Jejunal Diverticulosis Causing Small Intestinal Volvulus and Closed Loop Obstruction

Introduction

Jejunal diverticulosis are false diverticula of the small bowel that form from outpouching of the mucosa and submucosa [1–3]. They are pulsion diverticula that occur because of increased intraluminal pressure in the jejunum, are often asymptomatic, and can be found incidentally during surgery [2]. In some instances, jejunal diverticula can result in intestinal obstruction [1,2,4–6]. Small intestinal volvulus is an uncommon cause of small bowel obstruction that results in a closed loop obstruction and is an indication for emergent surgical intervention. We present a case of a patient presenting with significant proximal jejunal diverticulosis with volvulus and a closed loop obstruction. This is an extremely rare presentation sparsely reported in the medical literature.

Case Report

A 84-year-old man with history of hypertension, hyperlipidemia, coronary artery disease, requiring a bypass graft, coronary stenting, iliac vein stenting, benign prostatic hyperplasia, and cognitive decline, with a surgical history of laparoscopic cholecystectomy and an open left inguinal hernia repair was admitted for concerns of vague, dull, abdominal pain and generalized weakness for 3 days. On physical examination, he appeared frail and was not in acute distress. His abdomen was soft, tender in the epigastric region, and tympanic, with no guarding or rebound tenderness.

Laboratory findings were pertinent for a serum lactate level of 2.9 mmol/L, B-type natriuretic peptide level of 264, and a white blood cell count of 11 400 uL, with 4% bands. Due to the absence of signs of peritoneal inflammation, and the patient’s hemodynamic stability, a preoperative computed tomography (CT) scan was performed, revealing evidence of a high-grade closed loop small bowel obstruction with a transition point in the central abdomen and associated swirling of the mesentery (Figures 1, 2).

The decision was made to proceed to the operating room, and a diagnostic laparoscopy was performed. A small bowel volvulus without malrotation was apparent, with multiple dilated loops of small bowel. Extensive jejunal diverticula were also noted. Due to the significant bowel dilatation, as well as the need to detorse and evaluate the viability of the entire small bowel, the decision was made to convert to a laparotomy. A midline incision was made in the mid-abdomen, and the peritoneal cavity was entered. Entry into the abdomen revealed small bowel torsion, by approximately 180 degrees at the root of the mesentery. The diverticula of the proximal jejunum were large and ranged from 3 to 7 cm in diameter, with some diver-ticula surrounded by inflammatory exudate. Some diverticula had focal areas of necrosis; therefore, 90 cm of affected jejunum with diverticula was resected after manual detorsion. We re-established intestinal continuity at about 35 cm from the ligament of Treitz with a stapled side-to-side anti-peristaltic anastomosis. The mesenteric defect was closed with 3-0 silk sutures, we lavaged the abdomen with copious amounts of warm saline, and closed the fascia with number 1 looped polydioxanone sutures. The skin was closed with staples.

The patient was hemodynamically stable throughout the procedure and was extubated at the conclusion. He was transferred to the Surgical Intensive Care Unit postoperatively for hemodynamic monitoring. Serum lactate returned to normal on postoperative day 1, and the patient required 1 unit of packed red blood cells for a hemoglobin level of 6.9 g/dL. The nasogastric tube was removed on postoperative day 2, and diet was advanced over the next couple of days. The patient received piperacillin-tazobactam for 3 days postoperatively. On postoperative day 7, the patient was discharged to sub-acute rehabilitation facility for continued skilled physical therapy. Three weeks after discharge, the patient had an outpatient follow-up visit, where his staples were removed, revealing a healed incision and good clinical recovery overall. Surgical pathology revealed a segment of small bowel with foci of transmural ischemic-type necrosis with marked acute inflammation.

Discussion

Closed loop small bowel obstructions are surgical emergencies, which can lead to bowel ischemia, perforation, and sepsis if not treated expeditiously. We present this unusual case of an 84-year-old man with a closed loop small bowel obstruction from a proximal jejunal volvulus with concomitant extensive jejunal diverticulosis (Figure 3). Jejunal diverticulosis has been described in the literature as a cause of small bowel obstruction [1,2]. These diverticula are pulsion diverticula (arising from increased intraluminal pressure), thought to arise from intestinal dyskinesia [2]. Due to their wider necks, jejunal diverticula are less prone to diverticulitis than are colonic diverticula [3].

The previous reports of small bowel obstruction in patients with jejunal diverticulosis, describe the mechanism of obstruction involving adhesions, bowel wall thickening, and inflammation [1,2]. In the case report by Saxena et al, there was gut malrotation in addition to jejunal diverticulosis in an adult with small bowel obstruction, but the obstruction was due to external compression of the third part of the duodenum and the terminal ileum by the superior mesenteric artery requiring intestinal bypass procedures [4]. Our case was not characterized by malrotation or external compression of any sort but was a true volvulus, with twisting of the proximal small bowel around the mesentery. Apart from the twisting of the proximal jejunum, all other intraabdominal structures appeared to be in their anatomical position. The patient’s surgical history included a laparoscopic cholecystectomy and an open inguinal hernia repair, and we did not encounter significant adhesions intraoperatively. A review of the patient’s abdominal CT scan 5 years prior to this episode demonstrated a possible mesenteric swirl but normal small and large bowel caliber and orientation (Figure 4). It is important to note that the volvulus involved only the segment of the jejunum with extensive diverticulosis, which had to be detorsed to determine the proximal and distal extent of our resection. It is possible that the intestinal dyskinesia responsible for the diverticulosis also contributed to or resulted in the volvulus, or that the diverticulosis led to worsening of the dyskinesia, resulting in a volvulus; either way, the same segment of jejunum was involved in both processes, necessitating a resection and anastomosis. Hung and Huang published a similar case report in 2020, with a similar clinical presentation and radiologic and operative findings [5]. Quite similar to our patient, the jejunal diverticula were encountered from 30 to 130 cm distal to the ligament of Treitz. Management was similar to our case, with the exception of adding a Ladd procedure to the enter-ectomy and anastomosis [5]. Shen et al classified small intestinal volvulus as primary or secondary depending on the absence (primary) or presence (secondary) of intrinsic anatomic abnormalities, and described a case in 2015. The patient described had a single jejunal diverticulum and a small intestinal volvulus [6]. This patient was described as having a long mesentery with a narrow insertion, and relative paucity of mesenteric fat, which could have predisposed to his condition [6]. It is important to note that these anatomic findings were absent in our patient. The authors do describe a possible etiological link between the presence of large diverticula and volvulus [6]. We agree with the possibility of these diver-ticula serving as lead points for twisting, and hampering the repositioning of bowel after twisting in one direction, eventually leading to a volvulus [6].

Conclusions

Closed loop obstruction due to a small bowel volvulus and concomitant jejunal diverticulosis is very rare but is a surgical emergency requiring prompt intervention to prevent ischemia, perforation, and sepsis. Jejunal diverticulosis has been proposed to result from increased intraluminal pressure and intestinal dyskinesia. Large diverticula could serve as lead points, leading to twisting in one direction and hampering untwisting in the other direction. When this occurs repeatedly, it could result in a volvulus. Further studies need to be undertaken to determine the actual causality of these conditions, particularly when they occur concomitantly.