Massive rectal bleeding from acquired jejunal diverticula
© Yaqub et al; licensee BioMed Central Ltd. 2011
Received: 17 March 2011
Accepted: 13 May 2011
Published: 13 May 2011
Small bowel diverticulosis is an uncommon and often asymptomatic condition that is sporadically observed during radiographic examination or laparotomy. Although it is frequently seen in duodenum, jejunal and ileal locations are very rare. The majority of patients with jejunal diverticula have no symptoms. However, they can present with a number of acute and emergent complications with a high rate of mortality. Bleeding from jejunal diverticula occurs in less than 3% - 8% of patients and often present as fresh rectal haemorrhage. This can confuse the clinician since a bleeding source in colon is far more common. We report a patient with acute massive rectal bleeding. Abdominal CT angiography demonstrated a jejunal diverticulum as the bleeding source and the patient underwent resection of the affected segment. She has since remained free of gastrointestinal bleeding.
Although jejunal diverticulosis is rare, it is an important differential diagnosis for patients with gastrointestinal haemorrhage of unknown origin as it may cause extensive rectal bleeding. Abdominal CT angiography can localize the bleeding source and resection of the affected bowel and primary anastomosis is the treatment of choice.
Malabsorption due to bacterial overgrowth is the major clinical manifestation of jejunoileal diverticula. Inflammation, perforation, and bleeding are far less common than in colon diverticula. The most common lesions leading to small bowel bleeding are tumors, arteriovenous malformations, and inflammatory bowel disease. Massive gastrointestinal haemorrhage from jejunal diverticula is extremely rare. However, it has been associated with high mortality rate caused by delayed diagnosis.
We report a case of massive rectal haemorrhage from a jejunal diverticulum and discuss diagnostic evaluations and treatment options.
A 74-year-old female was admitted to our hospital after an episode of massive rectal bleeding. Her past medical history was significant for hypertension and non-insulin dependent diabetes mellitus. In addition to anti-hypertensive and anti-diabetic drugs, she was taking aspirin 75 mg daily. There was no previous history of gastrointestinal haemorrhage. The bleeding started at home some hours before admission. Upon arrival at the emergency room, she was awake and alert. On physical examination, the blood pressure was 130/80 mmHg, and the pulse was 60 beats/min. The abdomen was soft, non-distended and non-tender. On rectal examination, old blood on the glove was noticed. The initial haemoglobin level was 10.8 g/dL, trombocytes 186 x109/L, and C-reactive protein <5 mg/L. The bleeding appeared to have ceased and the patient was considered haemodynamically stable. She had no more episodes of rectal bleeding during the night or the next morning and was discharged with an urgent appointment for outpatient workup with colonoscopy.
Jejunoileal diverticula were first time described by Soemmering in 1794 and Sir Astley Cooper in 1807 . They are found at the mesenteric side of the small intestine where the arteries enter the intestine. Nearly 80% occur in the jejunum, approximately 15% in the ileum, and 5% in both . Jejunal diverticulosis is a rare entity and the majority of patients have no symptoms. As a result, identification of the disorder can be quite difficult. However, it can present with a number of complications that require quick diagnosis and acute surgical care [7, 8]. The reported complications of jejunal diverticulosis include haemorrhage, malabsorption, volvulus, diverticulitis, obstruction, abscess, and perforation, and occur in 10% - 30% of patients [1, 7, 8]. Colonic diverticula have a high association with the presence of jejunal diverticula . The clinician should suspect small bowel diverticulosis if there is a history of colonic diverticula. CT scan can be helpful in diagnosis of jejunal diverticula and can differentiate them from other inflammatory conditions such as colon diverticulitis and appendicitis . Our patient also had coexisting colonic diverticula which were initially suspected to be the source of bleeding.
Haemorrhage as a presenting symptom occurs in 3.4% - 8.1% of patients with this condition [3, 11]. There have been less than 60 case reports in the English literature describing massive haemorrhage from jejunal diverticula . Unfortunately, neither the history nor the physical examination are helpful in diagnosing jejunal diverticula. These patients often experience acute massive bleeding per rectum and most patients have had no previous gastrointestinal symptoms. Furthermore, the acute haemorrhage is likely to recur if the diagnosis of bleeding jejunal diverticula is missed at the initial presentation, as was the case with our patient.
Haemodynamically unstable patients with massive rectal haemorrhage should undergo emergency laparotomy . Although the colon is the most likely source of extensive rectal bleeding in patients above 50 years of age, a high index of suspicion of a small intestinal site of bleeding should be maintained. It is mandatory to systematically inspect the small intestine, and owing to the mesenteric location of the diverticula, the intraoperative recognition can be facilitated by jejunal insufflations using manual compression . If no small intestine diverticula are found, a subtotal colectomy is recommended . When jejunal diverticula are identified as the bleeding source, either preoperatively or intraoperatively, partial resection of the involved segment of jejunum with primary anastomosis is the procedure of choice. A special challenge is in patients with multiple diverticula along the small intestine, where it is not possible to remove all of them. In such cases it is easy and safe to perform an intraoperative endoscopy through an enterotomy, which effectively can localize the bleeding source . Another dilemma is that approximately 50% of patients with jejunal diverticula also have coexisting colonic diverticula. In such patients a preoperatively CT angiography can be helpful to pinpoint the bleeding source and thus avoid unnecessary colectomy. However, even when the preoperative studies implicate bleeding from colon, the finding of jejunal diverticula at laparotomy is justification for resection of the involved small intestine . Failure to identify and remove jejunal diverticula may lead to continued bleeding after blind colectomy.
In our case, as in many others with bleeding from jejunal diverticulosis, pathologic examination of the resected bowel segment did not localize the bleeding site. We consider the immediate and long-term cassation of bleeding achieved by resection of the diverticula as a satisfactory confirmation of diagnosis of jejunal diverticular haemorrhage .
Jejunoileal diverticulosis is an uncommon entity and a rare source of gastrointestinal haemorrhage. However, it should be considered in all patients with acute bleeding in the lower part of the gastrointestinal tract, especially in the elderly, because it may lead to life threatening complications and death. In case of massive ongoing rectal bleeding, CT angiography is an accurate, rapid, and non-invasive modality that may detect the bleeding site. If unstable or multiple jejunal diverticula, an intraoperative endoscopy can be performed safely via an enterotomy to localize the bleeding site. Surgical resection of the involved intestine and primary anastomosis 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.
List of abbreviations
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