Perforated small bowel diverticular disease: a case report to raise awareness for surgical treatment in complicated jejunal diverticulitis

Unlike colonic diverticulitis, small bowel diverticulitis is a rare disease, representing only 0.5% of all cases of diverticulitis. Thus, clinicians rarely encounter the disease and no treatment guidelines exist. Meckel’s diverticulum is the most common type (about 43%) of small bowel diverticulitis and is often detected incidentally during surgery; duodenal diverticula are the second most common. Symptomatic jejunal diverticulosis, with an incidence of about 0.25% in autopsy studies (of which only about 10% of cases present to hospitals with complications), is even rarer. The literature describes only isolated cases of diverticulitis with involvement throughout most of the small intestine. We report a case involving the entire jejunum/ileum with contained perforation, where diagnostic differentiation from colonic diverticulitis (e.g., with a micro-abscess < 3 cm, typically managed conservatively) was challenging. Unlike colonic diverticulitis, conservative therapy in jejunal diverticulitis carries a mortality rate of up to 40% compared to just 0.5% with surgical intervention.

A 69-year-old female patient presented to the emergency department with acute diffuse abdominal pain, C‑reactive protein (CRP) 11.3 mg/dL, and white blood cell count (WBC) 11.3 G/L. Computed tomography (CT) scan revealed a warren-like abscess conglomerate in the middle abdomen with partial air bubbles in the abscess cavities (differential diagnosis of enterocolic fistulas and contained perforation) and diverticula over almost the entire small intestine. Radiologically, no clear assignment of the pathology or differentiation from a chronic inflammatory disease could be made. After clinical worsening and elevated inflammation parameters following 3 days of antibiotic treatment, open surgical intervention was performed. Intraoperatively, diverticular involvement was observed throughout most of the small intestine, with inflammation extending over about 50 cm of the jejunum and ileum and a 15-cm inflammatory conglomerate tumor with an abscess, necessitating the resection of approximately 60 cm of the small intestine and creation of a side-to-side intestinal anastomosis. Histology showed pseudodiverticula with contained perforation, partial fecal serositis, and multiple abscesses. The patient was discharged on the 10th postoperative day after an uncomplicated stay, receiving i.v. antibiotics for a total of 10 days despite a 3-day therapeutic delay. Follow-up after 14 months was uneventful.

Accurate diagnosis can be challenging, and treatment is often delayed due to frequent attempts at conservative management with antibiotics in cases of contained perforated diverticulitis, which is associated with a high rate of complications such as bleeding or perforation (> 50%) in small bowel diverticulitis. However, conservative treatment is typically ineffective in complicated jejunal diverticulitis, whereas it may be more successful in colonic diverticulitis.