Overview
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.
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
- Intestinal obstruction- Colicky abdominal pain, constipation, nausea, vomiting
- 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
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.
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.
- 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.
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