What is the initial management for an adult patient with no significant past medical history presenting with jejunitis?

Management of Jejunitis

For an adult patient with no significant past medical history presenting with jejunitis, initial management depends critically on hemodynamic stability and presence of complications: hemodynamically stable patients without peritonitis should receive IV antibiotics with transition to oral as soon as possible, while those with peritonitis, perforation, or hemodynamic instability require urgent surgical intervention. 1

Initial Assessment and Risk Stratification

Immediately assess for signs of peritonitis, hemodynamic instability, and complications including:

• Generalized peritonitis or rebound tenderness 1
• Signs of shock or hemodynamic compromise 1
• Evidence of perforation (pneumoperitoneum on imaging) 1
• Intestinal obstruction or hemorrhage 2
• Large abscess formation (>4 cm on CT) 1

The underlying etiology must be considered, as jejunitis can represent jejunal diverticulitis, Crohn's disease, eosinophilic enteritis, or celiac-associated ulcerative jejunitis, each with different management implications. 1, 2, 3

Management Algorithm Based on Clinical Presentation

For Uncomplicated Jejunitis (Hemodynamically Stable, No Peritonitis)

Non-operative management (NOM) with IV antibiotics is the treatment of choice if the patient shows no signs of hemodynamic compromise. 1

• Initiate broad-spectrum IV antibiotics immediately 1
• Transition to oral antibiotics as soon as clinically appropriate 1
• Serial clinical examinations every 3-6 hours to monitor for deterioration 4
• Obtain cultures if drainage or aspiration is performed to guide antibiotic therapy 1

Common pitfall: Delaying surgical consultation when clinical deterioration occurs—patients who fail NOM must proceed to surgery expeditiously without delay. 1

For Complicated Jejunitis with Abscess Formation

If a large abscess (>4 cm) is visualized on CT scan, percutaneous drainage in addition to antimicrobial therapy is indicated. 1

• Radiological drainage provides both therapeutic benefit and allows cultural analysis to adapt antimicrobial treatment 1
• If percutaneous drainage is unavailable, manage with antibiotics but maintain low threshold for surgery if signs of sepsis or shock develop 1
• Patients failing this approach require expedited surgical intervention 1

For Jejunitis with Peritonitis or Hemodynamic Instability

Urgent surgical treatment is mandatory for patients presenting with generalized peritonitis, perforation, or hemodynamic instability. 1

Surgical options based on patient stability:

• For clinically stable patients: Intestinal resection with primary anastomosis is the best surgical option 1
• For unstable patients with shock and generalized fecal peritonitis: Intestinal resection with stoma creation should be considered to minimize operative time and avoid poor outcomes 1
• Damage control surgery principles apply in severely unstable patients 1

Critical caveat: Surgery is the preferred treatment for jejuno-ileal pathology due to high mortality and morbidity when managed conservatively, despite lack of formal consensus guidelines. 1

Special Considerations by Etiology

Crohn's Disease-Related Jejunitis

Patients with jejunal Crohn's disease have poorer prognosis and should be considered for early introduction of biological therapy. 1

• Jejunal involvement is associated with higher rates of stricturing disease and need for repeated surgery compared to terminal ileal disease 1
• Nutritional assessment and support is essential 1
• For mild disease without complications, trial of medical management with corticosteroids and early anti-TNF therapy 1

Celiac-Associated Ulcerative Jejunitis

This represents a rare but serious complication with high mortality risk (50% in recent series). 2

• Corticosteroids have shown no effectiveness in published case series 2
• Surgical resection may be required for obstruction or hemorrhage 2
• High risk of progression to enteropathy-associated T-cell lymphoma 2
• Strict gluten-free diet is essential, though outcomes remain variable 2, 5

Eosinophilic Jejunitis

Corticosteroids and montelukast are effective for eosinophilic jejunitis. 3

• Identify and eliminate triggering factors (smoking, specific foods) 3
• Endoscopic evaluation with biopsy confirms diagnosis 3

Nutritional Support

Nutritional assessment and support should be initiated early, particularly in patients with extensive small bowel involvement. 1

• Oral supplements and dietary adjustments as first-line 1
• Gastric feeding if oral route unsuccessful and patient not vomiting 1
• Jejunal feeding via nasojejunal tube, then PEGJ or direct jejunostomy if gastric feeding fails 1
• Parenteral support if jejunal feeding causes abdominal distension or pain 1

Monitoring and Follow-Up

Close monitoring is essential to detect treatment failure early:

• Serial clinical examinations every 3-6 hours in acute phase 4
• Monitor for signs of ongoing peritonitis, sepsis, or hemodynamic deterioration 4
• Low threshold for repeat imaging if clinical deterioration occurs 1
• Consider drain placement near surgical sites to monitor for leakage 4

Critical pitfall: Attempting conservative management with antibiotics alone when surgical intervention is indicated leads to increased morbidity and mortality. 1, 4