Small intestinal diverticulosis refers to the clinical entity characterized by the presence of multiple saclike mucosal herniations through weak points in the intestinal wall. Small intestinal diverticula are far less common than colonic diverticula. The singular form is diverticulum, and the plural form is diverticula.
Causes
The cause of this condition is not known. It is believed to develop as the result of abnormalities in peristalsis, intestinal dyskinesis, and high segmental intraluminal pressures.
The resulting diverticula emerge on the mesenteric border, ie, sites where mesenteric vessels penetrate the small bowel. Diverticula are classified as true and false. True diverticula are composed of all layers of the intestinal wall, whereas false diverticula are formed from the herniation of the mucosal and submucosal layers. Meckel diverticulum is a true diverticulum.
Diverticula can be classified as intraluminal or extraluminal.
Intraluminal diverticula and Meckel diverticulum are congenital. Extraluminal diverticula may be found in various anatomic locations and are referred to as duodenal, jejunal, ileal, or jejunoileal diverticula.
Frequency
United States : -
Duodenal diverticula are approximately 5 times more common than jejunoileal diverticula. The actual incidence of both types of diverticula is not known because these lesions are usually asymptomatic. The incidence at autopsy of duodenal diverticula is 6-22%. Jejunal diverticula are less common, with a reported incidence of less than 0.5% on upper GI radiographs and a 0.3-1.3% autopsy incidence.
International : -
Incidence parallels that in the United States.
Mortality/Morbidity
Small bowel diverticula are generally asymptomatic, with the exception of Meckel diverticulum. Major complications include diverticulitis, GI hemorrhage, intestinal obstruction, acute perforation, and pancreatic and/or biliary disease in duodenal diverticula. Mortality is influenced by patients' age, nature of complications, and timeliness of intervention.
Race : - No racial predilection exists.
Sex : - Duodenal diverticula occur in equal numbers of men and women, while a slight male preponderance exists in jejunoileal diverticula.
Age : - Most cases of duodenal diverticula are observed in patients older than 50 years, while jejunoileal diverticula are commonly observed in patients aged 60-70 years. Reports of this condition in young adults exist as well.
Symptoms
Most patients with small bowel diverticula are asymptomatic. Patients who develop symptoms generally report symptoms that reflect associated complications. The most common symptom is nonspecific epigastric pain or a bloating sensation. Complication rates as high as 10-12% for duodenal diverticulosis and 46% for jejunal diverticulosis have been reported.
These complications include the following : -
Diverticular pain - Abdominal pain in the absence of other complications (can be the only manifestation of small bowel diverticulosis)
Bleeding - Hematochezia, melena, or obscure bleeding that leads to iron deficiency
Diverticulitis - Fever and localized tenderness associated with inflammation
Perforation and localized abscess - Fever, abdominal pain with or without signs of peritonitis
Malabsorption - Diarrhea, flatulence, weight loss
Anemia - Fatigue, leg swelling
Biliary tract disease - Biliary colic
Volvulus - Intestinal obstruction
Enteroliths - Intestinal obstruction
Physical : -
Physical findings are also related to the complications mentioned above. These findings include abdominal fullness, localized or vague tenderness, rectal bleeding, and melena.
No set of symptoms or signs is pathognomonic for small bowel diverticulosis. In the absence of complications, history and physical examination findings are often negative.
Some of these symptoms may be manifestations of other unrelated comorbid conditions. The exact rate of these complications is difficult to estimate but has been reported to be from 10-40%.
Hemorrhage and pancreaticobiliary disease are the most common complications of duodenal diverticulum, while diverticulitis and perforation are more common with jejunoileal diverticula. Intestinal obstruction is a feature of intraluminal duodenal diverticulum, while Meckel diverticulum can be complicated by peptic ulcer infection and intestinal obstruction. Most patients are diagnosed serendipitously.
Specific features based on anatomic location and type
Duodenal diverticula: These vary from a few millimeters to several centimeters and may be multiple. Approximately 75% occur within 2 cm of the ampulla of Vater (juxtapapillary). This anatomic location is of clinical significance. It is associated with increased incidence of biliary stones, pancreatitis, and biliary and pancreatic anomalies. Incidence increases with age. Fifty percent of cases have associated colonic pseudodiverticulosis.
Jejunoileal diverticula: Duodenal and Meckel diverticulum excluded, small bowel diverticula are most common in the proximal jejunum. They usually are multiple and vary from a few millimeters to 10 cm. They are located on the mesenteric border within the leaves of the mesentery. These lesions are frequently associated with small intestine motility disorders, such as progressive systemic sclerosis, visceral myopathy, and visceral neuropathies.
Intraluminal diverticula: These are congenital diverticula resulting from defective recanalization of duodenal lumen during fetal development. These structures are believed to start as fenestrated diaphragm that, over time, transforms into diverticulum as a result of peristalsis. It occurs singly and has duodenal mucosa on both sides. Intraluminal diverticula are usually located in the second part of the duodenum and can manifest at any age.
Meckel diverticulum: This congenital diverticulum results from incomplete closure of the vitelline duct during fetal development. It is the most common true diverticulum of the GI tract. Incidence at autopsy is approximately 25%. Meckel diverticulum is generally asymptomatic, causing symptoms in only 2% of adults. The mucosa occasionally contains heterotopic gastric mucosa that is often responsible for peptic ulceration and bleeding.
Causes
The following risk factors apply to acquired pseudodiverticula : -
Low-fiber diet
High-fat diet
Advancing age
Heredity: No evidence indicates that heredity plays a role in the development of small bowel diverticula.
Systemic sclerosis
Visceral myopathy
Visceral neuropathy
Diagnosis
Laboratory Studies
Laboratory tests have limited value in diagnosing small bowel diverticulosis. The following tests may be indicated.
CBC count: Elevated white blood cell (WBC) count may occur in diverticulitis. Hematocrit may drop following significant acute or chronic blood loss.
Chemistry: Liver chemistries, serum amylase, and lipase levels are performed only if indicated by clinical presentation to exclude other differential diagnoses.
Urinalysis: Urinalysis may be indicated to rule out urinary tract infection.
Blood culture: This is useful in patients presenting with fever, diverticulitis, intestinal perforation, and abscess to exclude septicemia.
Imaging Studies : -
Plain abdominal radiograph and/or chest radiograph demonstrates evidence of perforation, including air under the diaphragm; free peritoneal air; evidence of intestinal obstruction; or evidence of ileus, including multiple air-fluid levels and bowel dilatation.
Abdominal CT scan with contrast provides more information in complicated as well as uncomplicated cases. Phlegmon can be identified, especially in the retroperitoneal space, providing the initial clue to the possibility of small intestinal diverticular disease.
A double contrast barium meal and enteroclysis is useful in diagnosis but is contraindicated in acute diverticulitis or perforation.
Other Tests : -
Bleeding scan: This is used to determine the site of bleeding if the patient is hemodynamically stable. It is helpful in localizing bleeding sites, detecting bleeding as slow as 0.5 cc/min.
Mesenteric angiography: This is used for brisk hemorrhages to identify the bleeding site and offers the opportunity for mesenteric occlusion therapy.
Procedures : -
Esophagogastroduodenoscopy: This procedure yields 9-20% on all upper GI endoscopy. Endoscopic procedures are generally contraindicated in acute diverticulitis. Colonoscopy may be useful in excluding other causes. The jejunoileal diverticulum is not accessible to colonoscopy and esophagogastroduodenoscopy (EGD).
Endoscopic retrograde choledochopancreatography: This demonstrates periampullary diverticula.
Enteroscopy: Jejunum and ileum can be investigated using either the Push or Sonde types of enteroscopy. Experience is of great importance in recognizing these lesions.
Double balloon enteroscopy can help identify the presence of disease and also the cause of any obscure bleeding. This procedure can also therapeutically intervene at the identified site of bleed. This is where the small bowel is pleated proximally on the scope to advance distally through the small bowel.
Capsule endoscopy helps identify the presence of diverticular disease and also the cause of bleeding. This procedure is excluded in small bowel obstruction, acute diverticulitis, or perforation. This procedure involves swallowing a capsule with a battery source, camera, and broadcasting capacity. The signals/images are sent to a device worn on the belt and recorded for further evaluation. The pill passes in the feces and does not need to be retrieved.
Treatment
Medical Care : -
The general recommendation favors a conservative approach to the management of asymptomatic diverticula. They are generally left alone unless they can be related to diseases. In certain locations, diverticula are associated with special complications. For example, periampullary diverticula can be associated with pancreatitis, cholangitis, or recurrent choledocholithiasis after cholecystectomy. Intraluminal diverticula are observed in the duodenum.
They can be complicated by intestinal obstruction and biliary and pancreatic diseases. A higher complication rate is associated with jejunoileal diverticulosis and, as such, may justify less conservative approach to its management. Capsule endoscopy might be of value if available to identify the site of the bleed. Push enteroscopy should be used once a lesion amenable to therapeutic intervention has been identified.
Prehospital care: Acute abdomen and obvious and occult GI hemorrhage are the clinical scenarios that necessitate prehospital intervention. Vascular access, intravenous fluid, oxygen, and prompt transport to the hospital are all that is required in the field.
Medical management
Abdominal pain without clinical evidence of diverticulitis or intestinal obstruction requires no specific treatment. Patients benefit from the use of bulk-forming agents, such as fiber, bran, and cellulose products. Intractable pain associated with anemia and jejunal loop dilatation on radiograph should heighten concern for jejunal diverticulosis.
For diverticulitis, patients often require hospitalization because preoperative diagnosis of small bowel diverticulitis is difficult. Initial interventions include the following : -
Bed rest
Nothing by mouth and/or nasogastric suctioning
IV fluid
Broad-spectrum antibiotic coverage
Surgical consultation: Urgent surgery rarely is indicated unless perforation, abscess, or neoplasm is suspected.
Management of complications: The approach to management of complicated small bowel diverticula involves initiation of medical and supportive management. Surgical consultation must be performed promptly. Patients can present with the following complications:
GI bleeding and/or hemorrhage
Patient is treated with IV fluid and blood products as necessary.
Diagnostic workup is usually completed in the intensive care setting.
Most patients stop bleeding, allowing elective surgery.
Mesenteric angiography with infusion of vasoconstrictors can be used in persistent hemorrhage.
Laparotomy may be indicated as an emergency therapy for continuing bleeding or as elective treatment if bleeding responds to conservative management.
Intestinal perforation: Early surgery is the treatment of choice. Fluid and electrolyte management as well as antibiotics are essential adjuncts.
Intestinal obstruction: Initial management is similar to uncomplicated diverticulitis. Urgent surgical consultation is mandatory.
Intestinal pseudoobstruction: Cautious conservative management is indicated while excluding mechanical obstruction.
Fistula formation: This is a rare complication.
Malabsorption: This is often a complication of bacterial overgrowth resulting from blind loop syndrome. It usually responds to antibiotics.
Preoperative diagnosis of diverticula is seldom made. This can present as intussusception, volvulus, or pseudoobstruction.
Surgical Care : -
Complications of small bowel diverticulosis, such as massive bleeding or diverticulitis with perforation, require surgery. Diagnosis is seldom made preoperatively. The aim is to control complications when present and/or to prevent future complications.
Emergency surgery is indicated for severe diverticulitis, intestinal perforation, intestinal obstruction, and hemorrhage that continue after conservative management.
Several operative procedures are available depending on the type of diverticulum, site, and nature of complications.
Simple diverticulectomy
This is most commonly used for symptomatic diverticulum or bleeding diverticulum of the duodenum. The diverticulum is simply excised, and the bowel is closed longitudinally or transversely, ensuring minimal luminal stenosis.
This procedure requires modification in cases involving a diverticulum that is embedded deep in the head of the pancreas or is associated with the ampulla of Vater, is perforated, or is intraluminal in location. It can be technically difficult in the presence of common duct obstruction. These patients benefit more from choledochoduodenostomy.
Meckel diverticulum can also be removed by this technique.
Intestinal resection and end-to-end anastomosis: This is the preferred approach to jejunoileal diverticulum, which tends to be multiple, irrespective of types of complications.
Enterotomy: This can be performed solely to remove enterolith of diverticular origin causing distal obstruction.
Caveats of surgical management: Perforated duodenal diverticulum requires a special approach. Simple excision and closure may be complicated by obstruction; therefore, consider complete diversion of the bowel from the duodenum, then perform vagotomy, antrectomy, closure of the duodenal loop, and Billroth II anastomosis. Dysmotility alone without obstruction is not an indication for bowel resection because resection would not prevent propagation of motility disorder.
Consultations : -
Consultation with a general surgeon is indicated for all patients requiring surgical management.
A gastroenterologist assists with diagnosis and follow-up strategy and performs both diagnostic and therapeutic endoscopy.
Diet : -
The role of diet is not clear. A high-fiber diet that improves bowel motility and is used in colonic diverticulosis may be beneficial.
Activity : -
No restriction of activity is indicated.
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