Applied Radiology

Prepared by Cynthia Janus, MD and Gargi Patel, MD, of Drs. Sheer, Ahearn, & Assoc., Team Physicians of Florida, P.A., Tampa, FL.

CASE SUMMARY

The patient is a 79-year-old woman with a history of chronic, vague abdominal pain. Physical examination was unremarkable, and there were no significant laboratory findings.

DIAGNOSIS

Primary acquired jejunoileal diverticulosis

IMAGING FINDINGS

A double-contrast upper GI series failed to demonstrate any evidence of an ulcer or mass lesion. A small-bowel series, however, revealed extensive diverticulosis involving the entire length of the small bowel with diverticula ranging in size from 5 mm to 2.5 cm (figure 1). There was no evidence of associated inflammatory change, fistulae, or mass effect. The patient subsequently underwent a barium enema examination, which demonstrated extensive involvement of the entire large bowel with diverticula (figure 2).

DISCUSSION

Primary acquired jejunoileal diverticulosis is an unusual entity. The diverticula are classified as false diverticula and result from herniation of mucosa and submucosa through the muscular layer of the bowel wall. ¹ The diverticula usually occur at the mesenteric border of the bowel and can vary in size from a few millimeters to >10 cm. The incidence of jejunoileal diverticulosis as determined at surgery, at postmortem evaluation, or by enteroclysis has been reported to be between 1.1% and 2.3%. Associated diverticula are found in the colon in 35% to 75% of cases. ¹

Small-bowel motor dysfunction has been postulated as an etiology, and the entity has been associated with abnormalities, such as scleroderma, involving a myopathic or neuropathic abnormality. It has been proposed that disordered contractions of the abnormal portion of the small bowel secondary to motor dysfunction of the smooth muscle or myenteric plexus causes increased intraluminal pressure. This results in herniation of mucosa and submucosa through the weakest part of the bowel wall at the site of penetration of mesenteric paired blood vessels. ^1,2

Patients are usually elderly, in the seventh decade and above. Most cases are asymptomatic. However, jejunoileal diverticulosis can be the cause of vague, chronic symptoms as in the case shown here. Most patients can be managed medically. However, the disorder may be associated with enterolith ileus, ^3,4,5 bacterial overgrowth, and malabsorption and can also result in other serious complications including severe inflammation, abcess, hemorrhage, and perforation. ^1,6 Computed tomography may be helpful in diagnosing and defining the extent of related complications. Diagnosis of the abnormality is often delayed.

CONCLUSION

Although rare, this disorder should be considered in the evaluation of patients with nonspecific, chronic abdominal complaints or undiagnosed gastrointestinal bleeding.