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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 20  |  Issue : 2  |  Page : 82-84

Midgut volvulus with giant jejunal diverticulum in an elderly patient: Case report with literature review


Department of Surgery, Colleage of Medicine, Al-Mustansiriya University; Department of Surgery, Al Yarmouk Teaching Hospital, Baghdad, Iraq

Date of Submission10-Dec-2020
Date of Acceptance08-Jul-2021
Date of Web Publication15-Dec-2021

Correspondence Address:
Dr. Hasanain Abdulameer Jasim
Department of Surgery, Colleage of Medicine, Al-Mustansiriya University, Baghdad; Al-Yarmouk Teaching Hospital, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mj.mj_44_20

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  Abstract 


Midgut volvulus is a rare cause of acute intestinal obstruction in elderly patients. It can be classified into primary (without obvious cause) or secondary (secondary to other abnormality). Jejunal diverticula are an uncommon type of diverticulum of the small bowel. However, associated with a high rate of complications such as diverticulitis, perforation, or rarely volvulus. In this case report, we present a female elderly patient with a proximal small bowel volvulus around the axis of superior mesenteric vessels with the giant jejunal diverticulum at the tip of the volvulus.

Keywords: Giant jejunal diverticulum, intestinal malrotation, mid-gut volvulus


How to cite this article:
Jasim HA. Midgut volvulus with giant jejunal diverticulum in an elderly patient: Case report with literature review. Mustansiriya Med J 2021;20:82-4

How to cite this URL:
Jasim HA. Midgut volvulus with giant jejunal diverticulum in an elderly patient: Case report with literature review. Mustansiriya Med J [serial online] 2021 [cited 2022 Jan 22];20:82-4. Available from: https://www.mmjonweb.org/text.asp?2021/20/2/82/332562




  Introduction Top


Intestinal malrotation (IMR) is a congenital anomaly due to complete or partial failure of rotation and fixation of the bowel during embryonic life. Incidence varies from 1/200–1/500[1] live birth, but is only symptomatic in 1/6000 patient.[2] Conventionally, 75% of patients present in the 1st year of life. However, recent studies show a higher presentation incidence in adults between 42% and 48%.[3],[4] IMR can present as acute (acute mid-gut volvulus [AMV], acute duodenal obstruction) or chronic (chronic midgut volvulus [CMV], chronic duodenal obstruction, and malabsorption syndrome) or even as an internal hernia. CMV tends to occur in older patients as recurrent abdominal pain and malabsorption syndrome, which may progress to AMV.[5]

Jejunal diverticulum (JD) refers to mucosal herniation through the weak point in the jejunal bowel wall forming saclike swelling, they are usually multiple and are less common than duodenal diverticula with a reported incidence of 0.3%–1.3% in autopsy reports.[6] Patients are usually asymptomatic and commonly observed at ages 60–70 years. JD may complicate with diverticulitis, intestinal obstruction, malabsorption, or hemorrhage.[7] Although JD is less common than duodenal diverticula the rate of complications tends to be high (46% vs. 10%).[6]


  Case Report Top


A 92-year-old female was presented with 2 weeks' history of epigastric dull pain, radiated to back, associated with attacks of repeated vomiting. The patient complains of chronic abdominal pain in the last year, which was neglected by her family (patient blind and deaf). There is no relevant past medical or postsurgical history. On physical examination, here vital signs were as follows: pulse 95 bpm, blood pressure: 95/60 mmHg, and respiratory rate: 20/min. The temperature was 37.4°C. The patient looks dehydrated tired and cachexic. Abdominal examination showed mildly distended abdomen and mild generalized tenderness to palpation especially in the epigastric region with voluntary guarding. Bowel sounds were absent. Rectal examination was unremarkable.

The patient's laboratory tests demonstrated a hemoglobin level of 10.9 g/dL, leukocyte count of 16,000/mm3 with prominent neutrophilia, urea level of 109 mg/dL, serum creatinine 1.7 mmol/dl, serum Na+ 134 mmol/dl, and serum K+ 2.8 mmol/L. All other basic biochemical parameters were within the normal limits. Abdominal X-rays at presentation showed distended small bowel and multiple air-fluid levels suggestive of intestinal obstruction. Abdominal ultrasound shows dilated bowel loops. The patient was managed with nasogastric decompression, intravenous fluid, and electrolyte replacement. Abdominal computed tomography revealed the (whirlpool sign). Correction of fluid and electrolyte abnormality started at admission nasogastric tube was inserted which drain more than 1000 cc bile stained fluid in the first a few hours. After 48 h from admission, decision was done to explore the abdomen in the operative theatre, where midline laparotomy incision was done midgut volvulus was found with clockwise twisting of proximal small bowel around the axis of superior mesenteric vessels (SMV) about 4 times with giant 7 cm in diameter JD in the tip of volvulus with other multiple small jejunal diverticula [Figure 1], the giant diverticulum looks ugly with multiple thin necrotic areas in the surface indicating previous attacks of inflammation (diverticulitis) [Figure 2], the volvulus cause obstruction and distension of proximal stomach and duodenum, also, the mesentery of small bowel was narrow at the base with long redundant mesentery with malrotation of the small bowel. Detwist of volvulus was done, 15 cm segment contains the giant diverticulum was resected with end to end anastomosis and widening of the base of the mesentery, pelvic tube drain was inserted. The patient admitted to the intensive care unit after surgery and she develops massive acute myocardial infraction at 3rd postoperative day and died on the 4th postoperative day.
Figure 1: Intraoperative photograph with mid-gut volvulus with multiple diverticulum of jejunum

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Figure 2: Intraoperative photograph with mid-gut volvulus with giant diverticulum at the tip of volvulus (the diverticulum shows thin necrotic area)

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  Discussion Top


Midgut volvulus is a rare complication of IMR in adulthood. However, it should be kept in mind in the differential diagnosis of acute abdomen in adults. While JD is symptomatic in only 42% of patients with bloating, early satiety, and chronic abdominal pain.[8] However, perforation is seen in 5% of JD.[7] In our patient, we think the presence of giant large diverticulum combined with unfixity and easy mobility of small bowel (due to narrow mesenteric base) lead to twisting of the small bowel that contains the giant diverticulum around the axis of SMV (we think the heavyweight giant diverticulum act as a leading point to start bowel rotation), other studies support this probability, wherein Huang et al. showed in his study 6 out of 19 patients with adult small bowel volvulus had jejunal diverticula,[9] Moreover Chiu et al., in his retrospective study showed that eight of nine patients of primary small bowel volvulus had small bowel diverticula and 4 of them sized more than 4 cm,[10] this may suggest an association between the presence of JD and adult small bowel volvulus.


  Conclusion Top


Adult small bowel rotation is a rare condition, it should consider as one of the causes of acute abdomen in adult patients, and the presence of giant JD may act as a triggering agent to start twisting in the small bowl, especially in the patient with IMR.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was supported by College of Medicine, Al-Mustansiriya University, Baghdad, Iraq.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bensard DD. Intestinal Malrotation; 2018. Available from: http\\wwww.emedicine.medscape.com. [Last accessed 2018 Dec 19]  Back to cited text no. 1
    
2.
Berseth CL. Disorders of the Intestines and Pancreas. Taeusch WH, Ballard RA, editors. Avery's Diseases of the Newborn. 7th ed. Philadelphia: WB Saunders; 1998. p. 918.  Back to cited text no. 2
    
3.
Nehra D, Goldstein AM. Intestinal malrotation: Varied clinical presentation from infancy through adulthood. Surgery 2011;149:386-93.  Back to cited text no. 3
    
4.
Durkin ET, Lund DP, Shaaban AF, Schurr MJ, Weber SM. Age-related difference in diagnosis and morbidity of intestinal malrotation. J Am Coll Surg 2008 206:658-63.  Back to cited text no. 4
    
5.
Wanjari AK, Deshmukh AJ, Tayde PS, Lonkar Y. Midgut malrotation with chronic abdominal pain. N Am J Med Sci 2012;4:196-8.  Back to cited text no. 5
    
6.
Akhrass R, Yaffe MB, Fischer C, Ponsky J, Shuck JM. Small-bowel diverticulosis: Perceptions and reality. J Am Coll Surg 1997;184:383-8.  Back to cited text no. 6
    
7.
Tsiotos GG, Farnell MB, Ilstrup DM. Nonmeckelian jejunal or ileal diverticulosis: An analysis of 112 cases. Surgery 1994;116:726-31.  Back to cited text no. 7
    
8.
Palder SB, Frey CB. Jejunal diverticulosis. Arch Surg 1988;123:889-94.  Back to cited text no. 8
    
9.
Huang JC, Shin JS, Huang YT, Chao CJ, Ho SC, Wu MJ, et al. Small bowel volvulus among adults. J Gastroenterol Hepatol 2005;20:1906-12.  Back to cited text no. 9
    
10.
Chiu KW, Changchien CS, Chuah SK. Small-bowel diverticulum: Is it a risk for small-bowel volvulus? J Clin Gastroenterol 1994;19:176-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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