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Terminal ileal diverticulitis

Case contributed by Dennis Odhiambo Agolah
Diagnosis almost certain

Presentation

One month of acute abdominal pain with one day of multiple episodes of vomiting and shivers. Pain more localized at the right iliac fossa.

Patient Data

Age: 35 Years
Gender: Male
ultrasound

There are multiple (at least two) small bowel out-pouchings at the terminal ileum at the right iliac fossa, the largest of which is medial in location and measuring 9.6 x 4.2 mm in size. The out-pouchings (diverticula) show mild edematous wall changes and relatively augmented vascular signals on color Doppler evaluation with echogenic reactive omental fat surrounding their peripheral margins in keeping with an inflammatory process (diverticulitis).

Gut signature is maintained within the diverticula with no obvious perforation. The terminal ileum exhibits diffuse mucosal layers thickening consistent with terminal ileitis, but with maintained Kerckring folds (piano keyboard appearance). The appendix (well visualized extrinsically over the ipsilateral right iliopsoas muscle belly) shows no inflammatory changes or appendicolith and measures 4.2 mm in diameter.

Case Discussion

The locality and multiplicity of the outpouchings (diverticula) in the right iliac fossa's around the terminal ileum is compatible with ileal diverticulitis as the cause of the excruciating right lower abdominal quadrant pain / acute abdomen in this patient. The narrow-necked bowel bulges appear superiorly located and lie roughly 1 cm beneath the right rectus sheath musculature. The appendix, which could have resulted in the right lower quadrant pain, looked normal.

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