoscopy [48]. Enteroscopy is an emerging technique to diagnose small bowel diverticular disease. Double balloon enteroscopy has shown promise in diagnosing and treating diverticuli in the jejunum causing UGI bleeding [48–50]. Similarly, radioisotope labelled mesenteric angiography is also reported to be sensitive in diagnosing cases which present as occult UGI bleeding [38]. Although double balloon enteroscopy is a promising technique, it was not available for our patient at that time.

Only 1-2% of single duodenal diverticuli [21] and 29% of jejunal diverticuli [10] become symptomatic. Symptomatic uncomplicated diverticuli are managed conservatively [11]. Nutrition modifications are essential in patients who are symptomatic with chronic malabsorption like our case. Symptomatic patients with diverticulitis are also initially attempted to manage conservatively with resting bowel and broad-spectrum antibiotics [13, 36, 51, 52]. Symptomatic patients with bowel perforation due to intestinal diverticuli are usually managed with surgery [53]. However, there are case reports on conservatively managed perforated diverticuli [54]. Up to 30% of complicated diverticulitis with bleeding may need surgical treatment [55]. Surgical resection of the affected segment is the commonest practice in such cases [26, 56, 57]. Excision of only the involved diverticulum is not recommended due to a high rate of complications [8]. Long-term outcome data on patients undergoing intestinal resection are sparse. Recurrence of diverticuli after surgical resection is also reported [1]. Recently, double balloon enteroscopy was used to treat symptomatic patients with bleeding [58]. Similar to our case, laparoscopy was reported as a diagnostic entity for small intestinal diverticulosis [59]. However, apart from laparoscopic resection of solitary small intestinal diverticuli [60], the reports of laparoscopy used as a therapeutic modality for multiple small intestinal diverticuli are sparse.

Nevertheless, there are no randomized controlled trials to compare efficacy and safety of conservative management, double balloon enteroscopy, and elective resections. Similarly, there are no comprehensive guidelines on management of this uncommon entity.

Ethical Approval

The study was conducted according to the guidelines set forth by the Declaration of Helsinki.

Written informed consent was obtained from the parents of the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editor of this journal.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this article.

Authors’ Contributions

JJ and AB were the clinicians looking after the patient. YM and US wrote the first draft of the manuscript with contributions from all. All authors reviewed, modified, and approved the final version of the manuscript.

Acknowledgments

The authors thank the patient and the family members.

References

E. Falidas, K. Vlachos, S. Mathioulakis, F. Archontovasilis, and C. Villias, “Multiple giant diverticula of the jejunum causing intestinal obstruction: report of a case and review of the literature,” World Journal of Emergency Surgery, vol. 6, no. 1, p. 8, 2011.
View at: Publisher Site | Google Scholar
Y. Yağmur, M. Aldemir, H. Büyükbayram, and İ. Taçyıldız, “Multiple jejunal diverticulitis with perforation in a patient with systemic lupus erythematosus: report of a case,” Surgery today, vol. 34, no. 2, pp. 163–166, 2004.
View at: Publisher Site | Google Scholar
W. E. Longo and A. M. Vernava, “Clinical implications of jejunoileal diverticular disease,” Diseases of the colon & rectum, vol. 35, no. 4, pp. 381–388, 1992.
View at: Publisher Site | Google Scholar
A. Sibille and R. Willocx, “Jejunal diverticulitis,” The American journal of gastroenterology, vol. 87, no. 5, pp. 655–658, 1992.
View at: Google Scholar
R. Akhrass, M. B. Yaffe, C. Fischer, J. Ponsky, and J. M. Shuck, “Small-bowel diverticulosis: perceptions and reality,” Journal of the American College of Surgeons, vol. 184, no. 4, pp. 383–388, 1997.
View at: Google Scholar
R. D. Wilcox and C. H. Shatney, “Surgical implications of jejunal diverticula,” Southern Medical Journal, vol. 81, no. 11, pp. 1386–1391, 1988.
View at: Publisher Site | Google Scholar
F. E. Ferreira-Aparicio, R. Gutierrez-Vega, Y. Galvez-Molina, P. Ontiveros-Nevares, C. Athie-Gutierrez, and E. E. Montalvo-Jave, “Diverticular disease of the small bowel,” Case Reports in Gastroenterology, vol. 6, no. 3, pp. 668–676, 2012.
View at: Publisher Site | Google Scholar
A. Gotian and S. Katz, “Jejunal diverticulitis with localized perforation and intramesenteric abscess,” The American Journal of Gastroenterology, vol. 93, no. 7, pp. 1173–1175, 1998.
View at: Publisher Site | Google Scholar
İ. Kırbaş, E. Yıldırım, A. Harman, and Ö. Başaran, “Perforated ileal diverticulitis: CT findings,” Diagnostic and Interventional Radiology, vol. 13, no. 4, pp. 188-189, 2007.
View at: Google Scholar
H. E. Rodriguez, M. F. Ziauddin, E. D. Quiros, A. M. Brown, and F. J. Podbielski, “Jejunal diverticulosis and gastrointestinal bleeding,” Journal of Clinical Gastroenterology, vol. 33, no. 5, pp. 412–414, 2001.
View at: Publisher Site | Google Scholar
T. C. Schroeder, M. Hartman, M. Heller, P. Klepchick, and K. Ilkhanipour, “Duodenal diverticula: potential complications and common imaging pitfalls,” Clinical Radiology, vol. 69, no. 10, pp. 1072–1076, 2014.
View at: Publisher Site | Google Scholar
R. Williams, D. Davidson, A. Serota, and S. Wilson, “Surgical problems of diverticula of the small intestine,” Surgery, Gynecology & Obstetrics, vol. 152, no. 5, pp. 621–626, 1981.
View at: Google Scholar
D. L. Transue, T. N. Hanna, H. Shekhani, S. Rohatgi, F. Khosa, and J. O. Johnson, “Small bowel diverticulitis: an imaging review of an uncommon entity,” Emergency radiology, vol. 24, no. 2, pp. 195–205, 2017.
View at: Publisher Site | Google Scholar
K. R. Kongara and E. E. Soffer, “Intestinal motility in small bowel diverticulosis: a case report and review of the literature,” Journal of clinical gastroenterology, vol. 30, no. 1, pp. 84–86, 2000.
View at: Publisher Site | Google Scholar
W. J. Cunliffe and J. Anderson, “Case of Cronkhite--Canada syndrome with associated jejunal diverticulosis,” British medical journal, vol. 4, no. 5579, pp. 601-602, 1967.
View at: Publisher Site | Google Scholar
L. S. Friedman, S. E. Kirkham, J. R. Thistlethwaite, D. Platika, E. H. Kolodny, and M. D. Schuffler, “Jejunal diverticulosis with perforation as a complication of Fabry’s disease,” Gastroenterology, vol. 86, no. 3, pp. 558–563, 1984.
View at: Google Scholar
F. Aksoy, G. Demirel, T. Bilgic, I. G. Gungor, and A. Ozcelik, “A previously diagnosed mitochondrial neurogastrointestinal encephalomyopathy patient presenting with perforated ileal diverticulitis,” The Turkish Journal of Gastroenterology, vol. 16, no. 4, pp. 228–231, 2005.
View at: Google Scholar
A. M. McLean, R. E. Paul Jr., J. Kritzman, and M. J. Farthing, “Malabsorption in Marfan (Ehlers—Danlos) syndrome,” Journal of clinical gastroenterology, vol. 7, no. 4, pp. 304–308, 1985.
View at: Publisher Site | Google Scholar
O. Shapira, E. Mavor, D. Simon, H. Rothstein, and R. Pfeffermann, “Multiple giant gastrointestinal diverticula complicated by perforated jejunoileal diverticulitis in Marfan syndrome,” Digestive surgery, vol. 9, no. 1, pp. 58–60, 1992.
View at: Publisher Site | Google Scholar
H. Edwards and C. Dukes, “Congenital diverticula of the intestine: with the report of a case exhibiting heterotopia,” British Journal of Surgery, vol. 17, no. 65, pp. 7–21, 1929.
View at: Publisher Site | Google Scholar
S. Bergman, J. Koumanis, L. A. Stein, J. S. Barkun, and S. Paraskevas, “Duodenal diverticulum with retroperitoneal perforation,” Canadian journal of surgery, vol. 48, no. 4, p. 332, 2005.
View at: Google Scholar
R. B. Drude Jr., D. Finkelman, W. D. Davis, and W. A. Ferrante, “Malabsorption in jejunal diverticulosis treated with resection of the diverticula,” Digestive diseases and sciences, vol. 25, no. 10, pp. 802–806, 1980.
View at: Publisher Site | Google Scholar
B. Van Beers, J. P. Trigaux, T. De Ronde, and M. Melange, “CT findings of perforated duodenal diverticulitis,” Journal of Computer Assisted Tomography, vol. 13, no. 3, pp. 528–530, 1989.
View at: Publisher Site | Google Scholar
K. L. Mathis and D. R. Farley, “Operative management of symptomatic duodenal diverticula,” American Journal of Surgery, vol. 193, no. 3, pp. 305–309, 2007, discussion 8-9.
View at: Publisher Site | Google Scholar
N. B. Ackerman, “Perforated diverticulitis of the terminal ileum,” American journal of surgery, vol. 128, no. 3, pp. 426–428, 1974.
View at: Publisher Site | Google Scholar
S. Greenstein, B. Jones, E. Fishman, J. Cameron, and S. Siegelman, “Small-bowel diverticulitis: CT findings,” American Journal of Roentgenology, vol. 147, no. 2, pp. 271–274, 1986.
View at: Publisher Site | Google Scholar
M. D. M. Kaushik Mukherjee, E. B. Rinker, M. K. Kressin, J. L. Tarpley, and R. L. Muldoon, “Small bowel diverticulitis masquerading as Crohn’s disease,” The American surgeon, vol. 79, no. 7, article E246-8, 2013.
View at: Google Scholar
G. Gayer, R. Zissin, S. Apter, E. Shemesh, and E. Heldenberg, “Acute diverticulitis of the small bowel: CT findings,” Abdominal imaging, vol. 24, no. 5, pp. 452–455, 1999.
View at: Publisher Site | Google Scholar
L. Graña, I. Pedraja, R. Mendez, and R. Rodríguez, “Jejuno–ileal diverticulitis with localized perforation: CT and US findings,” European journal of radiology, vol. 71, no. 2, pp. 318–323, 2009.
View at: Publisher Site | Google Scholar
M. S. Pearl, M. C. Hill, and R. K. Zeman, “CT findings in duodenal diverticulitis,” American journal of roentgenology, vol. 187, no. 4, pp. W392–W395, 2006.
View at: Publisher Site | Google Scholar
E. Amzallag-Bellenger, A. Oudjit, A. Ruiz, G. Cadiot, P. A. Soyer, and C. C. Hoeffel, “Effectiveness of MR enterography for the assessment of small-bowel diseases beyond Crohn disease,” Radiographics, vol. 32, no. 5, pp. 1423–1444, 2012.
View at: Publisher Site | Google Scholar
C. Y. Liu, W. H. Chang, S. C. Lin, C. H. Chu, T. E. Wang, and S. C. Shih, “Analysis of clinical manifestations of symptomatic acquired jejunoileal diverticular disease,” World journal of gastroenterology, vol. 11, no. 35, pp. 5557–5560, 2005.
View at: Publisher Site | Google Scholar
B. Coulier, P. Maldague, A. Bourgeois, and B. Broze, “Diverticulitis of the small bowel: CT diagnosis,” Abdominal imaging, vol. 32, no. 2, pp. 228–233, 2007.
View at: Publisher Site | Google Scholar
J. F. Hibbeln, A. A. Gorodetsky, and A. C. Wilbur, “Perforated jejunal diverticulum: CT diagnosis,” Abdominal imaging, vol. 20, no. 1, pp. 29-30, 1995.
View at: Publisher Site | Google Scholar
A. van Randen, W. Lameris, H. W. van Es et al., “A comparison of the accuracy of ultrasound and computed tomography in common diagnoses causing acute abdominal pain,” European radiology, vol. 21, no. 7, pp. 1535–1545, 2011.
View at: Publisher Site | Google Scholar
S. Kleyman, L. Logue, V. Lau, E. Maio, A. Sanni, and F. Khan, “Ileal diverticulitis: an uncommon diagnosis for right lower quadrant pain,” Journal of Surgical Case Reports, vol. 2012, no. 11, 2012.
View at: Publisher Site | Google Scholar
H. Bitterling, C. Rock, and M. Reiser, “Computed tomography in the diagnosis of inflammatory bowel disease -- methodology of MSCT and clinical results,” Der Radiologe, vol. 43, no. 1, pp. 17–25, 2003.
View at: Publisher Site | Google Scholar
E. C. Benya, G. G. Ghahremani, and J. J. Brosnan, “Diverticulitis of the jejunum: clinical and radiological features,” Gastrointestinal radiology, vol. 16, no. 1, pp. 24–28, 1991.
View at: Publisher Site | Google Scholar
B. Mansoori, C. P. Delaney, J. E. Willis et al., “Magnetic resonance enterography/enteroclysis in acquired small bowel diverticulitis and small bowel diverticulosis,” European radiology, vol. 26, no. 9, pp. 2881–2891, 2016.
View at: Publisher Site | Google Scholar
G. Masselli and G. Gualdi, “MR imaging of the small bowel,” Radiology, vol. 264, no. 2, pp. 333–348, 2012.
View at: Publisher Site | Google Scholar
D. J. Tolan, R. Greenhalgh, I. A. Zealley, S. Halligan, and S. A. Taylor, “MR enterographic manifestations of small bowel Crohn disease,” Radiographics, vol. 30, no. 2, pp. 367–384, 2010.
View at: Publisher Site | Google Scholar
M. Macari, E. J. Balthazar, G. Krinsky, and H. Cao, “CT diagnosis of ileal diverticulitis,” Clinical Imaging, vol. 22, no. 4, pp. 243–245, 1998.
View at: Publisher Site | Google Scholar
B. De Peuter, I. Box, R. Vanheste, and S. Dymarkowski, “Small-bowel diverticulosis: imaging findings and review of three cases,” Gastroenterology Research and Practice, vol. 2009, Article ID 549853, 3 pages, 2009.
View at: Publisher Site | Google Scholar
U. Böcker, D. Dinter, C. Litterer et al., “Comparison of magnetic resonance imaging and video capsule enteroscopy in diagnosing small-bowel pathology: localization-dependent diagnostic yield,” Scandinavian Journal of Gastroenterology, vol. 45, no. 4, pp. 490–500, 2010.
View at: Publisher Site | Google Scholar
F. Fintelmann, M. S. Levine, and S. E. Rubesin, “Jejunal diverticulosis: findings on CT in 28 patients,” American journal of roentgenology, vol. 190, no. 5, pp. 1286–1290, 2008.
View at: Publisher Site | Google Scholar
D. D. Maglinte, S. M. Chernish, R. DeWeese, F. M. Kelvin, and R. L. Brunelle, “Acquired jejunoileal diverticular disease: subject review,” Radiology, vol. 158, no. 3, pp. 577–580, 1986.
View at: Publisher Site | Google Scholar
R. K. Harper, Radiology of the Duodenum: Lloyd-Luke, Lippincott, 1967.
H. H. Yen and Y. Y. Chen, “Jejunal diverticulosis: a limiting condition to double-balloon enteroscopy,” Gastrointestinal Endoscopy, vol. 64, no. 5, pp. 847–847; author reply 848, 2006.
View at: Publisher Site | Google Scholar
H. H. Yen, Y. Y. Chen, C. W. Yang, and M. S. Soon, “The clinical significance of jejunal diverticular disease diagnosed by double-balloon enteroscopy for obscure gastrointestinal bleeding,” Digestive Diseases and Sciences, vol. 55, no. 12, pp. 3473–3478, 2010.
View at: Publisher Site | Google Scholar
H. H. Yen, Y. Y. Chen, C. W. Yang, and M. S. Soon, “Diagnosis and management of jejunoileal diverticular hemorrhage: a decade of experience,” Journal of Digestive Diseases, vol. 13, no. 6, pp. 316–320, 2012.
View at: Publisher Site | Google Scholar
N. Oukachbi and S. Brouzes, “Management of complicated duodenal diverticula,” Journal of Visceral Surgery, vol. 150, no. 3, pp. 173–179, 2013.
View at: Publisher Site | Google Scholar
V. C. Simões, B. Santos, S. Magalhães, G. Faria, D. S. Silva, and J. Davide, “Perforated duodenal diverticulum: surgical treatment and literature review,” International journal of surgery case reports, vol. 5, no. 8, pp. 547–550, 2014.
View at: Publisher Site | Google Scholar
G. G. Tsiotos, M. B. Farnell, and D. M. Ilstrup, “Nonmeckelian jejunal or ileal diverticulosis: an analysis of 112 cases,” Surgery, vol. 116, no. 4, pp. 726–731, 1994.
View at: Google Scholar
M. Veen, B. J. Hornstra, C. H. Clemens, H. Stigter, and R. Vree, “Small bowel diverticulitis as a cause of acute abdomen,” European journal of gastroenterology & hepatology, vol. 21, no. 1, pp. 123–125, 2009.
View at: Publisher Site | Google Scholar
R. D. Wilcox and C. H. Shatney, “Surgical significance of acquired ileal diverticulosis,” The American surgeon, vol. 56, no. 4, pp. 222–225, 1990.
View at: Google Scholar
A. Chendrasekhar and G. A. Timberlake, “Perforated jejunal diverticula: an analysis of reported cases,” The American surgeon, vol. 61, no. 11, pp. 984–988, 1995.
View at: Google Scholar
T. Eguchi, T. Kato, and I. Honda, “A case of large diverticulum of the distal jejunum,” Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association), vol. 65, no. 7, pp. 1850–1854, 2004.
View at: Publisher Site | Google Scholar
H. Yamamoto, H. Kita, K. Sunada et al., “Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases,” Clinical Gastroenterology and Hepatology, vol. 2, no. 11, pp. 1010–1016, 2004.
View at: Publisher Site | Google Scholar
K. Lee, C. Yeung, Y. Tam, W. Ng, and K. Yip, “Laparoscopy for definitive diagnosis and treatment of gastrointestinal bleeding of obscure origin in children,” Journal of pediatric surgery, vol. 35, no. 9, pp. 1291–1293, 2000.
View at: Publisher Site | Google Scholar
L. Sarli and R. Costi, “Laparoscopic resection of Meckel’s diverticulum: report of two cases,” Surgery Today, vol. 31, no. 9, pp. 823–825, 2001.
View at: Publisher Site | Google Scholar

Copyright

Copyright © 2019 Y. Mathangasinghe et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

PDF Download Citation

Download other formats

Order printed copies

Views

3306

Downloads

1072

Citations