Small bowel diverticula: Clinical manifestations, diagnosis, and management
- Vladan Milovic, MD, PhD
Vladan Milovic, MD, PhD
- Associate Professor of Medicine
- Head, Department of Gastroenterology & Oncology Reha-Zentrum Bad Reichenhall /
- Bayerisch Gmain Klinik Hochstaufen Bayerisch Gmain
- Bayern, Germany
Diverticula are sac-like protrusions of the bowel wall and occur throughout the small and large bowel. Small bowel diverticula are usually asymptomatic and are discovered incidentally. This topic will review the clinical manifestations, diagnosis, and management of small bowel diverticula with the exception of Meckel's diverticulum. The clinical manifestations, diagnosis, and management of Meckel’s diverticulum and the epidemiology and pathophysiology of colonic diverticular disease, the treatment of diverticulitis, and diverticular bleeding are discussed separately. (See "Lower gastrointestinal bleeding in children: Causes and diagnostic approach", section on 'Meckel's diverticulum' and "Colonic diverticulosis and diverticular disease: Epidemiology, risk factors, and pathogenesis" and "Clinical manifestations and diagnosis of acute diverticulitis in adults" and "Colonic diverticular bleeding".)
Duodenal diverticula have been reported in 2 to 5 percent of patients undergoing barium studies of the upper gastrointestinal tract and in 7 percent of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) . Jejunal diverticula have been reported in up to 1 to 2 percent of patients in autopsy series .
Small bowel diverticula occur most frequently in the duodenum. In one retrospective review of 208 patients with symptomatic small bowel diverticulosis, diverticula were located in the duodenum in 79 percent, in the jejunum or ileum in 18 percent, and in all three segments in 3 percent .
ETIOLOGY AND PATHOGENESIS
Duodenal diverticula usually occur near the papilla of Vater [1,3]. Less than 10 percent of duodenal diverticula are located in the first and fourth part of the duodenum. The vast majority of duodenal diverticula are extraluminal and are thought to be acquired as a result of herniation through a defect caused by the entrance of large vessels [1,4,5]. Intraluminal diverticula are usually congenital and result from incomplete canalization of the intestinal lumen after the embryonic proliferative epithelial stage, producing a duodenal diaphragm or web . Intraluminal diverticula are lined on both sides with duodenal mucosa, and an eccentric opening is usually proximal in the sac. Extraluminal duodenal diverticula are associated with an increased risk of pigment stones, possibly due to bacterial contamination of the biliary tree due to stasis within the diverticula resulting in deconjugation of bilirubin glucuronide [1,5].
Jejunal diverticula are usually multiple and localized to the proximal jejunum. Jejunoileal diverticula may be composed of mucosa and submucosa only, or of all layers of the jejunal wall. They are frequently associated with disorders of intestinal motility, such as progressive systemic sclerosis, visceral neuropathies, and myopathies. Familial aggregation has been described in case series, suggesting that some cases may be heritable [7,8]. The cause of jejunoileal diverticula is unclear, but abnormalities in peristalsis, intestinal dyskinesia, and high intraluminal pressure have been implicated in the pathogenesis. In patients with visceral myopathy, atrophy of the jejunal wall from one side and increased luminal pressure from the other may lead to the protrusion of the small intestinal mucosa through the defects in the lamina muscularis mucosae, resulting in the formation of small intestinal diverticula .
- Leivonen MK, Halttunen JA, Kivilaakso EO. Duodenal diverticulum at endoscopic retrograde cholangiopancreatography, analysis of 123 patients. Hepatogastroenterology 1996; 43:961.
- De Peuter B, Box I, Vanheste R, Dymarkowski S. Small-bowel diverticulosis:imaging findings and review of three cases. Gastroenterol Res Pract 2009; 2009:549853.
- Akhrass R, Yaffe MB, Fischer C, et al. Small-bowel diverticulosis: perceptions and reality. J Am Coll Surg 1997; 184:383.
- Psathakis D, Utschakowski A, Müller G, et al. Clinical significance of duodenal diverticula. J Am Coll Surg 1994; 178:257.
- Miyazawa Y, Okinaga K, Nishida K, Okano T. Recurrent common bile duct stones associated with periampullary duodenal diverticula and calcium bilirubinate stones. Int Surg 1995; 80:120.
- Fleming CR, Newcomer AD, Stephens DH, Carlson HC. Intraluminal duodenal diverticulum. Report of two cases and review of the literature. Mayo Clin Proc 1975; 50:244.
- Koch AD, Schoon EJ. Extensive jejunal diverticulosis in a family, a matter of inheritance? Neth J Med 2007; 65:154.
- Andersen LP, Schjoldager B, Halver B. Jejunal diverticulosis in a family. Scand J Gastroenterol 1988; 23:672.
- Krishnamurthy S, Kelly MM, Rohrmann CA, Schuffler MD. Jejunal diverticulosis. A heterogenous disorder caused by a variety of abnormalities of smooth muscle or myenteric plexus. Gastroenterology 1983; 85:538.
- Palder SB, Frey CB. Jejunal diverticulosis. Arch Surg 1988; 123:889.
- Chiu KW, Changchien CS, Chuah SK. Small-bowel diverticulum: is it a risk for small-bowel volvulus? J Clin Gastroenterol 1994; 19:176.
- Jochmans I, Pirenne J. IMAGES IN CLINICAL MEDICINE. Jejunal Diverticulosis with Midgut Volvulus and Intestinal Malrotation. N Engl J Med 2016; 375:e2.
- Chendrasekhar A, Timberlake GA. Perforated jejunal diverticula: an analysis of reported cases. Am Surg 1995; 61:984.
- Novak JS, Tobias J, Barkin JS. Nonsurgical management of acute jejunal diverticulitis: a review. Am J Gastroenterol 1997; 92:1929.
- Eriguchi N, Aoyagi S, Nakayama T, et al. Ileo-abdominal wall fistula caused by diverticulum of the ileum. J Gastroenterol 1998; 33:272.
- Yang CW, Chen YY, Yen HH, Soon MS. Successful double balloon enteroscopy treatment for bleeding jejunal diverticulum: a case report and review of the literature. J Laparoendosc Adv Surg Tech A 2009; 19:637.
- Wilcox RD, Shatney CH. Massive rectal bleeding from jejunal diverticula. Surg Gynecol Obstet 1987; 165:425.
- Spiegel RM, Schultz RW, Casarella WJ, Wolff M. Massive hemorrhage from jejunal diverticula. Radiology 1982; 143:367.
- Mendonca HL, Vieta JO, Ling WS. Jejunal diverticulosis with massive hemorrhage. Am J Gastroenterol 1978; 70:657.
- Terada T. Diverticulitis of multiple diverticulosis of the terminal ileum. Int J Clin Exp Pathol 2013; 6:521.
- Kirshtein B, Perry ZH, Klein J, et al. Giant enterolith in ileal diverticulum following ileoplastic bladder augmentation. Int J Surg Case Rep 2013; 4:385.
- Harris LM, Volpe CM, Doerr RJ. Small bowel obstruction secondary to enterolith impaction complicating jejunal diverticulitis. Am J Gastroenterol 1997; 92:1538.
- Lobo DN, Braithwaite BD, Fairbrother BJ. Enterolith ileus complicating jejunal diverticulosis. J Clin Gastroenterol 1999; 29:192.
- Kongara KR, Soffer EE. Intestinal motility in small bowel diverticulosis: a case report and review of the literature. J Clin Gastroenterol 2000; 30:84.
- Tsiotos GG, Farnell MB, Ilstrup DM. Nonmeckelian jejunal or ileal diverticulosis: an analysis of 112 cases. Surgery 1994; 116:726.
- Vernava AM 3rd, Moore BA, Longo WE, Johnson FE. Lower gastrointestinal bleeding. Dis Colon Rectum 1997; 40:846.
- Lough E, Richmond B, Maxwell D, Hayes JD. Obstructing phytobezoar arising from proximal jejunal diverticulum. Am J Surg 2008; 195:106.
- Gayer G, Zissin R, Apter S, et al. Acute diverticulitis of the small bowel: CT findings. Abdom Imaging 1999; 24:452.
- Blam ME, Metz DC. Image of the month. A wind sock web deformity of the proximal duodenum. Gastroenterology 2000; 119:292, 602.
- Yoon YS, Park IJ, Lee KH, et al. [Should small bowel diverticula be removed?]. Korean J Gastroenterol 2004; 44:275.
- ETIOLOGY AND PATHOGENESIS
- CLINICAL MANIFESTATIONS
- Asymptomatic/mild symptoms
- - Complete small bowel obstruction
- - Diverticulitis
- - Gastrointestinal bleeding
- Rare manifestations
- DIFFERENTIAL DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS