Authors: Jesús Alfonso Gaviño-Del Pozo, Eder Jonathan Amaro-Palomo, Sergio Solana-Sentíes
Categories: Case Report, acute abdomen, case report, jejunal diverticulitis, jejunal perforation, renal colic mimicry
Source: International Journal of Surgery Case Reports
Authors: Jesús Alfonso Gaviño-Del Pozo, Eder Jonathan Amaro-Palomo, Sergio Solana-Sentíes
Jejunal diverticulosis is an uncommon condition, usually asymptomatic that could lead to severe complications such as perforation, associated with high mortality, and its presentation can mimic other acute abdominal or even urologic disorders, often requiring urgent surgery for both diagnosis and treatment.
A 68-year-old woman with no significant medical history presented with sudden-onset severe colicky pain in the left lumbar and iliac regions, initially resembling renal colic. Laboratory tests revealed leukocytosis and elevated CRP. A non-contrast abdominal CT ruled out nephrolithiasis but demonstrated ileal wall thickening, peridiverticular gas, and inflammatory changes. Emergency laparotomy revealed 200 mL of purulent free fluid, a jejunal loop adherent to the left flank and a 0.5-cm perforation in the jejunum, 20 cm distal to the ligament of Treitz. Segmental resection with primary anastomosis was performed. Histopathology confirmed multiple jejunal diverticula with one perforated. The patient had an uneventful recovery and was discharged on postoperative day six.
The clinical manifestations of jejunal diverticulitis are often nonspecific and may mimic appendicitis, cholecystitis, colonic diverticulitis, or urologic disease, as in this case. Although CT is the diagnostic modality of choice, its sensitivity is limited, and definitive diagnosis often requires surgical exploration. Segmental resection with primary anastomosis remains the treatment of choice in perforated cases.
Although rare, perforated jejunal diverticulitis is a life-threatening entity. Clinicians should maintain a high index of suspicion in patients with atypical presentations of acute abdomen. Early surgical intervention is essential to improve outcomes.
Jejunal diverticulosis (JD) is a rare entity, with an incidence ranging from 0.06 to 5% in large autopsy series^[^1,2^]^. These are false diverticula, composed of mucosa and submucosa herniating through the muscularis layer, usually at weak points adjacent to the vasa recta^[^3–5^]^. The exact etiology remains unclear, though abnormal motility and increased intraluminal pressure have been implicated^[^1,6^]^.HIGHLIGHTSJejunal diverticulosis is a rare condition (<1% incidence) that is usually asymptomatic but may lead to life-threatening perforation.Clinical presentation in this case mimicked renal colic, delaying the suspicion of gastrointestinal disease.CT scan showed nonspecific findings (ileal thickening, peridiverticular gas), missing the jejunal perforation.Definitive diagnosis was only achieved through emergency laparotomy, which revealed a perforated jejunal diverticulum.Surgical resection with primary anastomosis led to an uneventful recovery and discharge on postoperative day six.
Diverticular disease most commonly affects the sigmoid colon in up to 95% of patients, whereas small-bowel diverticulosis is far less frequent. Among small-bowel segments, the duodenum accounts for approximately 79% of cases, while only 18% arise in the jejunum or ileum^[^7^]^. The rarity of jejunal involvement, combined with its often asymptomatic or nonspecific clinical presentation, contributes to the low rate of diagnosis and explains why severe complications such as perforation remain exceptionally uncommon^[^6^]^.
JD complications such as diverticulitis, hemorrhage, obstruction, and perforation may occur. Perforation is particularly rare but carries significant mortality, up to 40% when complicated by peritonitis^[^3^]^. Clinical manifestations of jejunal diverticular disease are often vague and nonspecific, and the condition may mimic other causes of acute abdomen. However, according to the literature, no previous reports have described a presentation mimicking renal colic, which underscores the unusual nature of this case^[^4,5^]^.
This case highlights the challenge of diagnosing jejunal perforation when imaging findings are nonspecific and underscores the importance of considering this rare but life-threatening condition in a patient with an exceptionally rare presentation in which perforated jejunal diverticulitis clinically mimicked renal colic. Such atypical manifestations can result in delayed recognition and increased morbidity. This case report outlines the clinical presentation, diagnostic workup, and surgical intervention and has been reported in line with the SCARE 2025 criteria^[^8^]^.
A 68-year-old woman with class I obesity (BMI: 31.4) and no history of chronic disease, prior surgery, or substance use was brought to the emergency department by family shortly after symptom onset, presenting with sudden severe colicky pain in the left lumbar and iliac regions radiating toward the pelvis. The pain began abruptly during urination and caused marked functional limitation. One week earlier, she had received empiric oral antibiotics for presumed urinary tract infection based on a general urinalysis. She had remained asymptomatic until this acute episode, which started 2 hours before presentation.
On admission, she was alert, visibly distressed, and diaphoretic, with mild tachycardia but normal blood pressure and temperature. Physical examination revealed rebound tenderness and involuntary guarding in the left lower quadrant, diminished bowel sounds, and a painful expression. Left-sided costovertebral angle tenderness (positive Giordano sign) and pain at the left ureteral points were also noted.
Laboratory results showed hemoglobin 11.8 g/dL, platelets 414 000/µL, leukocytosis 12.5 × 10^9^/L, and a mildly elevated C-reactive protein (8 mg/L). Renal function was preserved (creatinine 0.7 mg/dL). Other laboratory tests, including electrolytes, liver function, and coagulation studies, were within normal limits.
A non-contrast abdominal CT scan excluded nephrolithiasis but revealed bilateral perirenal inflammatory changes predominantly on the left, associated with adjacent small-bowel inflammatory changes, including thickened ileal walls with diverticula and localized extraluminal gas adjacent with surrounding fat stranding, and colonic diverticulosis (Fig. 1). No pneumoperitoneum or free intraperitoneal fluid was initially reported. Figure 1.Abdominal computed tomography (non-contrast).Non-contrast imaging was performed as part of the initial evaluation for suspected nephrolithiasis. (A) Coronal view demonstrating inflammatory fat stranding involving the mesentery and adjacent small-bowel loops, predominantly in the left hemiabdomen, associated with segmental small-bowel wall thickening (red circle). (B) Axial view showing focal extraluminal gas adjacent to the small bowel with surrounding fat stranding (white arrow), suggestive of localized perforation.
Given the signs of peritonitis, an emergency laparotomy was performed under general anesthesia. The patient was placed in the supine position, and a midline incision was made. Approximately 200 mL of purulent fluid was found and aspirated. A jejunal loop adherent to the left flank was identified; after adhesiolysis, a 0.5-cm perforation was located 20 cm distal to the ligament of Treitz (Fig. 2). The perforation site and intraoperative manipulation of the affected jejunal loop are demonstrated in Supplemental Digital Content Video 1, available http://links.lww.com/IJSCR/A20. Figure 2.Intraoperative findings.Intraoperative view of the jejunum demonstrating a perforated diverticulum, with the perforation site indicated by the surgeon’s finger. The affected bowel segment shows focal wall disruption with surrounding inflammatory changes and localized contamination, associated with inflamed and edematous adjacent mesentery. These findings were consistent with localized perforated jejunal diverticulitis and prompted segmental resection with primary anastomosis.
A 60-cm segmental resection with primary end-to-end anastomosis was performed. Intraoperative cultures were not obtained, as the purulent fluid encountered was consistent with acute localized peritonitis secondary to bowel perforation, without a well-defined or encapsulated abscess cavity suitable for sampling. Given that definitive source control was achieved through complete resection of the affected segment and thorough peritoneal lavage, routine intraoperative cultures were not considered necessary. A closed passive drain was placed adjacent to the anastomosis due to the degree of local contamination and inflammation, primarily to prevent postoperative fluid accumulation and to allow early detection of anastomotic leakage.
Histopathology revealed six intramesenteric diverticula (0.5–2 cm), one of which was perforated, without evidence of ischemia or neoplasia, confirming the diagnosis of perforated jejunal diverticulitis
A drain was left in situ and removed on postoperative day 5. The patient received intravenous antibiotics postoperatively and recovered uneventfully. She was discharged on the sixth postoperative day without any complications, in good condition, tolerating oral diet. No postoperative complications or adverse events occurred (Clavien–Dindo Grade 0). At one-month follow-up, the patient remained asymptomatic, and the surgical wound was well healed.
Most patients with JD remain asymptomatic, but 10%–19% may develop complications such as diverticulitis, bleeding, obstruction, or perforation^[^1,4,5,7^]^. Perforation is the most feared complication, and its presentation is highly variable. Reported cases often mimic appendicitis, cholecystitis, peptic ulcer perforation, or colonic diverticulitis^[^1–3^]^. Pain is the predominant symptom in complicated JD, but its characteristics vary according to the location of the affected loop^[^2,6^]^. This nonspecificity frequently delays diagnosis and increases morbidity.
The differential diagnosis of acute abdominal pain involving the small bowel includes rare entities such as intussusception, small bowel obstruction, Crohn’s disease flare, Meckel’s diverticulitis, or ischemic enteritis^[^2,4,7,9^]^. For example, recurrent intussusception caused by giant ileal gastric heterotopia, as described by Eghbali et al^[^9^]^, may mimic localized peritonitis and radiologic bowel wall thickening. However, unlike jejunal diverticular perforation, these conditions often present with intermittent episodes, characteristic imaging patterns, or a history of chronic gastrointestinal symptoms.
The clinical presentation of jejunal diverticular perforation is highly variable, and in previously reported cases it has most commonly manifested as epigastric or generalized abdominal pain, gastrointestinal bleeding, and diffuse abdominal tenderness. However, a flank-dominant pain pattern mimicking renal colic has not been previously reported, making this case particularly valuable in expanding the differential diagnosis of acute flank pain^[^4,5^]^ In our case, the patient presented with acute-onset left flank and lumbar pain closely mimicking this clinical presentation. This unusual manifestation can be explained by the inflamed jejunal loop adherent to the flank, thereby producing symptoms typically attributed to urinary tract pathology, further biased by her recent history of urinary tract infection 1 week earlier. Notably, up to one-third of CT scans ordered for suspected nephrolithiasis reveal alternative non-urologic diagnoses, including gastrointestinal disease^[^10^]^. This underscores the diagnostic complexity of jejunal diverticulitis and the need to maintain a broad differential diagnosis when evaluating atypical flank pain.
From a radiologic perspective, although the CT scan described segmental ileal wall thickening, it also demonstrated surrounding inflammatory fat stranding extending along the adjacent small bowel and into the left flank. The diagnosis may be difficult to establish in severe cases with marked local infiltration by fluid and gas, which can obscure the inflamed diverticulum itself. In such situations, the predominance of peritoneal changes along the mesenteric border of the small bowel, together with the identification of additional jejunoileal diverticula, may suggest the diagnosis^[^11^]^. Intraoperative exploration subsequently confirmed a perforated jejunal diverticulum. This apparent discrepancy is likely explained by the close anatomical proximity and overlap of small-bowel loops, together with extensive secondary inflammatory changes involving adjacent mesenteric and retroperitoneal fat.
Nevertheless, CT imaging is considered the gold standard for the diagnosis of jejunal diverticulitis, as it may reveal bowel wall thickening, peridiverticular edema, and extraluminal gas^[^1,4,11^]^. However, its sensitivity remains limited, with series reporting diagnostic accuracy as low as 20%–46%^[^2,5^]^. Diverticula may be obscured by surrounding inflammation, as occurred in our case, where CT suggested ileal diverticulitis but missed the jejunal perforation (Fig. 3). Thus, exploratory laparotomy remains essential for both diagnosis and treatment in unstable or unclear presentations^[^2,6,12^]^. Figure 3.Abdominal computed tomography (non-contrast). (A) Coronal view showing localized free fluid and inflammatory changes surrounding clustered small-bowel loops in the left abdomen (white arrow). (B) Sagittal view demonstrating segmental thickening and edema of the small-bowel wall with adjacent inflammatory fat stranding (white arrow). Although the absence of intravenous contrast limited vascular and mucosal assessment, these findings retrospectively support localized small-bowel inflammation and perforation.
The coexistence of colonic and jejunal diverticulosis in our patient supports the hypothesis of a shared pathophysiology, possibly related to motility disorders^[^1,6,7^]^. The relatively lower rate of jejunal compared to colonic diverticulitis may be explained by larger diverticular size, better luminal flow, and relatively sterile jejunal contents^[^12^]^.
Management of jejunal diverticulitis remains controversial, as no universal consensus exists. Nevertheless, surgery is widely regarded as the treatment of choice in cases of perforation, generalized peritonitis, or significant bleeding, with segmental resection and primary anastomosis being the most accepted approach^[^3,4,6^]^. Conservative strategies, including antibiotics and CT-guided drainage, have been described for selected cases with localized or contained perforations, but data are limited and recurrence rates remain uncertain^[^5,7,12^]^. Therefore, in practice, surgical exploration continues to be the definitive diagnostic and therapeutic step in most patients, particularly in acute or unstable presentations^[^2^]^.
In our case, intraoperative findings confirmed the jejunal diverticular perforation, and management with resection and primary anastomosis was performed successfully. This highlights a rare presentation of jejunal diverticular perforation in the absence of typical risk factors, underscoring the importance of maintaining a high index of suspicion in patients with acute abdomen and nonspecific imaging findings. It also emphasizes the value of prompt surgical intervention and effective collaboration between emergency, radiology, and surgical teams to achieve a favorable outcome. The main limitation was the lack of specific preoperative imaging findings, which delayed early diagnosis, and the limited histopathological and microbiological evaluation, restricting deeper understanding of the underlying mechanism. Nonetheless, timely surgical management and adequate postoperative care led to a complete and uneventful recovery.
To contextualize the present case and identify recently published reports of perforated jejunal diverticulitis, a focused literature search was conducted using PubMed, Google Scholar, and Scopus. We searched for articles published between January 2014 and December 2024 using the terms “jejunal diverticulitis,” “jejunal diverticular perforation,” “perforated jejunal diverticulum,” and “small bowel diverticulitis” in titles or abstracts.
We included individual case reports published in English in which perforated jejunal diverticulitis was confirmed intraoperatively or by histopathology. We excluded non-perforated diverticulitis, Meckel’s diverticulum, reviews, case series, conference abstracts without full clinical data, cases managed conservatively without surgical confirmation, reports with insufficient patient-level information, and non-English publications.
Based on these criteria, 14 comparable cases were identified and are summarized in Table 1. These reports describe adult patients aged 45–85 years, with marked heterogeneity in clinical presentation, ranging from localized abdominal pain to diffuse peritonitis, and highlight that CT findings are often subtle, misleading, or mislocalized. Surgical resection with primary anastomosis remains the most frequently reported management strategy, with favorable outcomes when early intervention is achieved^[^13–25^]^. Table 1Summary of published cases of perforated jejunal diverticulitis over the last decade.Author (year)Age/sexPresentation (main features)Imaging findings (CT)Treatment/managementSehgal (2016)^[^13^]^82/MTwo-day history of worsening lower abdominal pain associated with nausea and low grade pyrexiaIntra-abdominal free air and intrapelvic free fluid and inflammatory change in the left paramedian mesenterySmall bowel resection with a primary side-to-side anastomosis and washout of the abdomenGurala et al. (2019)^[^14^]^76/FAbdominal pain and confusion 2 days prior to presentation, epigastric tenderness, guardingThickened and edematous mid-jejunum and intraperitoneal free air, mesenteric inflammationSegmental resection + primary anastomosisLeigh et al. (2020)^[^15^]^59/FTwo-day history of diffuse abdominal pain, nausea without vomitus and feverExtensive edema of the entire jejunal loop and hazy infiltration of the adjacent mesenterySegmental resection + primary anastomosisDuggan et al. (2021)^[^16^]^78/MSudden onset, generalized lower abdominal painLarge inflammatory mass/abscess cavity containing gas and fecal like content, located centrally in the upper abdomenSegmental resection + primary anastomosisBen Ismail et al. (2021)^[^17^]^52/MTwo days of mild to moderately intense abdominal pain and vomiting initially with medical treatment. Three days later, a sudden worsening of pain, signs of peritonitisJejunal diverticulum with surrounding inflammatory changes in the mesenteric fatSegmental resection + primary anastomosisBenjamin et al. (2022)^[^18^]^76/MAbdominal distension associated with abdominal pain, and no signs of peritonitis, fever and tachycardiaMesenteric edema in the mesogastrium area, increased number of local lymph nodes, jejunal wall thickening, and an extraluminal focus of gasSegmental jejunum resection with primary intracorporeal latero-lateral enteroanastomosisVerma et al. (2023)^[^3^]^75/FGeneralized abdominal pain, sudden in onset and gradually progressive associated with multiple episodes of bilious vomiting and constipation, peritonitisRadiological evaluation, X-ray of abdomen suggestive of pneumoperitoneum, CT scan was not performedResection of 10 cm of jejunal segment and end-to-end anastomosis in two layers was doneJawed et al. (2023)^[^19^]^75/MA 4-day history of constipation, nausea, vomiting, and lower abdominal painX-rays showing dilated bowel loops, free air, air in the portal vein and Rigler’s sign (sign of pneumoperitoneum), CT scan was not performedResection of the affected jejunum and ileum with creation of a double-barrel ileostomy due to significant ileal edemaTapias et al. (2024)^[^20^]^84/FLeft lower quadrant abdominal pain for 2 days, accompanied by nausea and decreased appetiteA thickened loop of small bowel with inflammatory changes and a focus of air in the adjacent mesenterySegmental resection + primary anastomosisMaqbool et al. (2024)^[^21^]^45/MFever, vomiting, guarding, and rebound tenderness in the right iliac fossaA supine abdominal X-ray showed gas-filled bowel loops. An erect chest X-ray revealed no free air under the diaphragm, CT scan was not performedExploratory laparotomy for suspected perforated appendicitis, resection of jejunal segment and anastomosisMondragón et al. (2024)^[^22^]^61/FAbdominal pain, fever, multiple episodes of melena, septic shock of abdominal origin, signs of peritoneal irritationSac-like images suggestive of small bowel diverticula with abundant free fluid and intra-abdominal gasSegmental resection + primary anastomosisDourado et al. (2024)^[^23^]^79/F2-day history of left lower quadrant pain and nausea, no signs of peritonitisDiverticulitis of the transverse and descending colon, gas and fluid along the left colonic mesentery concerning for early abscess formationSegmental resection + primary anastomosisPark et al. (2024)^[^24^]^80/MGradual onset of left-sided abdominal painMesenteric inflammation and intraperitoneal free airSide-to-side jejunojejunostomy with closure of the mesenteric defectIslam et al. (2024)^[^25^]^85/MOne-week history of central abdominal pain, constipation, generalized tenderness with guardingMultiple locules of free air within the small bowel mesentery in the left upper quadrant, with mesenteric fat strandingResection of the affected segment + anastomosis
Our case adds to this body of literature by illustrating an atypical flank-dominant presentation that initially mimicked renal colic, a clinical scenario that may contribute to dangerous delays in diagnosis. Recognizing such unusual manifestations is essential to improving early detection and reducing complication-related mortality.
Perforated jejunal diverticulitis is a rare but potentially life-threatening condition that demands early recognition and prompt management. Its nonspecific clinical presentation and the limited sensitivity of imaging often lead to delayed or misleading diagnoses, as initial CT findings may not reveal the true extent of disease. Greater awareness of this condition and multicenter studies are essential to optimize diagnostic and therapeutic strategies.