INSTRUCTIVE CASE
Perforated jejunal
diverticular disease:
a diagnostic pitfall at frozen
section of a mesenteric mass
for adenocarcinoma of the
stomach
Pelvender Gill
Andrew Slater
Nicholas Maynard
Runjan Chetty
Abstract
This case illustrates an unusual associated pathology in a patient with
gastric adenocarcinoma. A 79-year-old male with biopsy-proven gastric
cancer was found intra-operatively to have a hard mass in the mesentery
involving proximal jejunum. A segment of small bowel was resected and
a frozen section was requested to confirm disseminated malignancy. After
a benign diagnosis was rendered, a total gastrectomy for adenocarcinoma
was then performed. The jejunum contained two diverticula, one of which
had perforated and this was the cause of the intra-abdominal mesenteric
pathology. Jejunal diverticular disease is highlighted and reviewed.
Keywords diverticula; frozen section; jejunum; perforation
Introduction
When considering curative gastrectomy the presence of meta-
static adenocarcinoma discovered within the peritoneal cavity at
surgery will indicate to the surgeon incurable disease for which
surgical resection is not appropriate. At surgery any peritoneal
Pelvender Gill BSc BM Department of Cellular Pathology, Oxford
University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK.
Conflicts of interest: none declared.
Andrew Slater BSc MBChB MRCP FRCR Department of Radiology, Oxford
University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, UK.
Conflicts of interest: none declared.
Nicholas Maynard BA Hons (Oxon) MBBS MS FRCS Department of Surgery,
Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford,
UK. Conflicts of interest: none declared.
Runjan Chetty MB BCh FRCPath Department of Cellular Pathology and
Oxford BRC, Oxford University Hospitals NHS Trust, John Radcliffe
Hospital, Oxford, UK. Conflicts of interest: none declared.
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nodules, or distant nodal disease in the abdomen require urgent
assessment and the surgeon is likely to request a frozen section
to ensure that any lesion detected is benign. Most often the
pathologist is confronted with liver nodules for which the usual
benign mimics of adenocarcinoma such as von Meyenburg
complex, bile duct adenoma or sclerosed subcapsular hae-
mangiomas are considered. Masses within the mesentery are less
common, but there are well-recognized mimics of adenocarci-
noma such as calcified or reactive mesenteric lymph nodes. In all
of these instances radiological correlation prior to surgery is often
very informative and the surgeon has no need to consult
a pathologist by requesting a frozen section. Discovering unex-
pectedly enlarged lymph nodes within the mesentery, in a patient
with known gastric adenocarcinoma at surgery is likely to cause
some alarm to the surgeon. The aetiology is likely to be meta-
static adenocarcinoma, until proven otherwise. Jejunal divertic-
ular disease is a rare benign condition, and discovering this
condition following subacute perforation, at surgery for GI
malignancy is very unusual. Perforated jejunal diverticular
disease masquerading and presenting as advanced intra-
abdominal malignancy, is the basis of this illustrative case report.
Case report
A 79-year-old white male with a biopsy-proven poorly differen-
tiated adenocarcinoma of the stomach, and preoperative staging
of T3 N1 M0, had received three cycles of neoadjuvant chemo-
therapy. Following this, repeat cross-sectional staging was per-
formed, and contrast CT scan of the chest, abdomen and pelvis
found a localized short segment of thick-walled jejunum with
evidence of perforation, considered at the time ischaemic or due
to chemotherapy (Figure 1). At laparotomy for the definitive
gastric resection procedure, the surgeon noted that there was
marked prominence of mesenteric lymph nodes and a distinct
mesenteric mass. This was associated with a segment of jejunum.
The surgeon resected a 205 mm length of segment of jejunum
with attached mesentery 50  45  22 mm, with a 60  50  30
mm segment of omentum adherent to the small bowel and
mesentery. A prominent palpable nodule, 35  40  22 mm, was
noted in the mesentery. Also noted were dilated semi-translucent
serosal nodules on the anti-mesenteric surface of the bowel, less
than 3 mm in diameter, considered at the time by the pathologist
to be incidental benign dilated lymphatics. The pathologist
inspected the bowel mucosa and noted that there were at least
two depressions, possibly diverticula, in the mucosal surface of
the specimen and one was adjacent to the mesenteric mass.
Samples at frozen section were taken from the mesenteric mass.
These were benign, with no evidence of carcinoma.
The patient went on to have a total gastrectomy e final histology
showed a poorly differentiated adenocarcinoma pT3, with lym-
phovascular invasion (Ly1, V1). Three lymph nodes from 37
identified in the gastric resection were positive for carcinoma (N1).
Microscopic findings
The nodular lesion sampled was markedly haemotoxyphilic, or
blue, on the frozen section raising some alarm. On more detailed
microscopic examination the mesenteric nodule comprised
fibrofatty tissue in which there were scattered blood vessels.
There was a vague nodularity and marked chronic inflammatory
484 2012 Elsevier Ltd. All rights reserved.
 INSTRUCTIVE CASE

Figure 1 Axial CT of the abdomen with intravenous contrast. A defect is

seen in the wall of the small bowel (short arrow) leading to an inflam-
matory mass between small bowel loops (long arrow).

cell infiltrate, there were lymph nodes present with reactive

germinal centres. There were bands of fibrosis, fat necrosis, as
well as foreign body giant cells. The bands of fibrosis contained
bland spindle cells and patchy chronic inflammation. The lym-
phovascular spaces were not seen to contain deposits of meta-
static adenocarcinoma. Polarizable material was not detected
(Figure 2a and b).
Correlating the findings to the gross identification of two
diverticular out-pouchings the diagnosis at frozen section of
small bowel diverticular disease with perforation and secondary
chronic inflammation and foreign body giant cell reaction was
made.
The frozen to paraffin sections confirmed the initial findings.
Following fixation further careful inspection confirmed small
bowel diverticula in the mesenteric and anti-mesenteric surface
of the small bowel with perforation (Figure 3aec).
Figure 2 A section of the tissue submitted for frozen section interpretation
under low magnification showing a nodular, cellular appearance within
Discussion the mesentery (a). Higher magnification shows a cellular lesion simulating
an infiltrate which given the clinical history of gastric cancer that may lead
Acquired small bowel, particularly jejunal, diverticular disease is
to an erroneous diagnosis of metastatic disease. However, closer
much rarer than its colonic counterpart although jejunal diver- inspection reveals an inflammatory infiltrate with fat necrosis (b).
ticulosis has been considered to be associated with colonic
diverticula in 50% of cases.1,2 In many cases there is an under- Certainly in our institution in the preceding 5 years, we have
lying gut motility disorder such as progressive systemic sclerosis diagnosed acquired diverticula in seven instances. Of those, one
or a visceral myopathy.3 For the historical record, a review by case was of duodenal diverticular disease and six of small bowel
Herrington in 1962 found that the first case of small bowel (jejunal) diverticula. The mean age of the latter six patients, four
diverticula was reported as an autopsy finding in 1907. The same females, two male, was 73 years, the age range being 46e92
author documents X-ray demonstration of small bowel diver- years. A recent review of 77 cases at a single institution similarly
ticula disease in 1920 and resection of the lesion by Hunt and recorded a wide age range of presentation for acquired small
Cook in 1921.4 In this review the author describes jejunal bowel diverticula (28e87 years, with a mean of 64 years).6
diverticula as acquired, and the condition is distinguished from Small bowel diverticula disease, can present with relatively
Meckels and other congenital diverticula. Congenital diverticula innocuous and benign symptomatology unexplained abdominal
(Meckels) represent more than half of small bowel diverticula. symptoms such as postprandial abdominal pain, distension, flatu-
Frozen section requests from either colonic or small bowel lence, borborygmi, nausea, vomiting, diarrhoea and constipation,
diverticular disease in order to exclude primary or metastatic symptoms which are often labelled as irritable bowel syndrome.2
carcinoma are unusual. There are case reports describing impacted enteroliths or
Autopsy series report the incidence of all small bowel diver- phytobezoars, within diverticula resulting in small bowel
ticula to be between 0.1 and 1.5%,5 duodenal diverticula are obstruction as well as perforation.7e9 Other more serious
more common with an incidence of 15% at autopsy, thus most of symptoms include chronic intestinal pseudo-obstruction, vitamin
the latter remain clinically silent. Although these figures are B12 deficiency and steatorrhoea. The latter two symptoms are due
historic there is no reason to doubt the rarity of this condition. to bacterial overgrowth within the diverticula creating a blind

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 INSTRUCTIVE CASE

The case we present highlights an important potential diag-

nostic pitfall at frozen section. This is particularly true when
mesenteric lymphadenopathy occurs in the background of
malignancy such as gastric adenocarcinoma as in this case and
there is no history of symptomatic small bowel diverticular
disease. The bland nature of infiltrative/diffuse gastric adeno-
carcinoma cells can often be overlooked even on paraffin
sections, and thus very difficult to identify at frozen section.
Correlation with the radiology reports in these cases and the
surgeons impression of the lesion is of paramount importance.
The pathologist must be convinced of malignancy at frozen
section and must be vigilant to the macroscopic appearances of
the small bowel, as well as the possibility of small bowel diver-
ticular disease and subacute perforation as in this case. A

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Figure 3 Sections showing the non-perforated diverticulum (a). The 60: 773, 813.
perforated diverticulum with associated peritonitis is highlighted in (b)
and (c).

loop syndrome. Unexplained anaemia and gastrointestinal hae- Practice points

morrhage as well as massive life threatening lower gastrointes-
tinal bleeding can occur.10e12 C Jejunal diverticular disease is a rare cause of intra-abdominal
Of the cases we have reported of small bowel diverticula pathology following perforation
disease three presented as perforation, two as small bowel C It may be associated with colonic diverticular disease in 50%
obstruction and one (the case discussed here) as an incidental of cases
finding at surgery for malignancy. In the series reported by C Duodenal diverticular disease is more common than jejunal
Mantas et al, of 77 cases which included congenital small bowel involvement
diverticula the complication rate was 53% for all diverticula with C May be asymptomatic or present with perforation, haemor-
peritonitis (pain) with or without perforation being reported in rhage, pain
22%, haemorrhage in 10%, and obstruction in 12%.

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