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Left abdominal pain.
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There is a single inflamed jejunal diverticulum in the left mid-abdomen, evidenced by a thickened wall and adjacent inflammation. There is a non-inflamed jejunal diverticulum as well, slightly cranially and anterior to the left kidney. No free air or fluid. No other acute findings.
It is a mind-blowing experience for the radiology resident to first learn that diverticulitis can occur outside of the colon, particularly in such an unassuming location such as the jejunum. I know I was thrilled. And when I read this case, it wasn't until I looked at the coronal reformats that the inflamed diverticulum stuck out to me. I think it is fairly subtle as it surrounded by several loops bowel on the axial images, and could be overlooked if you're not thinking about small bowel pathology. There are some great teaching points in this case to comment on:
1. Diverticulosis of the jejunum and ileum is uncommon and acquired. Jejunal diverticulitis is rare, but you likely will come across it with reasonable frequency in clinical practice. Colonic and duodenal diverticula are more common.
2. The cause of inflammation is the same as colonic diverticulitis, and thus treatment is basically the same: antibiotics and bowel rest.
3. This raises an important question to consider, and one that I imagine many radiologists are a little unsure of: what is your bowel search pattern? I personally believe there is no excuse not to run the entire colon through the TI on every case no matter what, and I start from anus->cecum. There is too much you risk overlooking if you don't do this, particularly early colorectal carcinoma.
The small bowel is a different animal, however, as it is not practical to run entirely unless you are doing an enterography or looking for melanoma mets. I personally run the distal esophagus, stomach, duodenal sweep, and a few loops of jejunum. The rest of the small bowel I just run in quadrants, and look at both axial and coronal images to increase sensitivity (which helped me in this case!). I have met many great GI radiologists who follow a similar approach to this.
- De Peuter, B., Box, I., Vanheste, R., Dymarkowski, S.. Small-bowel Diverticulosis: Imaging Findings and Review of Three Cases. (2018) Gastroenterology Research and Practice. 2009: 549853.
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