A 26-Year-Old Man With Abdominal Pain

Somprakas Basu, MS; Vivek Srivastava, MBBS, MS; Mumtaz Ahmad Ansari, MBBS, MS; Anand Kumar, MS

Disclosures

July 17, 2017

The mere presence of a diverticulum does not justify its surgical removal. If the diverticula are large and found in an isolated, dilated, and hypertrophied segment, and if they are the cause of intestinal obstruction, hemorrhage, adhesions, perforation, or intra-abdominal or retroperitoneal abscess formation, then they should be removed.

Patients with steatorrhea or pernicious anemia should be treated initially with a course of antibiotics as well as vitamin B12 and folate supplementation plus correction of the anemia. If a patient fails to respond to medical therapy, laparoscopy or laparotomy for resection should be considered. A single diverticulum is best treated by diverticulectomy. Inversions of small lesions are best avoided because these can create a lead point for intussusception. When the diverticula are confined to a segment of the intestine, resection with restoration of bowel continuity should be the goal.

Multiple diverticula scattered throughout the small bowel present a difficult treatment scenario. In order to avoid short bowel syndrome or malabsorption, resection should be restricted to those segments containing the largest diverticula or those producing complications such as perforation, abscess, and bowel adhesions.

In the case above, the patient underwent an exploratory laparotomy which revealed a single, giant, wide-mouthed diverticulum of 15 cm in diameter in the distal ileum with patent proximal and distal lumen (Figure 3).

Figure 3.

The ileal and distal jejunal loops were distended and aperistaltic. The diverticulum was thick-walled and inflamed, and it adhered to an adjacent loop of bowel. It did not show any evidence of perforation or gangrene. A segmental ileal resection including the diverticulum was performed, with end-to-end primary anastomosis. A thorough search of the peritoneal cavity did not reveal any other abnormalities. The postoperative course was uneventful. The histopathological examination of the resected specimen demonstrated a diverticulum with small-intestinal mucosa with mucous glands metaplasia, areas of ulceration, and acute inflammatory cell infiltration to the bowel wall, without recognizable nerve plexus. All of the above are suggestive of a heavily inflamed diverticulum with early infarction. After 1 year follow-up, the patient remains asymptomatic.

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