Huang Tzu Han, Marker Madeline, Urdahl Torben, Manivel Juan, Rezcallah Anthony T
University of Minnesota Medical School Minneapolis Minnesota USA.
Department of Laboratory Medicine and Pathology University of Minnesota Minneapolis Minnesota USA.
Clin Case Rep. 2024 Oct 21;12(10):e9489. doi: 10.1002/ccr3.9489. eCollection 2024 Oct.
Closed-loop bowel obstruction and contained perforation secondary to acute on chronic jejunal diverticulitis is rare and should be included in the differential diagnosis of acute abdomen. The association between polymyalgia rheumatica and diverticular disease requires further research but may prompt clinicians to consider appropriate therapies in patients with both diseases.
Jejunal diverticulosis is a sac-like outpouching of the intestinal wall that can cause complications such as diverticulitis, obstruction, abscess, perforation, or fistula formation. Complicated jejunal diverticulosis may present with acute abdomen and nonspecific symptoms which can lead to misdiagnosis and delayed treatment. A 76-year-old male with a remote history of polymyalgia rheumatica (PMR) presented with sudden onset abdominal pain, fever, nausea, vomiting, and inability to pass flatus. Physical exam revealed a distended and diffusely tender abdomen with signs of peritonitis. Laboratory test results were significant for neutrophil-dominant leukocytosis and elevated inflammatory markers. CT scan of the abdomen with IV contrast revealed a contained perforation and a closed-loop small bowel obstruction in the mid-abdomen. The patient underwent emergent exploratory laparotomy and resection of 100 cm of mid-jejunum which was found to have numerous diverticula surrounding the closed-loop obstruction and contained perforation. Pathology findings showed evidence of acute on chronic jejunal diverticulitis. Jejunal diverticulosis with complications may present with an acute abdomen and peritonitis. Closed-loop bowel obstruction and contained perforation secondary to acute on chronic jejunal diverticulitis is uncommonly thought of and should be considered in the differential diagnosis. Additionally, the association between PMR and diverticular disease is notable. While the patient had a remote history but no active PMR on presentation, studies suggest a possible association between gut inflammation and rheumatologic disease. This association should prompt clinicians to consider appropriate therapies and bear in mind the potential risk for diverticular perforation if glucocorticoids are given to treat PMR. Jejunal diverticulosis with multiple complications such as closed-loop bowel obstruction and contained perforation secondary to acute on chronic jejunal diverticulitis is rare and may present with an acute abdomen and nonspecific symptoms. Including rare pathologies as such in the differential diagnosis may prevent misdiagnosis and delayed treatment. While further investigation is needed, the association between diverticulosis and PMR is noteworthy as patients who present with both diseases would require mindful management due to the potential risk of diverticular perforation after treatment with steroids.
慢性空肠憩室炎继发的闭环性肠梗阻和局限性穿孔较为罕见，应纳入急腹症的鉴别诊断。风湿性多肌痛与憩室病之间的关联需要进一步研究，但可能促使临床医生对同时患有这两种疾病的患者考虑适当的治疗方法。
空肠憩室病是肠壁的囊状膨出，可导致憩室炎、梗阻、脓肿、穿孔或瘘管形成等并发症。复杂的空肠憩室病可能表现为急腹症和非特异性症状，从而导致误诊和治疗延误。一名有风湿性多肌痛（PMR）既往史的76岁男性，出现突发腹痛、发热、恶心、呕吐及无法排气。体格检查发现腹部膨隆且弥漫性压痛，有腹膜炎体征。实验室检查结果显示以中性粒细胞为主的白细胞增多及炎症标志物升高。腹部增强CT扫描显示中腹部有局限性穿孔和闭环性小肠梗阻。患者接受了急诊剖腹探查术，切除了100厘米的空肠中段，发现其在闭环梗阻和局限性穿孔周围有许多憩室。病理结果显示有慢性空肠憩室炎急性发作的证据。伴有并发症的空肠憩室病可能表现为急腹症和腹膜炎。慢性空肠憩室炎继发的闭环性肠梗阻和局限性穿孔较少被考虑到，应在鉴别诊断中予以考虑。此外，PMR与憩室病之间的关联值得注意。虽然该患者有既往史，但就诊时无活动性PMR，但研究表明肠道炎症与风湿性疾病之间可能存在关联。这种关联应促使临床医生考虑适当的治疗方法，并牢记如果给予糖皮质激素治疗PMR，可能存在憩室穿孔的风险。伴有多种并发症（如慢性空肠憩室炎继发的闭环性肠梗阻和局限性穿孔）的空肠憩室病较为罕见，可能表现为急腹症和非特异性症状。在鉴别诊断中纳入此类罕见病症可防止误诊和治疗延误。虽然需要进一步研究，但憩室病与PMR之间的关联值得关注，因为同时患有这两种疾病的患者在接受类固醇治疗后有憩室穿孔的潜在风险，需要谨慎处理。
