We retrospectively reviewed 34 cases of complicated JID identified in our tertiary referral hospital between 2010 and 2016 by means of multidetector computed tomography (MDCT), including 18 women (53%) and 16 men (47%), aged between 53 - 87 years  (mean age of 77 years).   

All patients underwent abdominal and pelvic CT examinations because of acute abdominal pain and other symptoms associated.  CT images were routinely obtained with the patient in a supine position during full inspiration. Axial images were obtained at 2mm slice collimations and reconstructed with a soft-tissue algorithm, with coronal and sagittal reformatting of the images.

Clinical presentation: 

Clinical symptoms and signs were unspecific, the most common manifestation was abdominal pain that occurs in all patients (100%), followed by nausea and vomiting (53%). Other associated symptoms were: constipation (29%), fever (26%), acute diarrhea (21%), abdominal distension (18%) and lower gastrointestinal bleeding (12%).

Fig. 1: Clinical symtoms (%).

At physical examination, most patients had abdominal pain (95%) and abdominal defense (80%) and two patients presented with swelling, erythema, tenderness and focal cutaneous induration, suggestive of abscess.  

These results confirms that the signs and symptoms of acute complications of JID are nonspecific and the diagnosis will not be evident until discovered by a imaging study or surgical exploration.

Imaging findings: 

In all cases of complicated JID, CT delineated the location and extent of disease, and in the case of patients treated with surgery, the diagnosis was suggested preoperatively based on the CT findings.

The main CT findings that allowed a diagnosis of complications were: segmental small-bowel wall thickening (100%), adjacent fat stranding (100%), diverticulum with inflammatory changes (88%), presence of neighbors diverticula (76%), extraluminal air (26%), intra-abdominal free fluid (35%), collections (12%), diverticular bleeding (12%) and hemoperitoneum (3%).

Fig. 2: The main CT findings (%).

CT scans revealed correctly tomographic findings of JID and its complications.  Jejunal in 30 patients (88%) and ileal in 4 patients (12%), This is not surprising since, as described in the literature, jejunal diverticula are more frequent than ileal diverticula. Concomitant diverticula in other locations were also identified: in the colon (85%), duodenum (65%), stomach (9%) and in the urinary bladder (6%).

Complications: 

The most frequent complication of JID was simple diverticulitis that occurred in 18 patients (53%), while complicated diverticulitis was found in 16 patients (47%), of which nine suffered perforation, four had diverticular bleeding, four formed collections, two had enterocutaneous fistula, and one had hemoperitoneum. These findings are consistent with the literature regarding the most frequent acute complication of the JID is diverticulitis with or without perforation.

Fig. 3: Complications.

1.  Simple diverticulitis (Fig. 4, Fig. 5, Fig. 6, Fig. 7, Fig. 8, Fig. 9):   

Simple diverticulitis was the main manifestation of the JID.  These patients received only medical treatment, some patients were hospitalized and treated with intravenous antibiotics for some days and others patients were discharged and treated with outpatient oral antibiotic, according to medical criteria.   

These patients evolved satisfactorily with resolution of their symptoms, except one patient treated with outpatient oral antibiotic who returned eight days later to the emergency room with persistent symptoms, a second CT scan with intravenous contrast was performed showing an increase of inflammatory signs, as well as an increase of free intraperitoneal fluid (Fig. 7). Because these findings and to a significant increase in leukocytosis and C-reactive protein (CRP), a surgical intervention was performed with resection of the affected intestinal segment and primary end to end anastomosis.

2. Complicated diverticulitis:  

• Perforation: (Fig. 10, Fig. 11, Fig. 12, Fig. 13).

Perforation was the main complication observed in patients with complicated jejunoileal diverticulitis.  It was identified by the presence of inflammatory changes in relation to diverticulitis, associated with the presence of extraluminal air within the leaves of the mesentery or intraperitoneal free air. These patients were mostly treated by surgery. Only one patient was treated with conservative management due to high surgical risk. All patients had good clinical and radiological outcomes. Only one patient died 6 days after surgery due to medical complications unrelated to surgery (acute decompensated heart failure).  

• Diverticular bleeding: (Fig. 14, Fig. 15).

Four patients presented to the emergency room with abdominal pain and lower gastrointestinal bleeding,  An abdominal angio-CT scan was performed in each case demonstrating contrast extravasation from a jejunal diverticulum, corresponding to active bleeding.  These patients were treated with embolization or surgery according to medical criteria, with resolution of bleeding and a favorable outcome.

• Collections:  (Fig. 16, Fig. 17).  

Four patients presented focal fluid collections adjacent to the diverticular inflammatory process. These patients were hospitalized and treated with intravenous antibiotics, with resolution of symptoms and good clinical outcome. 

•  Enterocutaneous fistula:  (Fig. 18, Fig. 19, Fig. 20).

Although fistulas between the small bowel, colon and bladder have been described as a complication of diverticulitis, we didn’t find any patient with these fistulas, nevertheless we found two patients with enterocutaneous fistula secondary to jejunal and ileal diverticulitis. These patients were treated with systemic antibiotic therapy and drainage of abscess, with clinical improvement.

• Hemoperitoneum: (Fig. 21).

One patient presented to the emergency department with a 4-day history of progressive abdominal pain, diarrhea, nausea, and vomiting. During the first hours after admission presented pallor and hypotension, a CT scan was performed showing signs of jejunal diverticulitis with high-density peritoneal fluid consistent with hemoperitoneum. No active bleeding point was seen. The patient rapidly developed hypovolemic shock and died despite resuscitation attempts.  

• Intestinal obstruction: 

We didn’t find any patient with intestinal occlusion compared with the frequency described in previous reviews. 

Prognosis 

The vast majority of patients (94%) with complicated JID showed good clinical evolution.  Only two patients had an unfavorable evolution. Therefore an early diagnosis of complicated JID is important in order to achieve a proper and early treatment.