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small bowel diverticuli are encountered most frequently in the duodenum , however complicated and symptomatic diverticuli occur most commonly in the jejunoileal region .
small bowel diverticuli are pulsion lesions acquired by herniation of mucosa and submucosa through a weak muscularis layer , hence forming a false diverticulum
diagnosis of small bowel diverticuli is often made during diagnostic or therapeutic interventions for unrelated issues .
while a small bowel barium study and enteroclysis are optimal diagnostic modalities for this disease , a computed tomography ( ct ) scan of the abdomen and pelvis is most ideal to identify the complications of small bowel diverticuli , such as formation of an abscess as was seen in our patient .
a 25-year - old african american female with no significant past medical or surgical history presented with moderate to severe abdominal pain and fever ( tmax 39.1c ) of three days duration .
she experienced a single episode of bilious vomiting , but denied any other obstructive symptoms .
vital signs were normal . on physical exam , her abdomen was soft but diffusely tender with rebound and guarding .
laboratory findings revealed leukocytosis ( wbc 13,600/mm ) and an elevated partial thromboplastin time ( ptt 46 ) .
a pelvic ultrasound showed a small amount of free fluid in cul - de - sac , but no ovarian mass or uterine fibroids . a ct scan of the abdomen and pelvis ( fig .
1 ) revealed a thickened jejunal wall with mild dilatation , several small adjacent enlarged mesenteric lymph nodes , and an air - fluid - containing structure measuring 1.9  2.9 cm in the left abdomen .
the patient was taken to the operating room for an exploratory laparotomy . at exploration , diffuse serous fluid was encountered , and a segment of the proximal jejunum appeared erythematous and edematous . a large abscess cavity in the adjacent jejunal mesentery was also identified .
segmental resection of the involved jejunum and mesentery including the abscess cavity was performed followed by a side - to - side anastomosis .
post - operatively , the patient had an uneventful recovery and was discharged home on hospital day 7 .
in a young female as the one described above , severe abdominal pain and tenderness with fever and leukocytosis , all of which suggest an acute abdomen , would draw a long list of differential diagnoses .
the most common things would involve perforated appendicitis , ectopic pregnancy , pelvic inflammatory disease , tubo - ovarian abscess , or hemorrhagic or ruptured ovarian cysts .
however , the ct scan image revealing an inflamed small bowel wall with an adjacent abscess was vital in determining the need for surgery .
in retrospect , laparoscopy followed by segmental resection of the involved bowel and the abscess would have been preferable over open surgery .
small bowel diverticuli are encountered most frequently in the duodenum , but complications arise most often when they occur in the jejunoileal region .
small bowel diverticuli are false diverticuli , which means they involve only the mucosa , submucosa and serosa , excluding the muscularis layer .
both duodenal and jejunoileal diverticuli are acquired pulsion lesions that may clinically present in a vague and diverse manner , such as epigastric or periumbilical abdominal pain , satiety , bloating , constipation and diarrhea . although colonic diverticular disease may be one of the extrarenal manifestations of autosomal dominant polycystic kidney disease ( adpkd ) ,
only a single case of small bowel diverticuli in a chronically hemodialysed adpkd patient has been reported , and there is insufficient evidence to suggest an association between these two entities .
duodenal diverticuli are common and found in 2 - 5% of patients undergoing upper gastrointestinal series .
etiologically most duodenal diverticuli are thought to be acquired by herniation of the mucosa and submucosa through a wall defect caused by entrance of large vessels .
rarely duodenal diverticuli are intraluminal , which may be congenital resulting from incomplete intestinal lumen canalization .
clinically less than 10% of duodenal diverticuli are symptomatic with approximately 1% requiring definitive treatment .
rare complications of duodenal diverticuli include obstruction , perforation , bleeding and diverticulitis , and interestingly they are strongly associated with a high frequency of common bile duct stones .
jejunoileal diverticuli are found in 1 - 2% of the general population   with most presenting during the sixth or seventh decade of life .
jejunoileal diverticuli are frequently associated with intestinal motility disorders such as progressive systemic sclerosis , visceral neuropathies or myopathies .
atrophy of the myopathic jejunal wall on one side and increased luminal pressure from the opposite leads to protrusion of small intestinal mucosa through defects in the lamina muscularis mucosae .
jejunoileal diverticuli are mostly asymptomatic , but malabsorption due to bacterial overgrowth within them may be a major clinical feature .
they may also present in unusual ways , such as with a gastrointestinal hemorrhage due to a ruptured congenital arteriovenous malformation in the diverticular submucosal , perforation with abscess progressing into a jejuno-   ileo-   abdominal wall fistula formation , or episodes of bowel obstruction secondary to volvulus , stricture formation   or an enterolith impaction .
jejunal diverticulitis occurs in about 2 - 6% of cases and has a mortality rate as high as 24% .
diagnosis of small bowel diverticuli is often incidental at endoscopic retrograde cholangiopancreatography , laparotomy , or double - balloon enteroscopy .
although endoscopy ( capsule and double - balloon ) may diagnose intraluminal abnormalities of the small bowel , its utility in emergency is limited .
barium follow - through and enteroclysis are the diagnostic modalities of choice for small bowel diverticuli .
a ct scan of the abdomen and pelvis is most useful to identify abscess formation following diverticular perforation .
although non - specific , this finding may suggest jejunoileal diverticulitis amongst other differential diagnoses , namely neoplasms , focal crohn 's disease , foreign body perforations , medication - induced ulcers and traumatic hematomas . in the absence of contraindications ,
diagnostic laparoscopy is a useful tool that may allow a thorough intra - abdominal surveillance to reach a precise diagnosis .
open or laparoscopic resection of the involved small bowel segment and primary anastomosis is indicated for jejunoileal diverticulitis , bowel perforation or bleeding [ 23 , 24 ] .
approximately 15% of patients with jejunal diverticulosis may require small bowel resection for treatment of such complications .
unlike colonic diverticulitis , conservative management involving bowel rest and antibiotic administration is rarely successful .
macari et al . have reported success in only one out of three patients with jejunal diverticulitis treated conservatively .
jejunoileal diverticulosis and its associated complications are rare . its preoperative diagnosis is difficult , but should be considered in cases of unexplained abdominal symptoms and peritonitis . given the high mortality rate of jejunal diverticulitis , a precise diagnosis followed by appropriate therapeutic intervention is essential .
if suspected , diagnostic laparoscopy unless contraindicated seems to be an apt approach to confirm the diagnosis . despite the successful outcome and uneventful recovery in our patient , we believe laparoscopic bowel resection may have been similarly beneficial in limiting the morbidity and recovery time associated with an open procedure .
all the authors listed declare that there are no conflicts of interest and that they accepted no financial sponsorship in producing and presenting this article .
a 25-year - old african american female with no prior medical / surgical history presented with abdominal pain and fever . a computed tomography scan of the abdomen and pelvis showed jejunal wall thickening with an air - fluid - filled mass in the adjacent mesentery . at laparotomy , a segmental jejunal resection with the abscess cavity followed by primary 
 anastomosis was performed . 
 pathological evaluation of the specimen revealed a large mesenteric abscess contiguous with a perforated solitary jejunal diverticulum . 
 we provide a discussion of jejunal diverticulitis as an unusual cause of peritonitis .