The Unfortunate 1%: Jejunal Diverticulitis: 1034

Purpose: A 75-year-old female was admitted with crampy abdominal pain and non-bloody diarrhea lasting 5 days. Medical history included metastatic renal cell carcinoma status post nephrectomy, currently receiving sunitinib, chronic kidney disease, pulmonary embolism on warfarin and laparoscopic gastric banding four years ago. Upon evaluation she was afebrile, hemodynamically stable with periumbilical tenderness on deep palpation. Lab work showed acute kidney injury and normal white cell count. Enhanced computed tomography (CT) scan of the abdomen confirmed retroperitoneal fat infiltration surrounding a proximal jejunal diverticulum consistent with jejunal diverticulitis. The diverticulum contained fecalized material suggestive of a bezoar. Treatment with metronidazole and ciprofloxacin resulted in rapid improvement of abdominal pain and diarrhea; the patient was discharged home with a three-week course of antibiotics. Follow-up CT showed complete resolution of diverticulitis. Small bowel diverticulosis is an uncommon disease occurring in 2-8% of the general population. Diverticula are more common in the jejunum than ileum, presumably due to the larger vasa recta of the jejunum. Jejunal diverticula also tend to have a larger diameter than distal diverticular disease and can be up to 10 cm. Most patients are asymptomatic and are diagnosed incidentally. When symptoms do occur, they are nonspecific and include abdominal pain, diarrhea and bloating. Barium enhanced upper GI studies can be helpful in detection, though CT scan can provide a definitive diagnosis and rule out other etiologies in the acute setting. Complications include obstruction, small intestinal bacterial overgrowth, perforation and abscess. Diverticulitis occurs in less than 3% of patients and management depends on the clinical presentation. Medical management with antibiotics is appropriate for uncomplicated diverticulitis. However, surgical treatment is needed for complications or refractory symptoms. Clinical awareness and a high index of suspicion are required for early detection due to the high mortality rate (up to 24%) associated with this clinical entity.Figure