Small bowel intramural hematoma caused by warfarin: case report and literature review.

BACKGROUND: Intramural hematoma of the small bowel is a rare yet acute gastrointestinal condition typically linked with impaired coagulation function, often posing diagnostic challenges. It is principally encountered in patients undergoing prolonged anticoagulant therapy, specifically warfarin. CASE PRESENTATION: We reported a case of intramural hematoma associated with warfarin use. The patient was admitted to hospital with abdominal pain and had received anticoagulant therapy with warfarin 2.5 mg/day for 4 years. Laboratory examination showed decreased coagulation function, abdominal CT showed obvious thickening and swelling of part of the jejunal wall, and abdominal puncture found no gastroenteric fluid or purulent fluid. We treated the patient with vitamin K and fresh frozen plasma. The patient was discharged after the recovery of coagulation function. Then we undertaook a comprehensive review of relevant case reports to extract shared clinical features and effective therapeutic strategies. CONCLUSION: Our analysis highlights that hematoma in the small intestinal wall caused by warfarin overdose often presents as sudden and intense abdominal pain, laboratory tests suggest reduced coagulation capacity, and imaging often shows thickening of the intestinal wall. Intravenous vitamin K and plasma supplementation are effective non-surgical strategies. Nevertheless, in instances of severe obstruction and unresponsive hemostasis, surgical resection of necrotic intestinal segments may be necessary. In the cases we reported, we avoided surgery by closely monitoring the coagulation function. Therefore, we suggest that identifying and correcting the impaired coagulation status of patient is essential for timely and appropriate treatment.

Management of granulomatosis with polyangiitis complicated by intestinal perforation and pancytopenia: a case report and literature review.

Granulomatosis with polyangiitis is a systemic vasculitis. While the classic triad typically comprises otorhinolaryngologic, pulmonary, and renal manifestations, it is essential to recognize that granulomatosis with polyangiitis can affect any organ. Furthermore, reports have documented less common sites of involvement, such as the gastrointestinal tract. In this case-based review, we focus on a case of granulomatosis with polyangiitis presenting with intestinal perforation and the added challenge of concurrent pancytopenia.A 25-year-old female was diagnosed with granulomatosis with polyangiitis, with her clinical course progressing from joint pain to severe multi-organ involvement, including gastrointestinal complications. Treatment challenges emerged with the development of pancytopenia. While this may not directly result from granulomatosis with polyangiitis, it introduced an additional layer of complexity and delayed the induction of remission with immunosuppressants. Despite initial stabilization, an unexpected jejunal perforation occurred, requiring surgical intervention and subsequent postoperative care. The case underscores the complex nature of granulomatosis with polyangiitis and its potential complications. A literature search yielded discrete relevant cases in the context of our patient's intricate presentation, which has been summarized.We highlight the complexities in diagnosing and managing granulomatosis with polyangiitis-related complications, especially in uncommon presentations, and emphasize the importance of a personalized approach to patient care in these circumstances.

Two cases of complicated jejunal diverticulosis in a low-resource peripheral teaching hospital.

Jejunal diverticula, like other intestinal diverticula, can become complicated and present as acute abdomen. Diagnosis is difficult and management in complicated cases can be surgical as well as conservative. We present two cases of complicated jejunal diverticulosis that presented with acute abdomen and were managed surgically. Post-operative recovery was satisfactory. Jejunal diverticula is a diagnostic challenge in a low-resource peripheral hospital.

Small bowel diverticula in elderly patients: a case report and review article.

BACKGROUND: Small intestine diverticula are rare findings that were mostly reported in the elderly population as asymptomatic findings. However, they can also present with a wide range of symptoms (bloating, early satiety, chronic abdominal discomfort, and diarrhea/steatorrhea) or complications (gastrointestinal bleeding, small bowel obstruction, acute diverticulitis, or perforation) which in turn warrant medical treatment or urgent surgical intervention. CASE PRESENTATION: This is a case report of an 84-year-old female who presented with an acute surgical abdomen. An exploratory laparotomy revealed complicated small bowel diverticula with a jejunal diverticulum perforation, for which a diverticulectomy was performed. CONCLUSIONS: Throughout this paper, we are aiming to outweigh the consideration of the possibility of complicated small bowel diverticula as a differential in the evaluation of any acute abdomen, especially in the elderly, which warrants emergency surgical management.

Unusual radiological findings of pediatric jejunojejunal intussusception: A case report.

Intussusception is a common cause of intestinal obstruction in children, especially in those of age <5 years. The typical signs and symptoms of this condition is colicky abdominal pain, bloody mucous stool, and palpated abdominal mass, with a classic target sign finding on abdominal ultrasound. In older children, the symptoms may vary, which necessitates investigation of the cause of intussusception, as it is often caused by a pathologic lead point. We report here the case of a 14-year-old girl with total bowel obstruction, hematochezia, a very dilated reverse C-shaped bowel loop, and intestinal pneumatosis on abdominal X-ray. During laparotomy, we detected jejunojejunal intussusception caused by jejunal polyp. After bowel resection and anastomosis, the patient recovered well and had no other events during follow-up.

Elevated postischemic tissue injury and leukocyte-endothelial adhesive interactions in mice with global deficiency in caveolin-2: role of PAI-1.

Ischemia/reperfusion (I/R)-induced rapid inflammation involving activation of leukocyte-endothelial adhesive interactions and leukocyte infiltration into tissues is a major contributor to postischemic tissue injury. However, the molecular mediators involved in this pathological process are not fully known. We have previously reported that caveolin-2 (Cav-2), a protein component of plasma membrane caveolae, regulated leukocyte infiltration in mouse lung carcinoma tumors. The goal of the current study was to examine if Cav-2 plays a role in I/R injury and associated acute leukocyte-mediated inflammation. Using a mouse small intestinal I/R model, we demonstrated that I/R downregulates Cav-2 protein levels in the small bowel. Further study using Cav-2-deficient mice revealed aggravated postischemic tissue injury determined by scoring of villi length in H&E-stained tissue sections, which correlated with increased numbers of MPO-positive tissue-infiltrating leukocytes determined by IHC staining. Intravital microscopic analysis of upstream events relative to leukocyte transmigration and tissue infiltration revealed that leukocyte-endothelial cell adhesive interactions in postcapillary venules, namely leukocyte rolling and adhesion were also enhanced in Cav-2-deficient mice. Mechanistically, Cav-2 deficiency increased plasminogen activator inhibitor-1 (PAI-1) protein levels in the intestinal tissue and a pharmacological inhibition of PAI-1 had overall greater inhibitory effect on both aggravated I/R tissue injury and enhanced leukocyte-endothelial interactions in postcapillary venules in Cav-2-deficient mice. In conclusion, our data suggest that Cav-2 protein alleviates tissue injury in response to I/R by dampening PAI-1 protein levels and thereby reducing leukocyte-endothelial adhesive interactions.NEW & NOTEWORTHY The role of caveolin-2 in regulating ischemia/reperfusion (I/R) tissue injury and the mechanisms underlying its effects are unknown. This study uses caveolin-2-deficient mouse and small intestinal I/R injury models to examine the role of caveolin-2 in the leukocyte-dependent reperfusion injury. We demonstrate for the first time that caveolin-2 plays a protective role from the I/R-induced leukocyte-dependent reperfusion injury by reducing PAI-1 protein levels in intestinal tissue and leukocyte-endothelial adhesive interactions in postcapillary venules.

Melatonin-Activated Receptor Signaling Pathways Mediate Protective Effects on Surfactant-Induced Increase in Jejunal Mucosal Permeability in Rats.

A well-functional intestinal mucosal barrier can be compromised as a result of various diseases, chemotherapy, radiation, and chemical exposures including surfactants. Currently, there are no approved drugs targeting a dysfunctional intestinal barrier, which emphasizes a significant medical need. One candidate drug reported to regulate intestinal mucosal permeability is melatonin. However, it is still unclear if its effect is primarily receptor mediated or antioxidative, and if it is associated with enteric neural pathways. The aim of this rat intestinal perfusion study was to investigate the mechanisms of melatonin and nicotinic acetylcholine receptors on the increase in intestinal mucosal clearance of 51Cr-labeled ethylenediaminetetraacetate induced by 15 min luminal exposure to the anionic surfactant, sodium dodecyl sulfate. Our results show that melatonin abolished the surfactant-induced increase in intestinal permeability and that this effect was inhibited by luzindole, a melatonin receptor antagonist. In addition, mecamylamine, an antagonist of nicotinic acetylcholine receptors, reduced the surfactant-induced increase in mucosal permeability, using a signaling pathway not influenced by melatonin receptor activation. In conclusion, our results support melatonin as a potentially potent candidate for the oral treatment of a compromised intestinal mucosal barrier, and that its protective effect is primarily receptor-mediated.

Rare Cause of Left Upper Abdominal Pain.

Inflamed diverticular disease of the small bowel is an uncommon cause of acute abdominal pain. Despite its low prevalence rate (0.3-2%), it is associated with a high mortality rate between 20-25% (Fisher and Fortin, 1977; Ferreira-Aparicio et al., 2012). This is due to complications including perforation, bleeding, and obstruction. This case report presents the diagnosis and management of Mr. X, a 70-year-old male with jejunal diverticulitis and a duodenal diverticulum. Mr. X has a background of type 2 diabetes mellitus and sigmoid diverticulosis, he presented with a three-day history of left upper quadrant pain radiating to the left iliac fossa. He was haemodynamically stable despite his elevated inflammatory markers (C-reactive protein 161 mg/l and neutrophils 13.3×109/l) and computerised tomography (CT) of the abdomen and pelvis showing jejunal diverticulitis and a duodenal diverticulum. Mr. X was successfully treated with intravenous antibiotics and analgesia and a follow up CT scan showed that the jejunal diverticulitis had resolved. Previous operative management of the discussed pathology has been reported, the current report is novel as the diagnosis was made early and the case managed conservatively.

Small Intestinal Intussusception Due to Complicated Giant Jejunal Diverticulosis.

Background: Jejunal diverticulosis and jejunal lipomatosis are uncommon conditions. Usually asymptomatic, they may cause severe complications in some cases. Intussusception is unusual in adults, but when diagnosed swiftly it can be treated surgically, usually with good outcome. Case presentation: We present a 60-year-old female patient with a history of chronic malnutrition and anemia, complaining of acute abdominal pain, vomiting and diarrhea. Contrast-enhanced abdominal computed tomography (CT) showed intussusception, multiple giant jejunal diverticula and multiple lipomas. The patient underwent urgent surgery, but radical treatment was not possible due to the extent of the diseases. One month later, another surgery was needed due to ileostomy obstruction caused by lipomas. The patient's condition deteriorated due to malnutrition and concomitant metabolic disorders, which eventually led to her demise. Conclusions: Radical treatment is not always possible in an extensive jejunal disease. Prolonged malnutrition impairs postoperative healing, and therefore surgical or nutritional treatment should be considered in jejunal diverticulosis before the onset of severe complications requiring urgent surgical intervention.

Females Are More Resistant to Ischemia-Reperfusion-induced Intestinal Injury Than Males: A Human Study.

BACKGROUND AND OBJECTIVE: Sex differences in responses to intestinal ischemia-reperfusion (IR) have been recognized in animal studies. We aimed to investigate sexual dimorphism in human small intestinal mucosal responses to IR. METHODS: In 16 patients (8 men and 8 women) undergoing pancreaticoduodenectomy, an isolated part of jejunum was subjected to IR. In each patient, intestinal tissue and blood was collected directly after 45 minutes of ischemia without reperfusion (45I-0R), after 30 minutes of reperfusion (45I-30R), and after 120 minutes of reperfusion (45I-120R), as well as a control sample not exposed to IR, to assess epithelial damage, unfolded protein response (UPR) activation, and inflammation. RESULTS: More extensive intestinal epithelial damage was observed in males compared to females. Intestinal fatty acid binding protein (I-FABP) arteriovenous (V-A) concentrations differences were significantly higher in males compared to females at 45I-0R (159.0 [41.0-570.5] ng/mL vs 46.9 [0.3-149.9] ng/mL). Male intestine showed significantly higher levels of UPR activation than female intestine, as well as higher number of apoptotic Paneth cells per crypt at 45I-30R (16.4% [7.1-32.1] vs 10.6% [0.0-25.4]). The inflammatory response in male intestine was significantly higher compared to females, with a higher influx of neutrophils per villus at 45I-30R (4.9 [3.1-12.0] vs 3.3 [0.2-4.5]) and a higher gene expression of TNF-α and IL-10 at 45I-120R. CONCLUSION: The human female small intestine seems less susceptible to IR-induced tissue injury than the male small intestine. Recognition of such differences could lead to the development of novel therapeutic strategies to reduce IR-associated morbidity and mortality.

Jejunogastric intussusception after Whipple procedure with B-II reconstruction: a case report.

BACKGROUND: Jejunogastric intussusception (JGI) is a rare but severe complication after gastric surgery. JGI can occur from a few days to 55 years postoperatively and has a reported incidence of < 0.1% in patients who undergo gastric surgery. We firstly report a male patient with duodenal cancer who underwent Whipple's procedure with side-to-side gastrojejunostomy and who subsequently developed JGI. A literature review is provided. CASE PRESENTATION: A 68-year-old man was admitted to our emergency department with left upper quadrant abdominal pain and hematemesis of 4 h' duration. He had undergone Whipple's procedure (duct-to-mucosa pancreaticojejunostomy and side-to-side gastrojejunostomy) with B-II reconstruction for duodenal papillary adenocarcinoma 5 years earlier. His vital signs were stable with a blood pressure of 163/93 mmHg, temperature of 37.0 °C; and heart and respiratory rates of 86 per/min and 20 per/min, respectively. Physical assessment showed mild tenderness in the left upper quadrant, only. A complete blood count showed white cell and platelet counts of 11.69 × 103/L and 196 × 103/L, respectively, and a hemoglobin level of 13.5 g/L. Abdominal computed tomography (CT) suggested a retrograde intussusception of the intestines into the stomach with dilatation of the remnant stomach. The patient immediately underwent exploratory laparotomy, which revealed a 20-cm retrograde efferent limb at the remnant stomach that had travelled through the previous gastrojejunostomy. There was no evidence of malignancy. We manually reduced the intussuscepted loop using gentle traction, and the viability of the intestinal loop was preserved. The patient had an uneventful postoperative recovery. CONCLUSION: JGI is a rare but potentially fatal complication after gastric surgery, especially following Whipple's procedure. Early diagnosis and treatment are crucial, and surgery is considered the most effective treatment for JGI.

S054: incidence and management of jejunojejunal intussusception after Roux-en-Y gastric bypass: a large case series.

INTRODUCTION: Jejunojejunal intussusception after Roux-en-Y gastric bypass (RYGBP) for morbid obesity is a rare but potentially catastrophic complication. There are limited data regarding the incidence of intussusception and the different surgical options for management of this disease. METHODS: This is a retrospective review of all patients that underwent RYGBP and subsequently developed intussusception at the jejunojejunostomy. Data were collected between 1/1/2008 and 5/31/2018 and included demographics, details related to the index procedure, presentation, and management of intussusception. Perioperative outcomes and complications were also collected. RESULTS: 665 patients underwent RYGBP. A total of 34 patients developed intussusception, with 31 (4.7%) of them having undergone RYGBP in our hospital. Demographics included age, gender, and BMI at both the index surgery and at the time of intussusception. The jejunojejunostomy was created during RYGBP using a linear stapler in all patients with 64.5% of them achieving a length of 90 mm. All intussuscepted patients presented acutely with abdominal pain. All but one patient required surgical intervention. 42.4% of the patients were found to have intraoperative intussusception which appeared to be retrograde in 78.6% of them. Reduction followed by enteropexy or just enteropexy was performed in 20 patients (60.6%) that required surgery. No immediate post-operative complications were noted but 8 patients (26.5%) had recurrence of intussusception requiring another surgical intervention. In the reoperated group, 75% of the patients were treated with reduction followed by enteropexy or just enteropexy. CONCLUSIONS: This is the largest case series describing jejunojejunal intussusception following RYGBP. All patients that developed intussusception had jejunojejunostomy length greater than 60 mm. The most commonly performed surgical repair was reduction of the intussuscepted segment (if present) followed by enteropexy. Jejunojejunostomy length greater than 60 mm might be associated with the occurrence of intussusception and could explain the higher incidence noted in our series. Minimal intervention with enteropexy can offer effective treatment for most patients.

Benign postoperative hepaticojejunostomy stricture: percutaneous recanalisation using the reverse end of a microwire.

AIM: To evaluate the technical feasibility and safety of percutaneous recanalisation of benign postoperative hepaticojejunostomy strictures using the reverse end of a microwire. MATERIALS AND METHODS: Twenty-one patients with benign postoperative hepaticojejunostomy strictures that had failed to recanalise following management with conventional percutaneous techniques from January 2012 to March 2019 were included in the study. The stricture was punctured by the reverse end of a microwire. Subsequently, serial balloon dilatation and covered stent placement was performed. Technical as well as clinical success, complications, and patency of the hepaticojejunostomy were evaluated. RESULTS: Technical success was achieved in 19 of 21 (90.5%) patients. The mean number of treatment sessions was 1.2 (range, 1-2). The obstructive symptoms were resolved within 3 days after the procedure in 19 patients (100%). There were no major complications. The 1-year and 3-year patency rates were 76.9% and 61.5%, respectively. CONCLUSION: Percutaneous recanalisation using the reverse end of a microwire is technically feasible and safe in the treatment of benign postoperative hepaticojejunostomy strictures. This technique is useful when the conventional percutaneous technique cannot be used to cross the stricture.

Of aortic valve and bleeding: Heyde's syndrome.

An 80-year-old woman with severe aortic stenosis presented with relapsing enterorrhagia and severe anemia. A video capsule pan-endoscopy showed multiple sites of complex mucosal angiodysplasia in the jejunum. Direct hemostatic treatment of accessible angiodysplasia was done with argon plasma coagulation, and the patient was urgently referred for trans-catheter aortic valve replacement (TAVR). At follow-up 1 month and 3 months later, she was doing well with no further episodes of bleeding. Heyde's syndrome is referred to as the association of aortic stenosis, gastrointestinal angiodysplasia, bleeding, and anemia. It is an acquired type2A von Willebrand syndrome caused by the proteolysis and loss of the largest polymers of vWF due to the high shear forces generated through the stenotic aortic valve. The qualitative and quantitative vWF defects play a central role in the angiogenesis and development of gastrointestinal angiodysplasia The vWF abnormalities are closely associated with the hemodynamic severity of the aortic valve stenosis. Valve replacement is the pivotal strategy to achieve the long-term resolution of bleeding recurrences. TAVR is a valuable option particularly in high-risk patients for whom surgical valve replacement is not feasible.

Juvenile dermatomyositis resembling late-stage Degos disease with gastrointestinal perforations successfully treated with combination of cyclophosphamide and rituximab: case-based review.

Dermatomyositis (DM) is a multi-system disease that results in chronic inflammation principally of the skin and striated muscle. Small blood vessel injury in the GI tract has been described in dermatomyositis, manifesting as bleeding, ulceration, pneumatosis intestinalis, and ultimately perforation. Recent histopathological studies have shown deposits in the capillaries of the skin, gastrointestinal tract, and brain of patients with dermatomyositis similar to that found in patients with Degos disease, suggesting these disease processes are closely related or represent varying degrees of severity on the same pathologic spectrum. We report a case of juvenile dermatomyositis (JDM) resembling late-stage Degos disease with gastrointestinal perforations successfully treated with combination rituximab and cyclophosphamide therapy. We systematically reviewed the literature detailing the medical and surgical treatments for gastrointestinal perforation in dermatomyositis, Degos-like dermatomyositis, and Degos disease. In addition to our case, as of October 2019, we identified 36 cases describing gastrointestinal perforation in patients with underlying dermatomyositis, 5 cases of Degos-like dermatomyositis and 17 cases of idiopathic Degos disease. Corticosteroid therapy was used widely for dermatomyositis and Degos-like dermatomyositis, while antiplatelet and anticoagulant medications were chiefly used for patients with idiopathic Degos disease. However, there were no cases that detailed the successful treatment of dermatomyositis or Degos disease with gastrointestinal perforation with rituximab alone or combined with cyclophosphamide. We report that rituximab, in combination with cyclophosphamide, can be used as a novel adjunctive therapy to successfully treat dermatomyositis with Degos-like gastrointestinal perforation.

Successful laparoscopic surgery combined with selective arterial embolization for bleeding due to jejunal angiodysplasia: a case report.

BACKGROUND: Angiodysplasia of the gastrointestinal tract is a rare vascular pathology that sometimes causes massive hemorrhage. Angiodysplasias are particularly difficult to find in the small intestine for anatomical reasons, often impeding their diagnosis and treatment. Lesion localization is a major challenge in cases of small bowel bleeding requiring surgical intervention. CASE PRESENTATION: The present case was a 52-year-old woman who was urgently hospitalized with repeated tarry stools. Surgical intervention was chosen after conservative treatment failed to improve her condition. The source of bleeding was suspected to be a vascular lesion discovered in the small intestine during a past double-balloon endoscopy. Abdominal contrast computed tomography revealed a jejunal hemorrhage. We chose selective arterial embolization to stabilize her hemodynamics followed by surgical intervention as her treatment plan. Several embolic and contrast agents (cyanoacrylate, indigo carmine, and Lipiodol) were combined to help identify the location of the lesion during surgery. This multi-pronged approach allowed us to localize the lesion under laparoscopic guidance with high confidence and accuracy, and to excise a 6-cm segment of the small intestine. The lesion was histologically diagnosed as angiodysplasia. No re-bleeding has been observed since the operation. CONCLUSION: We report our experience with a case of jejunal angiodysplasia, which was localized with selective arterial embolization using an array of embolic and contrast agents, and then excised laparoscopically. Selective arterial embolization with indigo carmine dye to treat small bowel bleeding preoperatively not only makes the surgery safer by stabilizing the patient's hemodynamics, but is also very useful for localizing the lesion intraoperatively.

Pancreatic fistula after pancreatoduodenectomy due to compression of the superior mesenteric vessels: a case report.

BACKGROUND: Pancreatic fistula is a common complication after pancreaticoduodenectomy, which could be caused by: soft pancreatic tissue, pancreatic duct diameter < 3 mm and body mass index ≥25 kg/m2. Here we report a case of pancreatic fistula due to obstruction of the jejunal loop due to compression of the jejunal loop by the superior mesenteric vessels. CASE PRESENTATION: A 68-year-old man was admitted to our ward due to intermittent epigastric distension and pain. After various examinations and treatments, he was diagnosed with middle bile duct cancer. Pancreaticoduodenectomy was performed, and pancreaticojejunostomy and hepaticojejunostomy were completed by lifting the jejunal loop from behind the superior mesenteric vessels to the upper region of the colon. On postoperative day 9, the patient developed acute diffuse peritonitis, and on postoperative day 10, the patient underwent a second exploratory laparotomy, during which it was confirmed that the pancreatic fistula was caused by obstruction of the jejunal loop due to compression of the jejunal loop by the superior mesenteric vessels, then the patient recovered and was discharged alive after retrograde drainage in the jejunum. CONCLUSIONS: The superior mesenteric vessels after pancreaticoduodenal surgery can compress the jejunal loop and cause obstruction leading to serious complications, and it is recommended that general surgeons should avoid lifting the jejunal loop from the posterior aspect of the superior mesenteric vessels to complete the anastomosis.

Enteritis and Severe Abdominal Pain as the First Presentation of Covid-19.

Presentation A male patient with no significant past medical history presented to emergency department with progressive in severity abdominal pain, associated with mild nausea and diarrhea. No other significant symptoms were reported. Diagnosis On investigation with CT, duodenojejunitis was diagnosed as the cause of abdominal pain. Lung basal changes were also visualized and subsequently proven to be secondary to Covid-19 infection. Treatment After few days of hospitalization and supportive treatment, the patient improved clinically and was discharged. Conclusion Covid-19 infection typically presents with respiratory symptoms associated with fever and myalgia. Anorexia, diarrhea and nausea have been reported. Severe abdominal pain is rare, particularly as the initial presenting compliant. It is important to be aware of the varied clinical presentations that may occur in Covid-19, including isolated gastrointestinal symptoms. This will allow to increase the timely detectability of infected patients and more effective contact control measures.

[Non-surgical management of small bowel diverticulitis with localized perforation:a case report].

A 40-year-old man presented to the emergency department with periumbilical pain and fever. A computed tomographic scan confirmed multiple jejunal diverticulum with localized extraluminal air and panniculitis around it, and jejunal diverticulitis with localized perforation was suspected. His symptoms were mild, and extraluminal air was localized;therefore, he was advised bowel rest and administered only antibiotics. The patient's symptoms resolved without surgical treatment, and at the time of writing this report, there had been no recurrence. Small bowel diverticulitis is rare, and careful analysis of imaging studies is necessary for establishing a diagnosis. This was a rare case where small bowel diverticulitis was resolved without surgical treatment.