AB184. 144. Perforated jejunal diverticulum as an unusual cause of pneumoperitoneum

Background: Jejunal diverticulosis is rare with an incidence of 1–4%. Perforation has a high mortality and early recognition and management are essential. Pathophysiology is thought to be multi-factorial.

Methods: An 86-year-old man presented with a one-week history of intermittent central abdominal pain, acutely worse over past twelve hours and associated abdominal distension. He had a previous presentation with pneumoperitoneum of unknown cause treated conservatively two years earlier. His medical history included polymyalgia rheumatica (PMR) and ischemic heart disease. His medications included prednisolone 30 mg once daily (started for exacerbation of his PMR 10 days prior). On presentation he was hemodynamically stable with a distended abdomen and mild tenderness in the epigastrium. He had a raised white cell count of 17 and C-reactive protein of 66. Computed tomography revealed an extra-luminal collection of air immediately adjacent to a small bowel diverticulum, associated fat stranding and intestinal malrotation. He was commenced on broad-spectrum antibiotics and although stable, the decision for laparotomy was made as he was immunosuppressed with high dose steroids.

Results: At laparotomy multiple jejunal diverticula were identified; one perforated mid-jejunal diverticulum with associated local inflammatory changes was found to be the cause of pneumoperitoneum. There was minimal intra-abdominal contamination. A segmental small bowel resection and side-to-side stapled anastomosis was performed. He was discharged after an uneventful post-operative course.

Conclusions: At laparotomy multiple jejunal diverticula were identified; one perforated mid-jejunal diverticulum with associated local inflammatory changes was found to be the cause of pneumoperitoneum. There was minimal intra-abdominal contamination. A segmental small bowel resection and side-to-side stapled anastomosis was performed. He was discharged after an uneventful post-operative course.

Keywords: Congenital malrotation; perforation; small bowel diverticula; steroids