Jejunum, ileal diverticulum
Introduction
Introduction of jejunum and ileum diverticulum The jejunal diverticulum is more common than the ileum, often near the Treitz ligament, and can be single, but often multiple. If it is multiple, the number in the lower intestine is gradually reduced, the volume is also small, sometimes only a small protrusion, but it is not uncommon in the end of the ileum. basic knowledge Sickness ratio: 0.05% Susceptible people: no specific population Mode of infection: non-infectious Complications: intestinal obstruction, gastrointestinal bleeding, abdominal distension, abdominal pain
Cause
Jejunum, ileal diverticulum
Increased intra-abdominal pressure (30%):
Jejunal diverticulum is often acquired, associated with increased intra-abdominal pressure, usually accompanied by changes in intestinal movement, such as progressive systemic sclerosis, visceral disease and neuropathy, which can cause intestinal smooth muscle atrophy and fibrosis, thereby making the intestinal wall capsule Sexual expansion, from the weak muscle layer into the submucosa, visceral neuropathy caused small intestinal dysfunction, resulting in high pressure in the intestinal lumen.
Systemic muscular sclerosis (30%):
In the large blood vessels entering the weak muscle layer, the diverticulum is created, sometimes causing paralytic intestinal obstruction. Krishnamurthy (1983) performed histological studies and found that the patient was empty, the number of muscle cells in the ileum muscle layer was reduced and degeneration or fibrosis Some neurons in the myenteric plexus and degeneration are also degenerative changes, so it is suggested that this disease may be the manifestation of systemic sclerosis in the small intestine.
Pathology (30%):
The small intestine diverticulum has both true and false. The true diverticulum includes various layers of the intestinal wall, such as congenital diverticulum, and the diverticulum formed by inflammatory adhesions. The pseudo-diverticum only includes the mucosa and submucosa, which is a weak point of the mucous membrane through the muscular layer ( Such as the formation of nutrients throughout the intestinal wall, which is formed by outward protrusion. It is generally considered to be associated with abnormally elevated intestinal pressure. For example, temporary intestinal obstruction, constipation, and intestinal fistula can increase intestinal pressure. Others believe that it is due to the small intestine. The uncoordinated peristalsis promotes the onset.
The diverticulum occurs in the upper jejunum, a few in the ileum, the terminal blood vessels in the upper part of the normal jejunum are thick, and the intestinal wall of the mesenteric vascular access is weak, which is easy to become a good site for the diverticulum. The diverticulum can be single, more often. Sexuality, multiple diverticulum is concentrated in a certain jejunum, occasionally scattered in the whole small intestine, the number of multiple diverticulum varies from 2 to 40; the diameter is from several millimeters to several centimeters, and the diverticulum is along the intestinal wall of the small mesenteric side. The vascular zone is distributed in a circular or oval-shaped bag-like structure that bulges outside the intestinal wall and opens to the intestine cavity with a wide or narrow diameter base. The diverticulum wall without the muscular layer is weak, and the small diverticulum Concealed in the mesenteric of the two leaves, it is easy to be missed during surgery. The intestinal tube containing multiple diverticulum is often dilated and hypertrophied, causing the intestinal dysfunction and pseudo-intestinal obstruction. The jejunal diverticulosis is often accompanied by other digestive tract diverticula such as esophagus. , stomach, duodenum and colon, accompanied by colonic diverticulum is particularly common, it has been reported that 44% to 50% of cases in the jejunal diverticulum coexist with colonic diverticulum, so patients with jejunal diverticulum should explore the entire digestive tract to prevent omission. Diverticulum.
Prevention
Jejunum, ileal diverticulum prevention
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Jejunum and ileal diverticulum complications Complications, intestinal obstruction, gastrointestinal bleeding, abdominal distension, abdominal pain
Common complications of jejunal diverticulum are as follows:
Intestinal obstruction
As the main complication, the causes of intestinal obstruction are different. The small sputum turns into the starting point of intussusception. The large diverticulum can cause diverticulum torsion. Chronic diverticulitis can cause thickening and distortion of the intestinal wall adjacent to the small intestine. Acute intestinal obstruction, the contents of the sputum in the chamber are deposited for a long time to form intestinal stones, and the large intestinal stones slide down the intestinal cavity to block the intestinal tract. Clinically, intestinal obstruction caused by other causes is difficult to identify, and it is often diagnosed after laparotomy.
2. Gastrointestinal bleeding
Jejunal diverticulum hemorrhage is one of the important causes of gastrointestinal bleeding. Hemorrhage accounts for 5% to 29% of jejunal diverticulum complications. The way of diverticulum hemorrhage is very inconsistent. There are a large number of hematemesis or bloody stools with acute attacks, and there is a chronic interval. Sexual tar or vomiting of coffee-like substances, there may be a period of gastrointestinal symptoms before bleeding, the reasons for diverticulum bleeding are:
1 ventricle inflammation or sputum ulceration caused by rupture of ventricular wall rupture;
2 indoor bacterial overgrowth caused intestinal dysfunction, peristaltic hyperthyroidism damage indoor mucosa;
3Intestinal stone movement damage mucosa, diverticulum hemorrhage is often misdiagnosed as peptic ulcer hemorrhage, intestinal hemangioma or leiomyoma and colitis, therefore, for elderly patients over 60 years old with gastrointestinal bleeding, should consider this The possibility of the disease.
3. Chamber perforation
In the thin-walled diverticulum without muscle layer, diverticulitis or diverticulum ulcer is easy to be perforated. The foreign body in the intestine slides into the chamber and punctures the thin wall and perforates. The sudden increase in intestinal pressure during abdominal closed crush injury can also lead to Perforation of the diverticulum, which is caused by localized or diffuse peritonitis after perforation, is often confused with peptic ulcer or appendicitis perforation.
4. Pneumoperitoneum and small intestinal wall balloon swelling
In a few cases, peritonitis has not formed peritonitis and has manifested as spontaneous pneumoperitoneum. Wright (1975) reported that a 72-year-old multiple diverticulum patient had multiple spontaneous pneumoperitoneum in 4 years due to multiple intestinal diverticulum dysfunction. Unintentional and irregular strong peristalsis, resulting in small perforation of the thin-walled diverticulum, gas in the intestinal lumen can easily overflow into the abdominal cavity through the perforation, the intestinal gas overflow causes the intestinal lumen pressure to drop, and the perforated diverticulum wall collapses or closes. Prevent the contents of the small intestine or feces from flowing into the abdominal cavity. Patients may have abdominal distension, abdominal pain, abdominal discomfort and nausea and vomiting. Abdominal X-rays show free gas under the armpit. If the perforation is hidden between the two leaves of the mesentery, the overflowing intestines Confined to the intestinal wall and the mesentery is the extraluminal balloon swelling, even perforation involving only the mucosa and submucosal layer, the formation of subserosal wall air sac.
In addition to the above complications, it has been reported that diverticulosis is secondary to leiomyosarcoma, lymphosarcoma or adenocarcinoma.
Symptom
Jejunum, ileal diverticulum symptoms common symptoms dyspepsia abdominal discomfort diarrhea bowel nausea jejunum diverticulum flatulence hypoproteinemia cyst abscess
Because of its large opening, the small intestine diverticulum has good drainage and is often asymptomatic. The jejunal diverticulum is about 60% asymptomatic. It is often found in the upper digestive tract angiography. Sometimes it can be mild dyspepsia, nausea, and upper abdominal discomfort after meals. , fullness, bowel or flatulence, but this is not a specific symptom, often diagnosed in the small intestine diverticulum after complications, diverticulum complications such as diverticulitis, bleeding, perforation or obstruction; especially jejunal diverticulum, can lead to Blindness syndrome, causing malabsorption and giant cell anemia.
Diverticulitis often caused by foreign bodies or stones, may have an acute attack, but rarely diagnosed, perforation is less common, the distal ileal perforation can be misdiagnosed as perforation of the appendix, after perforation can form a localized abscess, intestinal fistula or diffuse Peritonitis, bleeding is a relatively common complication, mostly small amount of chronic bleeding, recurrent episodes of major bleeding are rare, often need emergency surgery, but often mistaken for ulcer bleeding, intraoperative exploration should pay attention to find whether there is a small intestine diverticulum, seriously determined The source of bleeding, combined with intestinal obstruction, there are paroxysmal abdominal cramps and other symptoms, intestinal obstruction can be caused by the intestine fistula of the diverticulum, caused by the nest, the diverticulum becomes the beginning of the intussusception, can also be after diverticulitis or perforation Caused by the formation of inflammatory adhesions, surgery is often required, in addition, the diverticulum also has a combination of balloon swelling, malignant transformation.
Small bowel diverticulosis can also cause blindness syndrome, but there are malabsorption, chronic diarrhea, fatty diarrhea, anemia, malnutrition, weight loss, etc. It has been reported that the incidence of malabsorption syndrome in intestinal diverticulosis is as high as 50%. When the normal person is fasting, the jejunum is sterile, and in the case of jejunal diverticulosis, a variety of bacteria can be cultured. When the normal peristalsis of the small intestine is disturbed, the food stagnates and cannot move to the distal side quickly, and the intestinal bacteria Will breed; the mobility of the contents of the diverticulum is also poor, the accumulation of food, corruption, provides good conditions for bacterial proliferation, excessive bacterial growth in the small intestine can produce chronic diarrhea, steatorrhea, malabsorption, malnutrition, anemia, etc. The steatorrhea is mainly related to bile salts. The proliferating bacteria can decompose all the combined bile salts in the intestine into unconjugated bile salts, lacking the bound bile salts, and the lipids cannot form a fine microcapsule state, while the fat only forms microcapsules. The granules can be dissolved in water, and they are easily caught by the small intestine villi and absorbed into the epithelial cells. The non-binding bile salts have no such effect on fat, so that the fat cannot be absorbed. It produces steatorrhea. At the same time, the product of bacteria on fatty acids can also cause watery diarrhea in patients, and metabolic disorders of water and electrolytes. Some patients with chronic diarrhea can show peripheral neuropathy or comorbidity, and bacterial overgrowth in the small intestine. It also interferes with the normal metabolism of carbohydrates, and also affects the absorption of protein. Or the bacteria use the protein in food, so patients can be combined with hypoproteinemia. The excessive growth of bacteria also affects the absorption of vitamins, especially vitamin B12. Vitamin B12 malabsorption may not be the inhibition of intestinal mucosal absorption by bacterial toxins, but vitamin B12 is used by bacteria. Some experimental studies have shown that even when vitamin B12 and internal factors are combined, bacteria can compete to capture vitamins. B12, therefore small bowel diverticulosis can be combined with megaloblastic anemia.
Examine
Examination of jejunum and ileum diverticulum
1. Routine examination: in the absence of bleeding and inflammation, hematocrit, hemoglobin level and white blood cell count are in the normal range, fecal occult blood test is negative.
2. Bacterial culture: If there is metabolic disorder of fat and vitamin B12, it is necessary to culture the bacteria in the small intestine.
3. Small intestine gas sputum double contrast examination
Intestinal angiography has a high diagnostic rate. The catheter is inserted into the duodenal jejunum and injected into the 50% (w/v) suspension 300-400 ml via the catheter. After the tincture reaches the ileocecal area, an appropriate amount of air is injected. Intramuscular injection of sputum, gentle compression of each group of small intestine, need to use a variety of body position to operate, so that the tincture can fill the diverticulum in various directions, the developed diverticulum in the small mesenteric side of the round or oval bag The shadows, the edges are neat and smooth, open to the intestine cavity with wide and narrow openings. The larger diverticulum chamber can display the three layers of gas, liquid and expectorant. In the diverticulum with wide opening, visible contrast agent in the diverticulum and intestine Free access between the cavities, this is the unique X-ray angiography of the disease.
4. Radionuclide imaging diagnosis
Patients with concurrent gastrointestinal hemorrhage can be diagnosed by 99mTc red blood cell imaging. After intravenous injection of 99mTc labeled red blood cells 550740MBq, images are collected at 1 frame/5min speed with camera or SPECT system for 30min, then 1h and 2h are collected again. And lateral imaging, delayed imaging after 6h if necessary, when the amount of bleeding in the intestinal wall is 0.1ml/min, the marked red blood cells flow into the intestinal lumen with the blood to form abnormal radioactive accumulation. This method can perform bleeding localization and continuous dynamic observation. The positive diagnosis rate can reach 75%~97% when multiple imaging is performed within 24~36h. The diagnosis of this part of the jejunum can be confirmed by this method.
5. Selective superior mesenteric artery angiography
Excellent angiographic examination is valuable for a large number of bleeding cases. The bleeding rate is >0.5ml/min. The contrast agent in the intestinal lumen clearly shows the bleeding site, and even directly shows the nature of the lesion.
6. Fiber enteroscopy
Some authors recommend that fiberoptic enteroscopy can be used for direct observation of small intestine diseases, and there is a high rate of diagnosis. Only the mastery of this technology is highly specialized and needs to be further promoted.
Diagnosis
Diagnosis and identification of jejunum and ileum diverticulum
diagnosis
The clinical symptoms of this disease lack specificity. Anyone who is 60-80 years old and weak, has digestive dysfunction for a long time, often has flatulence, pain or sputum pain in the stomach area, or diarrhea, megaloblastic anemia, etc. The possibility of this disease should be thought of. The upper digestive tract sputum angiography shows that the small mesenteric side has a round or oval shape, the edges are neat and smooth, and the shadow of the bag, or the larger diverticulum cavity shows the gas, liquid and tincture. Feature images such as layer plane can be clearly diagnosed, and patients with suspected gastrointestinal hemorrhage, radionuclide examination, and selective superior mesenteric artery angiography can assist in diagnosis.
Differential diagnosis
This disease occurs in the diverticulum mucosal hemorrhage, perforation of the diverticulum, pneumoperitoneum and small intestinal wall balloon or intestinal obstruction, should be differentiated from peptic ulcer bleeding and perforation, mechanical intestinal obstruction.
