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Histoplasma capsulatum is a dimorphic fungi endemic to the Ohio and Mississippi River valleys. Immunocompetent persons who become infected are generally asymptomatic or present with mild symptoms. Symptomatic disease is seen primarily in immunocompromised patients with pulmonary manifestations being the most common presentation. We present a case of a young HIV-negative male who required 4 exploratory laparotomies over the course of 4 months during 2 hospitalizations due to discrete perforations of the ileum and jejunum caused by biopsy-proven gastrointestinal histoplasmosis despite maximal medical therapy as well as a gastric perforation., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Posttransplant lymphoproliferative disorder (PTLD) is not uncommon in pediatrics. This case report describes a case of intestinal intussusception that occurred secondary to lymphoid hyperplasia in a child with PTLD following a cardiac transplant. This case was unique in its presentation with multiple areas of intussusception and with need for surgical intervention. The diagnosis of intussusception secondary to lead points from PTLD should be strongly considered in pediatric transplant patients presenting with abdominal complaints.

Jejunal diverticulosis is a rare condition that is usually found incidentally. It is most often asymptomatic but presenting symptoms are nonspecific and include abdominal pain, nausea, diarrhea, malabsorption, bleeding, obstruction, and/or perforation. A retrospective review of medical records between 1999 and 2012 at a tertiary referral center was conducted to identify patients requiring emergency management of complicated jejunal diverticulosis. Complications were defined as those that presented with inflammation, bleeding, obstruction, or perforation. Eighteen patients presented to the emergency department with acute complications of jejunal diverticulosis. Ages ranged from 47 to 86 years (mean, 72 years). Seven patients presented with evidence of free bowel perforation. Six had either diverticulitis or a contained perforation. The remaining five were found to have gastrointestinal bleeding. Fourteen of the patients underwent surgical management. Four patients were successfully managed nonoperatively. As a result of the variety of presentations, complications of jejunal diverticulosis present a diagnostic and therapeutic challenge for the acute care surgeon. Although nonoperative management can be successful, most patients should undergo surgical intervention. Traditional management dictates laparotomy and segmental jejunal resection. Diverticulectomy is not recommended as a result of the risk of staple line breakdown. The entire involved portion of jejunum should be resected when bowel length permits.

Jejunoileal diverticulosis is a rare entity. Jejunoileal diverticulosis is not a disease that surgeons see often in clinical practice; however, it should remain on the differential diagnosis for any patient with an acute abdomen or gastrointestinal bleeding of unknown origin. It can present with a wide range of clinical scenarios and when patients experience chronic symptoms such as bloating, abdominal pain, nausea, bacterial overgrowth, or malabsorption, medical therapy is successful in most patients. However, when patients present with acute symptoms of bleeding, inflammation, perforation, or obstruction, surgical resection and primary anastomosis is often the treatment of choice. If patients are asymptomatic, they are better left alone, even when discovered incidentally in the operating room. In closing, the possibility of a patient having jejunal diverticular disease should be suspected whenever the symptoms of obscure abdominal pain, anemia, dilated jejunal loops on abdominal radiographs, a history of colonic diverticuli, and a history of acute appendicitis.

Jejunal diverticuli are rare and usually asymptomatic. More commonly, they are seen as incidental findings on CT images, enteroclysis, or during surgery. Complications such as bleeding, perforation, obstruction, malabsorption, diverticulitis, blind loop syndrome, volvulus, and intussusception may warrant surgical intervention. An interesting case of an unborn enterolith (enclosed calculus) from a jejunal diverticulum presenting as a small bowel obstruction is presented. The patient is a 66-year- old woman with no prior history of abdominal surgery who presented with a high-grade bowel obstruction. CT with intravenous barium contrast confirmed the presence of a transition point from dilated to decompressed small bowel in the mid jejunum. At laparotomy, a freely mobile mass was found in this area leading to the bowel obstruction. The mass was removed by making a small enterotomy in the jejunum. While running the small bowel proximally, a small segment of jejunum, approximately 8 cm, containing several diverticuli was found. This bowel obstruction was the result of an unborn enterolith from this segment of bowel. The patient's hospitalization was benign and she was discharged home on postoperative day 4.

Major bleeding from the small intestine is uncommon and difficult to localize. We examined its etiologies and assessed available diagnostic and therapeutic approaches. The records of all adults undergoing operation for small intestinal hemorrhage over a 10-year period (1/89-12/98) were reviewed. There were eight men and four women with a mean age of 54 years. Six patients presented with arteriovenous malformations. Preoperative diagnosis was by endoscopy (three of six), scintigraphy (two of two), and/or angiography (two of six). Intraoperative panendoscopy was used for localization in 5 cases. Three other patients had tumors (leiomyoma, leiomyosarcoma, and adenocarcinoma) by CT scan (two) and/or scintigraphy (two). All were resected but one patient died of recurrence. Two patients underwent resection of a Meckel's diverticulum, one after angiographic diagnosis. Another patient with Crohn's disease had a positive angiogram and colonoscopy before resection. There were no operative deaths but major morbidity occurred in five patients (42%) and hospitalization averaged 17 days. We conclude that jejunoileal lesions are a rare cause of intestinal bleeding but can be associated with substantial morbidity. Arteriovenous malformations and tumors remain the most common causes. An accurate diagnosis and definitive management depend on selective preoperative imaging and judicious operative exploration.

Primary aortoenteric fistulae (AEFs) are extremely rare vascular entities, with fewer than 250 cases reported in the world medical literature as of 1996. Incidence is less than 1 per cent, with a mortality ranging from 33 to 85 per cent. Atherosclerosis remains the most common etiology, accounting for more than two-thirds of the cases reported. Other etiologies include carcinoma, ulcers, gallstones, diverticulitis, appendicitis, and foreign bodies. Early diagnosis is crucial for survival and mandates recognition of the typical "herald bleed." Additional findings on initial presentation frequently include flank pain, abdominal pain, hematemesis, melena, and an abdominal mass. More than 80 per cent of primary AEFs involve the duodenum, with the overwhelming majority located in the third or fourth portion. Successful management of primary AEF requires a high index of suspicion for diagnosis and prompt surgical intervention for survival.

Jejunal diverticular (JD) perforation is an uncommon cause of acute abdominal pain in the elderly. From 1971 to 1994 we treated 13 such patients, 9 men and 4 women, with a mean age of 68 years. All patients experienced sudden onset of abdominal pain, nausea and vomiting, and leukocytosis (range of white blood cell counts, 14,000-21,000). On physical examination, three patients had localized peritonitis, were thought to have appendicitis, and underwent immediate laparotomy and segmental jejunal resection for perforated JD. The remaining 10 patients had abdominal tenderness without peritoneal signs. They were hospitalized and managed expectantly. All experienced worsening signs and symptoms and underwent exploratory laparotomy and resection of the involved jejunal segment 13 hours to 8 days after admission. Although 6 of 13 patients had had JD documented previously, in only 2 patients was perforated JD diagnosed preoperatively. In 8 of 13 patients peritoneal contamination was minimal and was contained within the leaves of the mesentery. Soilage was severe with abscess formation in 5 patients. The longer the delay in operative intervention, the greater the peritoneal soilage. The 3 patients undergoing immediate surgery had minimal contamination. Of the 10 patients initially observed, the mean interval before operation was 74 hours in the 5 patients with severe soilage versus 21 hours in those with minimal contamination. The postoperative course was uneventful in 11 patients. Two patients died. Surgical consultation was delayed (8 days, 12 days) in both patients, who had severe peritoneal contamination and died of sepsis. In conclusion, JD perforation is an uncommon and frequently overlooked cause of acute abdominal pain in elderly patients. Timely operative intervention and resection of the involved jejunum are the keys to a successful outcome. Because the presentation and physical findings of perforated JD can be highly variable, a history of preexisting JD should arouse suspicion for JD perforation as the etiology of acute abdominal pain in the elderly.

Four patients with small bowel obstruction were treated nonoperatively after being misdiagnosed as chronic idiopathic intestinal pseudo-obstruction. Three patients with pseudo-pseudo-obstruction developed significant morbidity, and one patient died while being treated medically. Differentiation between pseudo-obstruction and mechanical obstruction can be difficult and may require laparotomy to establish the diagnosis. Intestinal manometry suggested a mechanical cause for obstruction in two patients and should be done in all patients that carry the diagnosis of intestinal pseudo-obstruction. Other clues to the diagnosis of intestinal pseudo-obstruction are discussed. Intestinal pseudo-obstruction is an uncommon disease that should not be a diagnosis of exclusion but should be diagnosed using historical, radiographic, manometric, pathologic, and operative data.

Massive diffuse subcutaneous emphysema resulting from perforation of the proximal jejunum is presented. Seventy-nine reported instances of subcutaneous emphysema of gastrointestinal origin were reviewed. Emphysema originating from the jejunum has not been previously reported. The colon (26 patients) and rectum (16 patients) were the more common sites of perforation. Perforations of the stomach and duodenum were found in 14 patients. The most common site for presentation of the subcutaneous air was the lower abdominal wall and thigh, and the more common causes were carcinoma of the colon and rectum and diverticulitis. The pathogenesis of emphysema in the patient described, as well as in the great majority of other patients, is from intraluminal gas rather than from gas-forming organisms. The air spreads along neurovascular bundles and other anatomic planes and may rapidly reach areas distant from the perforation. The recognition of these phenomena in the diagnosis of gastrointestinal perforation is important.