TWO FOR ONE: MULTIPLE LARGE JEJUNAL DIVERTICULA CONTRIBUTING TO SMALL BOWEL OBSTRUCTION AND HEMODYNAMICALLY SIGNIFICANT GASTROINTESTINAL BLEED.
Katherine Kazen*, Edward Gray
Surgery, East Tennessee State University, Johnson City, TN
Introduction: Jejunal diverticula are exceedingly rare entities that are often asymptomatic but can lead to numerous complications including obstruction, diverticulitis, and gastrointestinal bleed. In this case, we present a patient who initially was diagnosed with jejunal diverticula after a small bowel obstruction secondary to enterolith formation treated via enterotomy and then re-presented 7 years later with gastrointestinal bleed.
Case Presentation: An 81 year old male with history of dementia as well as known history of jejunal diverticular disease discovered intraoperatively during exploratory laparotomy 7 years prior for small bowel obstruction secondary to enterolith presented as a transfer from an outside hospital with chief complaint of melena. The patient was found to have anemia with initial presenting hemoglobin of 7.8 as well as both confirmed melena and occasional hematochezia. Exam revealed hypotension which stabilized with transfusion. Initial work-up and management included EGD and colonoscopy on 3 separate occasions which were unrevealing of the source. The patient was then transferred to higher level of care to be seen by interventional radiology. Upon arrival, he underwent mesenteric angiography which did not localize the bleed. The patient continued to require transfusion for blood pressure stabilization as well as brief initiation of vasopressor support. Finally, he was taken urgently with gastroenterology at the second facility for repeated EGD and colonoscopy which demonstrated active bleeding at the jejunum as well as significant blood clot formation and evidence of diverticula (Figure 1). Hemoclips were applied. Due to persistent bleeding after attempted endoscopic intervention, the area of interest was tattooed to assist with intraoperative localization and general surgery was called for intra-procedural consultation. The patient was stabilized and taken emergently to the operating room for exploration.
Intraoperatively, the patient was found to have several large jejunal diverticula. He underwent exploratory laparotomy and enterectomy with resection of 60cm of jejunum (Figure 2). The patient had an uneventful post-operative course and recovered fully with no further episodes of melena.
Discussion: Although rare, jejunal diverticula should be considered among the diagnoses which may contribute to hemodynamically significant gastrointestinal bleed, especially in patients with known diverticular disease and populations at increased risk.
Conclusion: It may be efficacious to resect symptomatic small bowel diverticula when discovered intraoperatively if feasible in order to prevent future complications.
Figure 1: Endoscopic view
Figure 2: Surgical Specimen
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