JOURNAL OF MEDICAL
Butler et al. Journal of Medical Case Reports 2010, 4:172
Perforated jejunal diverticula: a case report
© 2010 Butler et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Joseph S Butler*, Christopher G Collins and Gerard P McEntee
Introduction: Jejunal diverticula are rare and are usually asymptomatic. However, they may cause chronic non-specific
symptoms or rarely lead to an acute presentation.
Case presentation: We report the case of an 82-year-old Caucasian woman presenting with a one-day history of
generalized abdominal pain, with three episodes of vomiting. An abdominal X-ray displayed multiple dilated loops of
the small bowel. A subsequent computed tomography scan of the abdomen and pelvis revealed a thickening of the
duodenum and dilatation of the proximal jejunum. Multiple small bowel diverticula were identified with surrounding
pockets of free air adjacent to the jejunal diverticula suggestive of a small bowel perforation. Our patient underwent a
laparotomy, which identified multiple jejunal diverticula with two pinhole jejunal perforations and associated fecal
contamination. The perforations were repaired with primary closure and extensive washout was performed.
Conclusion: Jejunal diverticulosis in the elderly can lead to significant morbidity and mortality and so should be
suspected in those presenting with crampy abdominal pain and altered bowel habits.
Jejunal diverticula are rare with an incidence of less than
0.5% . Pathologically, they are pseudodiverticula of the
pulsion type, resulting from increased intra-luminal pres-
sure and weakening of the bowel wall. These outpouch-
ings only contain mucosa and submucosa.
Despite most cases of jejunal diverticulosis remaining
completely asymptomatic, complications are reported in
10 to 30% of patients [2-4]. These include chronic
abdominal pain, malabsorption, hemorrhage, diverticuli-
tis, obstruction, abscess formation and rarely diverticular
We present a rare cause of acute abdominal pain with a
case of perforated jejunal diverticula. We also review the
literature associated with the management of small bowel
An 82-year-old Caucasian woman of Irish background,
presented to the emergency department with a one-day
history of generalized abdominal pain, with three epi-
sodes of vomiting. The patient had a past medical history
significant for hypothyroidism and hypoalbuminemia
secondary to malnutrition.
On physical examination our patient's vital signs were a
temperature 36°C, heart rate 105, blood pressure 90/50
and respiratory rate 16 breaths/min. Abdominal exami-
nation revealed a generalized abdominal tenderness and
signs of peritonitis. Laboratory investigations revealed an
elevated white cell count (WCC 18.29 × 109/L), an
impaired renal profile (urea 13.2 mmol/L; creatinine 139
μmol/L) and an elevated serum lactate (4.6 mmol/L).
Abdominal X-ray (Figure 1a) displayed multiple dilated
loops of small bowel. A subsequent computed tomogra-
phy (CT) scan of the abdomen and pelvis (Figures 1 and
2) revealed a thickening of the duodenum and dilatation
of the proximal jejunum. Multiple small bowel diverticula
were identified with surrounding pockets of free air adja-
cent to the jejunal diverticula suggestive of a small bowel
The patient underwent a laparotomy which identified
multiple jejunal diverticula (Figures 3 and 4) with two
pinhole jejunal perforations and associated fecal contam-
ination. The two sites of perforation were closed primar-
ily and oversewn. Extensive abdominal washout was
performed. Our patient's post-operative course was com-
plicated by an episode of aspiration pneumonia from
which she made a full recovery.
* Correspondence: firstname.lastname@example.org
1 Department of Surgery, Mater Misericordiae University Hospital, Dublin,
Full list of author information is available at the end of the article
Butler et al. Journal of Medical Case Reports 2010, 4:172
Page 2 of 3
Jejunal diverticula are the least common type of small
bowel diverticula, with an incidence of less than 0.5% .
They are multiple outpouchings of mucosa and submu-
cosa. Although the true etiology of jejunal diverticulosis
is unknown, this condition is believed to develop from a
combination of abnormal peristalsis, intestinal dyskine-
sis, and high segmental intra-luminal pressures. These
diverticula arise on the mesenteric border where the mes-
enteric vessels penetrate the jejunum.
Usually, this disorder is clinically silent until it presents
with the complications associated with diverticular dis-
ease. When symptomatic, patients may describe a vague,
chronic abdominal pain of varying severity, localized
either to the epigastrium or peri-umbilical region. The
only definitive way to confirm jejunal diverticulosis as the
primary source of abdominal pain is cessation of symp-
toms after surgical resection of the involved segment of
small bowel. Complications of jejunal diverticulosis war-
ranting surgical intervention occur in eight to 30% of
patients . Common acute complications include diver-
ticulitis, bleeding, intestinal obstruction and perforation
Jejunal diverticulosis is a challenging disorder from a
diagnostic perspective, with no truly reliable diagnostic
tests. Abdominal radiographs and/or chest radiographs
may demonstrate evidence of perforation, such as free air
under the diaphragm or free peritoneal air; evidence of
intestinal obstruction, or evidence of ileus, including
multiple air-fluid levels and bowel dilatation. CT may
identify thickening or inflammation of the jejunum or
localized abscess formation [7,8]. Endoscopic procedures,
such as double-balloon enteroscopy and capsule endos-
Figure 1 Abdominal X-ray displayed multiple dilated loops of
Figure 2 CT scan of abdomen showing thickening of the duode-
num and dilatation of the proximal jejunum. Multiple small bowel
diverticula were identified with surrounding pockets of free air and flu-
id adjacent to the jejunal diverticula suggestive of a small bowel perfo-
Figure 3 Intra-operative video images displaying dilated loops of
jejunum with multiple jejunal diverticula.
Figure 4 Intra-operative images of dilated loops of jejunum with
multiple jejunal diverticula.
Butler et al. Journal of Medical Case Reports 2010, 4:172 Download full-text
Page 3 of 3
copy, are useful in diagnosing small-bowel disorders .
However, these procedures cannot be used in the emer-
gency setting, such as intestinal obstruction or perfora-
Diagnostic laparoscopy can be very useful in investigat-
ing patients with a complicated symptomatology. It
enables an accurate conclusive diagnosis to be made,
avoiding the need for unnecessary laparotomy. In the
presence of laparoscopic findings such as perforation,
abscesses, and mechanical obstruction, exploratory lapa-
rotomy is required with resection of the diseased bowel
and primary anastomosis is appropriate.
If the perforation of a jejunal diverticulum causes only
localized peritonitis and the patient remains stable, it is
has been reported that a trial of non-surgical manage-
ment with intravenous antibiotics and other supportive
measures alongside percutaneous CT-guided aspiration
of localized intraperitoneal collections may be suitable
and avoid the need for surgery . However, the current
treatment of choice for perforated jejunal diverticula
causing generalized peritonitis is prompt laparotomy
with segmental intestinal resection and primary anasto-
mosis. The extent of the bowel resection depends upon
the length of the bowel that is affected by the diverticula
and the patient's peri-operative condition . If divertic-
ula are extensive, resection may have to be limited to
include only the segment containing the perforated diver-
ticulum and to leave a segment of small bowel that still
contains non-perforated diverticula in order to avoid
short bowel syndrome .
In our case the decision to perform a primary closure
was based on the age of our patient and the extent of the
diverticulosis, which precluded a safe resection and anas-
tomosis. Jejunal diverticulosis, unlike colonic diverticulo-
sis, tends not to be associated with surrounding
diverticulitis and in our case the adjacent tissue was nor-
mal in appearance when examined intra-operatively.
Jejunal diverticula are rare and usually asymptomatic.
However, they may lead to chronic non-specific abdomi-
nal symptoms or rarely, as displayed by this case, can
present as an acute presentation. Jejunal diverticulosis in
the elderly can lead to significant morbidity and mortality
and so should be suspected in those presenting with
crampy abdominal pain and altered bowel habits. Once
jejunal diverticulosis has been diagnosed, conservative
medical management should be instituted to alleviate
symptoms and reduce the risk of complications associ-
ated with diverticular disease. Rarely, jejunal diverticular
disease may present as intestinal perforation, for which
surgical repair is the treatment of choice.
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
JSB conceived the study, acquired patient data and drafted the manuscript.
CGC critically reviewed the manuscript. All authors (JSB, CGC, GPMcE) contrib-
uted intellectual content and have read and approved the final manuscript.
No financial support was received towards this manuscript.
Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
1. Zager JS, Garbus JE, Shaw JP, Cohen MG, Garber SM: Jejunal
diverticulosis: a rare entity with multiple presentations, a series of
cases. Dig Surg 2000, 17:643-645.
2.Wilcox RD, Shatney CH: Surgical implications of jejunal diverticula.
South Med J 1988, 81:1386-1391.
3. Sibille A, Willocx R: Jejunal diverticulitis. Am J Gastroenterol 1992,
4.Akhrass R, Yaffe MB, Fischer C, Ponsky J, Shuck JM: Small-bowel
diverticulosis: perceptions and reality. J Am Coll Surg 1997, 184:383-388.
5. Wilcox RD, Shatney CH: Surgical significance of acquired ileal
diverticulosis. Am Surg 1990, 56:222-225.
6.Woods K, Williams E, Melvin W, Sharp K: Acquired jejunoileal
diverticulosis and its complications: a review of the literature. Am Surg
7. Hyland R, Chalmers A: CT features of jejunal pathology. Clin Radiol 2007,
8.Fintelmann F, Levine MS, Rubesin SE: Jejunal diverticulosis: findings on
CT in 28 patients. AJR Am J Roentgenol 2008, 190(5):1286-1290.
9. Carey EJ, Fleischer DE: Investigation of the small bowel in
gastrointestinal bleeding--enteroscopy and capsule endoscopy.
Gastroenterol Clin North Am 2005, 34(4):719-734.
10. Novak JS, Tobias J, Barkin JS: Nonsurgical management of acute jejunal
diverticulitis: a review. Am J Gastroenterol 1997, 92(10):1929-1931.
11. Mattioni R, Lolli E, Barbieri A, D'Ambrosi M: Perforated jejunal
diverticulitis: personal experience and diagnostic with therapeutical
considerations. Ann Ital Chir 2000, 71(1):95-98.
12. Alvarez J Jr, Dolph J, Shetty J, Marjani M: Recurrent rupture of jejunal
diverticula. Conn Med 1982, 46(7):376-378.
Cite this article as: Butler et al., Perforated jejunal diverticula: a case report
Journal of Medical Case Reports 2010, 4:172
Received: 24 October 2009 Accepted: 7 June 2010
Published: 7 June 2010
This article is available from: http://www.jmedicalcasereports.com/content/4/1/172 © 2010 Butler et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal of Medical Case Reports 2010, 4:172