A seventy-year-old male presented with severe myasthenia gravis and an episode of obscure bleeding. There was a history of gastric ulcer leading to Billroth II surgery twenty-five years ago. Upper endoscopy revealed no pathology. Colonoscopy showed a few solitary diverticula and traces of old blood in the terminal ileum. Capsule endoscopy pictured red smear in the upper jejunum. Diverticula were seen as well. Suspecting bleeding jejunal diverticulosis double balloon enteroscopy was performed. The complete jejunal ascending loop and about 100 cm of the jejunum through the descending jejunal loop could be inspected. Large diverticula with fecoliths were found in both loops. Bleeding had ceased. The patient was discharged to neurology for optimizing therapy for myasthenia gravis.
Diverticulosis of the big bowel is a common disorder in elderly patients with a high percentage of clinical symptoms and complications. Contrary to this, diverticulosis of the small bowel is considered a rare clinically silent disease.
We present a case with extensive diverticulosis of the small bowel and discuss it in the light of recent literature.
A seventy-year-old male presented with an episode of obscure bleeding. There was a history of gastric ulcer leading to Billroth II surgery twenty-five years ago. No medication affecting blood coagulation was taken. The patient suffered from a severe myasthenia gravis that was treated with pyridostigmine 360 mg. Extensive examination had been done to exclude neoplastic disease. Family history was negative for any neuromuscular or gastrointestinal disorders, for example, inflammatory bowel disease or diverticulosis. No medication affecting blood coagulation was taken. Upper endoscopy revealed no pathology. Colonoscopy showed a few solitary diverticula and traces of old blood in the terminal ileum. Random biopsies did not show any pathology; especially no histological signs of inflammatory bowel disease were present.
Capsule endoscopy was indicated. The patient required
mechanical ventilation and could not swallow the Pillcam capsule. So a flexible
tube constructed for the Endocinch system was inserted in the oesophagus (Figure
Little is known about diverticulosis of the small
bowel. The prevalence of the disorder on autopsy ranges 0.06–1.3%. The
disorder seems to be mostly acquired, but two families with extensive jejunal
diverticulosis have been published in 1988 and 2007 [
Diverticula can occur anywhere in the small intestine,
but they are the most common in the jejunum. Jejunal diverticulosis is
associated with many diseases, for example, scleroderma, celiac disease, Fabry
disease, and Cronkhite-Canada syndrome. An association with myasthenia gravis
has not been described so far. Myasthenia gravis has been associated with inflammatory
bowel disease [
Usually the disorder is clinically silent.
Complications requiring intervention—perforation, bleeding diverticulitis, or
intestinal obstruction—occur in 8–30% of patients [
Bleeding from diverticula of the small bowel may be difficult to localize. The available diagnostic tools are intraoperative enteroscopy, angiography, CT-angiography, multidetector-row CT enteroclysis, wireless capsule enteroscopy, and double balloon enteroscopy.
Visceral angiography is commonly used for identifying
the active gastrointestinal bleeding site. A bleeding rate of 0.5 mL/min. is
required for diagnosis [
Wireless capsule enteroscopy is the instrument of
choice not only for the overt but also for the obscure gastrointestinal
bleeding with a detection rate of the source of bleeding of an average 67% [
Diverticulosis of the small bowel is a rare disease with a potential for the development of bleeding. Optimal diagnostic tools for this situation should be able to show not only the mucosa but also the vessels and the surrounding structures. CT angiography would fulfil these criteria though it is less sensitive as wireless capsule enteroscopy.