A Giant Lipoma Incidentally Found in Massive Jejunal Diverticular Bleeding / 대한소화기내시경학회지

Jejunal diverticulosis is a rare malady and it is often asymptomatic. It may lead to chronic non-specific or acute symptoms such as malabsorption, intussusception, obstruction, bleeding, perforation and abscess formation. It usually is seen as an incidental finding on computerized tomography, enteroclysis or during an emergency operation. Since the advent of double balloon enteroscopy and capsule endoscopy, several cases of small bowel diverticulosis with complications have recently been reported. Lipomas are the rare benign tumors of the small intestine with no malignant potential and they are mostly incidentally encountered during investigation of the gastrointestinal tract. We report here on a case of massive small bowel bleeding with jejunal diverticulosis, and a pedunculated elongated lipoma was incidentally found.

Massive Bleeding from Multiple Jejunal Diverticulosis

Jejunoileal diverticulosis is formed by herniation of mucosa and submucosa through the muscular layer of the bowel wall. The condition usually consists of multiple diverticula at the mesenteric border, in contrast to the true congenital Meckel's diverticulum. Small bowel diverticulum is a rare disease that can give rise to unexpected problems such as malabsorption, perforation, diverticulitis, obstruction and bleeding. Since the reported complication rate is low, uncomplicated small bowel diverticula are generally recommended to be left untreated. Bleeding from a diverticulum is often sudden and massive. We report herein a case of a 43-yearold women who presented with massive bleeding from multiple jejunal diverticula. She had been admitted to hospital one day previously with the chief complaint of severe whole abdominal pain which was aggravated progressively. On physical examination, she showed an acute, ill appearance. The abdomen was slightly distended and tender with rebound tenderness. On the abdomen CT, the jejunal wall was thickened and the mesenteric lymph nodes were enlarged. An emergency laparotomy was performed. Multiple jejunal diverticula, distributed from 20 to 100 cm distal to the ligament of Treitz, were found, along with massive bleeding from diverticulosis. A segment of the jejunum containing all diverticula was resected and end to end anastomosis was performed. Due to the relative rarity of these lesions and their complications, diagnosis is often difficult and delayed. Awareness of their tendency to cause nonspecific abdominal symptoms and serious complications may lead to earlier diagnosis and timely treatment.

Massive Bleeding from Jejunal Diverticulosis with an Angiodysplasia in a Patient with End Stage Renal Disease

Small bowel diverticulum, although not common and usually asymptomatic, can give rise to unexpected problems such as malabsorption, perforation, obstruction and bleeding. Bleeding from a diverticulum is often sudden and massive, therefore requiring emergency operation. We report herein a case of a 75-year-old man who presented with massive bleeding from multiple jejunal diverticula. He had been diagnosed with hypertensive end stage renal disease and treated with hemodialysis since 14 years previously. He was admitted with both hematemesis and hematochezia, and treated conservatively at first. However, bleeding continued and the anemia did not improve despite blood transfusions. An gastroduodenofiberscope and selected angiography revealed no bleeding focus. An emergency laparotomy was performed and multiple jejunal diverticula, distributed from 15 to 60cm distal to the ligament of Treitz, were found. A segment of the jejunum containing all diverticula was resected and end to end anastomosis was performed. A histologic examination revealed some dilated blood vessels in the submucosa of the diverticulum, which was compatible with the findings of the angiodysplasia. Based on these findings, we suggest that angiodysplasia was the cause of bleeding from the jejunal diverticula in this case.