https://orcid.org/0000-0002-5286-3532
Abstract
While colonic diverticulosis affects approximately half of adults over 60 years of age in Western populations, jejunal diverticulosis are rare with a reported prevalence of 0.2%–1.9% associated with high mortality rate (up to 40%) when presented as complicated. Performing lifesaving surgery while respecting patient’s autonomy and informed refusal of blood transfusion represents a challenge on its own for the medical team. We present a case of a 74-year-old Jehovah’s Witness man who was diagnosed intraoperatively with perforated jejunal diverticulitis. Emergency laparotomy with segmental jejunal resection and primary anastomosis was performed. On the fifth postoperative day the patient developed post-operative haemorrhage secondary to laparotomy disruption with omental tearing, requiring urgent reoperation. Despite refusing allogenic blood transfusion, blood loss was successfully managed without transfusion. Post-operative anemia was treated with intravenous iron, vitamin B12, Folic acid, and supportive care which resulted in gradual improvement. The patient was discharged on post-operative Day 11. This case highlights that successful management of perforated jejunal diverticulitis and post-operative haemorrhage is feasible in Jehovah’s Witness patient through prompt surgical intervention, meticulous haemostasis, and bloodless postoperative anaemia treatment. To our knowledge, this is the first reported case of perforated jejunal diverticulitis in a Jehovah’s Witness patient.
Introduction
Diverticulosis rarely affects the jejunum. The reported incidence reaches up to 1.3% of all intestinal pathology [1]. About 15% of the jejunal diverticula present with complications (bleeding, diverticulitis with perforation, obstruction, and fistulas). The mortality in case of perforation is reported to be as high as 40% [2]. Performing surgery in Jehovah’s Witnesses patients who refuse full blood and other blood product transfusion represents a challenging situation for the surgeon, especially in emergency settings and when a loss of blood is encountered. The main objective of this report is to present a Jehovah’s Witness patient who was treated in emergency settings due to perforated jejunal diverticulitis, which, to our knowledge, is the first published case of such a clinical scenario. The second objective is the successful bloodless reoperation due to a postoperative complication (haemorrhage). Written informed consent was obtained from the patient regarding this publication.
Case report
A 74-year-old male patient presented to the emergency department of a private hospital complaining of constant abdominal pain over the past 4 days. The medical history revealed that an abdominal computed tomography (CT) scan had been performed at a state hospital 2 days earlier, with a surgeon’s report recommending hospital admission and emergency surgery for an acute abdomen. The patient refused admission to the state hospital because of a lack of guarantees regarding blood transfusions during his treatment, as he was a proclaimed Jehovah’s Witness. The current physical examination confirmed the clinical diagnosis of an acute abdomen. The CT scan revealed signs of mesenteric inflammation, small-intestinal wall thickening, and free air within the mesentery (Figs 1 and 2).
Abdominal CT (sagittal scan) showing signs of mesenteric inflammation, small-intestinal wall thickening, and free air within the mesentery (encircled).
Abdominal CT (coronal scan) showing signs of mesenteric inflammation, small-intestinal wall thickening, and free air within the mesentery (encircled).
Serum analysis showed elevated inflammatory markers (leukocyte count of 23.5 × 103/μl and C-reactive protein of 193 mg/L), erythrocyte count of 3.58 × 106/μl, haemoglobin of 9.3 g/dl, thrombocyte count of 706 × 103/μl, alanine aminotransferase of 122 IU/L, aspartate aminotransferase of 97 IU/L, alkaline phosphatase of 140 IU/L, and gamma-glutamyl transferase of 128 IU/L. The patient was offered emergency admission and surgery without any blood product transfusion, given the potential risks and consequences of refusing blood transfusions. The patient signed a consent form refusing blood and blood product transfusion.
A midline laparotomy was performed under general anaesthesia. Signs of contained secondary peritonitis were encountered as a consequence of perforated jejunal diverticulitis, and no gross intra-abdominal contamination was noted (Fig. 3). Several intact jejunal diverticula were also present (Fig. 4). A segmental jejunal resection with primary anastomosis was performed. Intraoperative blood loss was unremarkable. On the fifth postoperative day, an intense cough, accompanied by increased intra-abdominal pressure, led to the appearance of fresh blood on the wound dressing (Fig. 5).
Perforated jejunal diverticulitis.
Intact jejunal diverticulum (incidental finding).
Not a pleasant appearance of the wound dressing for the surgeon, especially in a Jehovah’s witness patient.
The patient underwent reoperation despite refusing a blood transfusion. However, intraoperative cell salvage (ICS) was offered and accepted by the patient in the event of excessive blood loss during surgery. Intraoperatively, a laparotomy disruption was found, with a tear of the greater omentum caused by the suture used for laparotomy closure. Local haemostasis of the greater omentum was done. Total blood loss did not exceed 500 ml. The laparotomy wound was closed. On the first postoperative day (after the second surgery), haemoglobin was 7 g/dl, and the erythrocyte count was 2.67 × 106/μl. The patient was given 100 mg of iron hydroxide sucrose complex every second day, 1 ml of cyanocobalamin (Vitamin B12) per day, and 5 mg of folic acid three times per day. On the second postoperative day, haemoglobin was 6.6 g/dl, and erythrocyte count was 2.51 × 106/μl. On the fifth postoperative day, a positive trend was noted, with haemoglobin 7.5 g/dl and erythrocyte count 2.9 × 106/μl. In parallel, the patient was mobilized from bed. Total length of hospital stay was 11 days. Oral therapy was prescribed as a combination of ferrous gluconate hydrate, manganese gluconate, and copper gluconate (20 ml in the first 7 days), followed by 10 ml for one month. The patient experienced gradual improvement in general condition alongside improvement in haematologic values. Data on the haemogram and blood loss therapy are given in Table 1.
Erythrocyte and haemoglobin data and postoperative therapy given for anemia correction per day in the postoperative period (after second surgery)
| Reoperation day | Postoperative day 1 | Postoperative day 2 | Postoperative day 3 | Postoperative day 4 | Postoperative day 5 |
|---|---|---|---|---|---|
| Erythrocyte count (×106/μl) | 2.67 | 2.51 | − | − | 2.9 |
| Haemoglobin (g/dl) | 7 | 6.6 | − | − | 7.5 |
| Iron hydroxide sucrose complex | 100 mg | − | 100 mg | − | 100 mg |
| Vitamin B12 | 1 ml | 1 ml | 1 ml | 1 ml | 1 ml |
| Folic acid | 3 × 5 mg | 3 × 5 mg | 3 × 5 mg | 3 × 5 mg | 3 × 5 mg |
Discussion
After a thorough literature review, this case is the first report regarding a perforated jejunal diverticulitis in a Jehovah’s Witness patient.
Perforated jejunal diverticulitis is a serious, life-threatening complication of jejunal diverticulosis. The proximal jejunum is affected in most cases (75% of all small intestine diverticula), and the diverticula are often multiple [3], as in this case. Mortality rates of uncomplicated jejunal diverticulitis rise sharply up to 40% when a perforation is encountered [2]. The condition more often affects male patients with a reported median age of 74.4 years [1, 2].
The diagnosis of perforated jejunal diverticulitis might be delayed in cases of contained contamination and can be mixed with other abdominal conditions. Abdominal CT scan is reported to be the preferred diagnostic tool for acute jejunal diverticulitis [4].
The reported treatment options range from conservative management (antibiotics), combinations of antibiotics and abscess drainage under CT, to resuscitation and emergency surgery [2, 5].
In this case, the operative treatment of the patient was inevitable due to the clinical signs of peritonitis. The additional obstacle (blood transfusion refusal and patient hesitation for offered surgical treatment) delayed surgery for 4 days.
Despite the life-threatening condition due to perforated jejunal diverticulitis, further challenge for the anaesthetic and the surgical team is present in Jehovah’s Witness patients. Still, major surgeries are being performed in these patients using meticulous surgical technique, rapid intraoperative haemostasis, and balanced anaesthesia [6–8].
Patient preparation is feasible and recommended when planning elective surgery. Preoperative measures include eventual correction of anemia and/or clotting abnormalities [6]. In mild iron deficiency, oral iron supplementation is recommended. Yet this kind of iron supplementation has shown gastrointestinal side effects, and at the same time, its efficacy might be delayed. In time-dependent planned surgery, intravenous iron supplementation, ferric carboxy-maltose or ferric derisomaltose, is preferred. Moderate to severe anemia requires the use of erythropoiesis-stimulating agents, such as recombinant human erythropoietin. It should be combined with vitamin B12 and folate to provide DNA synthesis in the Megakaryocyte–erythroid progenitor cells in the bone marrow. Autologous blood donation is reported to be another option in planned surgeries, but most of the Jehovah’s Witnesses patients refuse it since the removal and storage outside the body is contrary to their religious beliefs [9]. Despite the preoperative moderate anemia in this report, the emergency setting rendered its correction.
Intraoperative management in Jehovah’s Witnesses patients represents a set of measures such as intraoperative homeostasis (normothermia, normovolemia, and stable blood pH value), coagulation management (prophylactic administration of tranexamic acid) and intraoperative cell salvage and re-transfusion [9, 10]. Intraoperative cell salvage is generally accepted by the majority of Jehovah’s Witnesses, as in this report. Its use is recommended when the intraoperative blood loss exceeds 500 ml [6, 9]. One should take precautions when using the ICS in cases with bacterial contamination and oncologic procedures due to the risk of tumour dissemination [9].
In the immediate postoperative period, anaemia correction is recommended by the use of erythropoiesis-stimulating agents, intravenous iron, Vitamin B12, Folic acid, oxygen support, minimizing phlebotomy, and patient monitoring and close observation [6]. A summary of the recommended pre-, intra-, and postoperative measures to reduce and minimize blood loss is given in Table 2. A recently published update on the management of severe peri-operative bleeding was issued by the European Society of Anaesthesiology and Intensive Care, providing specific guidance for bleeding management in a variety of clinical situations [10].
Pre-, intra-, and postoperative measures to reduce and minimize blood loss in Jehovah’s witness patients
| Preoperative measures | Intraoperative measures | Postoperative measures |
|---|---|---|
| Anemia correction (Iron, Vitamin B12, Folic acid, Erythropoietin stimulating agents); Clotting abnormalities correction (Vitamin K, Protamine sulphate) | Minimizing blood loss (meticulous technique, intraoperative cell salvage, normothermia, tranexamic acid, Normovolaemic/hypervolaemic haemodilution | Erythropoietin stimulating agents, intravenous iron, Folic acid, Vitamin B12, minimize phlebotomy. Hyperbaric oxygen, prompt reaction in case of post-operative bleeding, monitoring and observation |
Conclusion
In this case, successful surgical treatment of perforated jejunal diverticulitis complicated by postoperative haemorrhage in a Jehovah’s Witness patient is reported. Prompt reoperation decision minimized blood loss and allowed appropriate bloodless treatment of the postoperative anemia. To our knowledge, this is the first reported case of perforated jejunal diverticulitis in a Jehovah’s Witness patient.
Conflicts of interest
None declared.
Funding
None declared.
