Download jejunal diverticula causing unusual massive lower gastrointestinal

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CASE REPORT
JEJUNAL DIVERTICULA CAUSING UNUSUAL MASSIVE
LOWER GASTROINTESTINAL BLEEDING
Chiong-Hee Wong1, I-Tsung Lin2*, Shou-Chuan Shih2,3, Wen-Hsinug Chang2,3, Horng-Yuan Wang2,3
1
Division of Rheumatology, Department of Internal Medicine, and 2Division of Gastroenterology,
Department of Internal Medicine, Mackay Memorial Hospital, and 3Mackay Medicine,
Nursing and Management College, Taipei, Taiwan.
SUMMARY
Jejunal diverticula are rare and difficult to diagnose. They are often asymptomatic, but they may infrequently
cause serious acute complications, such as diverticulitis with or without perforation, volvulus, intussusception,
or hemorrhage. Hemorrhage of jejunal diverticula usually presents as lower gastrointestinal bleeding.
Diverticula with bleeding may be associated with some anticoagulants, antiplatelets or nonsteroidal antiinflammatory agents in the elderly. In our case, upper gastroscopy and colonoscopy could not easily disclose
the bleeding. Selective mesenteric angiography is the gold standard for diagnosis of active and fatal bleeding.
The management of a bleeding jejunal diverticulum is surgical resection of the involved segment of jejunum.
[International Journal of Gerontology 2008; 2(3): 120–123]
Key Words: aged, diverticulum, gastrointestinal hemorrhage, jejunum, NSAIDs
Introduction
Diverticular disease of the small bowel is a rare condition characterized by retroflection of the intestinal wall.
Small bowel diverticulum has not been well understood
owing to its infrequent incidence and underdeveloped
diagnostic tools for the small intestine. Most diverticula
of the small intestine are asymptomatic. The frequent
site of a diverticulum is the duodenum, followed by
Meckel’s diverticulum. Although a jejunal diverticulum
is uncommon, it is complicated by diverticulitis with
or without bowel perforation, bleeding, and intestinal
obstruction1,2. Massive gastrointestinal (GI) bleeding
caused by a jejunal diverticulum is extremely rare, with
fewer than 50 cases reported. It may be a serious condition with a high mortality rate and difficult definitive
*Correspondence to: Dr I-Tsung Lin, Division of
Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, 92, Section 2,
Chungshan North Road, Taipei, Taiwan.
Email: [email protected]
Accepted: May 16, 2008
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preoperative diagnosis3. We report the case of an elderly
patient with massive lower GI bleeding from a jejunal
diverticulum and discuss the diagnostic evaluations
and treatment.
Case Report
A 79-year-old man was admitted to our institution,
complaining of dizziness, general weakness, mild epigastric pain, and melena presenting as bloody stool with
coffee-ground vomitus. Initially, hemoglobin was as low
as 4.0 g/dL (normal range, 13–17 g/dL). Physical examinations showed pale conjunctiva and a distended
abdomen. His abdomen was soft with mild epigastric
tenderness. No peritoneal signs were presented. Furthermore, he had a history of type 2 diabetes mellitus and
gouty arthritis with regular medications. He took longterm nonsteroidal anti-inflammatory drugs (NSAIDs) for
gouty arthritis.
Esophagogastroduodenoscopy was carried out; it
revealed some coffee-ground material in the stomach
and one gastric ulcer at the lesser curved side of the
International Journal of Gerontology | September 2008 | Vol 2 | No 3
© 2008 Elsevier.
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Jejunal Diverticula Causing Lower GI Bleeding
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A
B
Figure 2. Gross specimen of resected jejunum.
C
Figure 1. Superior mesenteric artery angiography reveals
bleeding jejunal diverticulum. (A) Cannulation of the superior mesenteric artery (arrow). (B) An oval hypervascular stain
(diverticulum; arrow). (C) Contrast medium extravasation
(arrow).
antrum without active bleeding. Conservative treatment
with an intravenous proton pump inhibitor and blood
transfusion with 10 units of red cell was instituted
in the following 3 days. The amount of bloody stool
seemed to be decreased. His hemoglobin returned to
10.3 g/dL after transfusion of six units of packed red
cells and four units of fresh frozen plasma.
International Journal of Gerontology | September 2008 | Vol 2 | No 3
Unfortunately, the patient had massive bloody to
dark-red colored stool passage of about 5,000 mL on the
fourth day after hospitalization. Low blood pressure
(71/40 mmHg) presented as shock and confusion.
Emergent rigid sigmoidoscopy was done; there was
too much blood to complete the examination. Repeat
esophagogastroduodenoscopy performed in the intensive care unit showed a gastric ulcer remaining at the
lesser curved side of the antrum, but no active bleeding
was found in the whole stomach. When an endoscope
was inserted into the second portion of the duodenum,
much fresh blood from the inlet of the third portion of
the duodenum was noted. A bleeder below the second
portion of the duodenum was suspected. Emergent
angiography was carried out, and superior mesenteric
arteriography revealed an oval hypervascular stain with
contrast medium extravasation to the mucosa of the
proximal jejunum (Figure 1). Because of the intractable,
acute and massive GI bleeding, laparotomy was done
immediately. At laparotomy, six variable sized diverticula at the proximal jejunum (located at 10, 27, 42,
49, 51, and 56 cm from the Treitz ligament) were found
(Figure 2). Active bleeding with fresh blood clotting
was noted in the diverticulum located at 10 cm from
the Treitz ligament. About 45 cm of jejunum was resected and about 460 cm of small bowel was preserved.
The patient was discharged uneventfully on day 13
after operation.
Discussion
The first reports of jejunal diverticulosis were described
by Sommervit in 1794 and Cooper in 1807. These
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C.H. Wong et al
acquired lesions consist of mucosa, submucosa and
serosa, without muscularis, and occur along the mesenteric side of the small bowel where the arteries enter
the intestine. They mainly affect males between 60 and
70 years of age4,5. The incidence of small bowel diverticula is 0.5–7.1% in small bowel barium studies and
0.3–4.5% in autopsy studies. The incidence of small
and colonic diverticula also increases with age1,2. The
incidence of diverticula of the small bowel is low.
Diverticula located at the jejunum are extremely rare.
Although most jejunal diverticula are asymptomatic,
complications of small bowel diverticula present as
inflammation, obstruction, dysmotility, perforation,
volvulus, intussusception, malabsorption, and bleeding.
A few cases of jejunal diverticula causing massive GI
bleeding have been reported3,6. The preoperative diagnosis of jejunal diverticula with bleeding is difficult.
The history and physical examination is of little help.
The patient frequently presents with acute and recurrent lower GI hemorrhage or occasional hematemesis.
As in our case, upper GI endoscopy and colonoscopy
have limitations in finding the definitive bleeder in the
jejunum. Acute lower GI bleeding with negative findings
with esophagogastroduodenoscopy and colonoscopy
should be considered as possible small bowel bleeding.
In our case, scintigraphy with red blood cells labeled
with technetium 99 m was not a helpful and suitable
technique because of acute and fulminate GI bleeding.
Selective superior mesenteric arteriography revealed
oval extravasation of contrast from one of the jejunal
branches, indicating the bleeder as diverticula with
active bleeding in our patient. Tisnado et al.7 showed
the typical angiographic findings in the bleeding
diverticulum; the contrast accumulated in a smooth
walled “lake” and did not change the oval appearance
for many seconds during the arterial phase and capillary phase, then the contrast spilled into the bowel
lumen and outlined the mucosal pattern in the venous
phase. If the contrast had immediate extravasation into
the bowel lumen from an ulcerative or other mucosal
pattern, mucosal lesions including ulcer, tumor,
angiodysplasia, aneurysm and arteriovenous malformation should be considered7. Angiography may be
a useful diagnostic tool for location of the bleeding.
Surgery can allow definitive diagnosis and rule out
the presence of tumor and malignancy in the small
bowel8.
The mechanism of bleeding from the jejunal diverticula is thought to be ulceration involving an artery,
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diverticulitis with or without ulceration, or irritation
from a concretion. A few reports revealed that diverticulum bleeding is associated with drugs, such as warfarin and low-dose aspirin. An international normalized
ratio of 3 under warfarin treatment was detected in a
patient with jejunal diverticulum bleeding. As we
know, a high international normalized ratio causing
coagulopathy is one of the risk factors of GI bleeding.
There is strong evidence for a link between GI bleeding
and aspirin in the elderly, either ulcer or nonulcer GI
bleeding9,10. In our case, the elderly male patient took
long-term NSAIDs for gouty arthritis. NSAID-related GI
bleeding in the elderly has been reviewed in a previous
article11. Topical injury and systemic effects of NSAIDs
cause mucosal damage of the stomach and duodenum.
NSAID enteropathy of the small bowel is increasingly
diagnosed because of the advances in endoscopy, like
capsule endoscopy and double-balloon enteroscopy12.
It usually manifests as ulcers, diaphragm strictures,
or both. There are different mechanisms of upper GI
toxicity from small bowel enteropathy of NSAIDs. The
stepwise process includes direct mucosal toxicity, mitochondrial damage, enterohepatic recirculation, breakdown of intercellular integrity, and neutrophils activated
by bacteria13. NSAID consumption may be associated
with more complications of diverticular disease, such as
perforation and bleeding14. Warfarin, antiplatelet agents
and NSAIDs should be used with caution in elderly
patients who have diverticular disease.
In conclusion, diverticular disease is increasing in
incidence with age. Diverticular bleeding may be induced by common drugs in the elderly, such as aspirin,
warfarin and NSAIDs. Jejunal diverticula with bleeding
are rare and difficult to diagnose. This can mimic upper
or lower GI bleeding. In our case, upper gastroscopy and
colonoscopy cannot easily disclose the bleeder. Selective
mesenteric angiography is the gold standard to diagnose
active and fatal bleeding. The importance of a careful
search for the malformation in the patient with intestinal bleeding is stressed. The management of bleeding
jejunal diverticula is surgical resection of the involved
segment of jejunum.
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