History of presenting illness

57 yrs old Mr.x. presented with Abdominal distension 2days Vomiting bilious 2days Obstipation 2 days - not on oral feeds 2days - oliguria 2days

GENERAL EXAMINATION conscious,oriented,afebrile with an anxious look,answering questions. moderately built/nourished hydration fair *patient is pale
VITALS pulse:88/m BP :100/70mm Hg Temp: N Respiratory rate:20/min

Past history
k/c of APD 30years on peptic ulcer drugs.Advised surgery Vague abdominal discomfort yrs

personal history . Not a known smoker/alcoholic .bowel/bladder habits normal

SYSTEMIC EXAMINATION
CVS :s1,s2 present.no added sounds,no murmurs
RS:
NVBS ,occasional creps heard in both lower lobes no FND

CNS:

INSPECTION : abdomen distended flanks full hernial orifice/scrotum-N PALPATION

PER ABDOMEN

: no warmth tenderness + in epigastric and umblical region guarding/rigidity + in upper abdomen no mass palpable shifting dullness present

PERCUSSION : resonant no obliteration of liver dullness AUSCULTATION : BS- sluggish P/R : sphincter tone N ,rectum empty,no fecal staining.

INVESTIGATIONS
CBC: TC - 10200 DC - P65,L32,E3 ESR -20 mm-first hour Hb -7.6g/dl PCV -24 Plt - 1.9 lacs RFT: Sugar 96 Urea -38 Crt - 1.1 Na 133 K 3.2

CHEST X-RAY

X-RAY ABDOMEN - erect

L R

X-RAY ABDOMEN -supine

L R

ECG small q waves in leads 2,3,aVf USG abdomen distended stomach with food particles with multiple dilated bowel loops

DIAGNOSIS
ACUTE INTESTINAL OBSTRUCTION
PLAN LAPROTOMY AND PROCEED..

Management
Iv fluids Ryles tube aspiration : bilious Bladder catheterisation Abdomen girth chart

DRIP AND SUCK EVERY CASE OF INTESTINAL OBSTRUCTION

ON LAPROTOMY.

Abdomen opened midline incision

Findings * minimal purulent peritoneal fluid * flakes adherent to intestine

FINDINGS
*multiple diverticulum seen in antimesenteric border of jejunum with peri diverticular adhesions to other diverticula and to other small bowel loops. *kinking of ileum about 3 feet proximal to ileocaecal junction with distension of proximal loop with compressed distal loops.
*perforation about 0.5cm seen in one of the diverticula.

PROCEDURE DONE
*adhesions released *resection of about 1.5feet of jejunum starting 15cm from DJ flexure *two layered end to end anastamosis done *thorough laprotomy done .No other diverticulum seen *peritoneal wash given *DTs in pelvis and morrisons space.

POST OPERATIVE PERIOD

*On ET tube- extubated on 3rd day *started sips of fluid 5th day *LFT increased [TB- 6mg/dl] on 6th day.settled with lactulose.

MICROSCOPY
Ulceration of the diverticular mucosa and dense inflammatory cell infiltrate in all four gut layers. IMP:diverticulitis with perforation

DIVERTICULAR DISEASE
TRUE *mostly congenital *has all 4 layers FALSE *mostly acquired *has mucosa and sub mucosa and serosa

DIVERTICULUM IN SMALL BOWEL

Congenital M/c meckels Acquired - M/c duodenum (75%) > jejunum (20%) > ileum (5%) Ref:

Edwards HC. Diverticulosis of the small intestine. Ann Surg 1936; 103: 230-54.

JEJUNAL DIVERTICULA
*incidence 0.1% - 1.5%(men 58% > women 42%) *mostly false *old age > 6th decade *multiple mostly in mesenteric border *may contain ectopic gastric/pancreatic tissue at base *may associate with connective tissue disorders

JEJUNAL DIVERTICULUM IN MESENTERIC BORDER

JEJUNAL DIVERTICULUM IN ANTI-MESENTERIC BORDER

 CAUSE : motor dysfunction of myentric plexus/smooth muscle.

disordered contraction increased intra luminal pressure herniation

INVESTIGATION

CT ABDOMEN

INVESTIGATION
ENTEROCLYSIS BARIUM MEAL FOLLOW THROUGH

REF:Benya EC, Ghahremani GG,. Diverticulitis of the jejunum: clinical and radiological features. Gastrointest Radiol 1991; 16:24.

CLINICAL FEATURES mostly incidental(42%)

Acute complications(6-10%) *Diverticulitis .perforation .abscess *hemorrhage *obstruction .enterolith Chronic complications *vague abdominal pain(51%) *diarrhea (58%) *bloating (44%) *low grade GI hemorrhage *functional pseudo obstruction *malabsorbtion .blind loop syndrome .megaloblastic anemia .steatorrhea

REF:Tsiotos GG, Farnell MB, Ilstup DM. Non-Meckelianjejunal or ileal diverticulosis: an analysis of 112 cases. Surgery 1994; 116:

TREATMENT
*Asymptomatic no treatment *malabsorbtion antibiotics,nutrient supplements *with acute complications intestinal resection and end to end anastamosis (surgery of choice)
REF:A. Gotian and S. Katz, Jejunal diverticulitis with localized perforation and intramesenteric abscess, American Journal of Gastroenterology,

TREATMENT
*enterolith causing obstruction enterotomy and removal *simple closure,excision-greater mortality (25-50%) and morbidity *diffuse peritonitis-enterostomy
REF:Chendrasekhar A, Timberlake GA. Perforated jejunal diverticula: an analysis of reported cases. Am Surg1995;