Diagnostic Image: Small bowel diverticulosis

A. Aravinth1 *, T. Elammullai 2

1 Consultant, Department of Surgical Gastroenterology, Kauvery Hospital, Trichy, India

2 1st year DNB General Surgery Postgraduate, Department of Surgical Gastroenterology, Kauvery Hospital, Trichy, India

*Correspondence: [email protected]

Introduction:

Diverticula are sac-like protrusions of the bowel wall and can occur throughout the small bowel but are most often found in the duodenum. Bowel diverticula are classified as congenital or acquired based on the etiology. Diverticula can be also classified as intra- and extraluminal and based on their anatomic location as duodenal, jejunal, ileal, or jejunoileal. Majority of diverticula are extraluminal and acquired. Intraluminal and Meckel diverticula are congenital. Small bowel diverticula are usually asymptomatic and are discovered incidentally.

Epidemiology:

In a 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(1). Duodenal diverticula have been reported in 2 to 5 percent of patients undergoing barium studies of the upper gastrointestinal tract, 10 percent of patients undergoing endoscopic retrograde cholangiopancreatography(2,3). The most common duodenal location is near the papilla of Vater, while less than 10 percent of duodenal diverticula are located in the first and fourth part of the duodenum. Jejunoileal diverticula are rare and reported to affect 0.3 to 1.9 percent of individuals in radiographic series(4). They are more commonly reported in men with the highest incidence in the sixth and seventh decades of life. Sixty Percent of patients with small bowel diverticula have concurrent colonic diverticula.

Figure 1: Axial CT Scan images showing Jejunal Diverticulosis

Figure 2: Same Imaged marked for better understanding; Blue line marks Antimesenteric border of jejunum and Red line marks the Jejunal Diverticulosis.

Figure 3: Intraoperative image of the same patient showing Jejunal Diverticulosis

Etiopathogenesis

Diverticula are thought to be acquired as a result of herniation through a defect caused by the entrance of large vessels supplying the bowel wall. A combination of increased intraluminal pressures and intrinsic weakness of the muscular layer is thought to play a role. Intraluminal duodenal diverticula are rare congenital anomalies, known as “windsock diverticula,” resulting from an incomplete canalization of the foregut, producing a duodenal diaphragm or web during embryonic development(5).

Jejunoileal diverticula are usually multiple and localized to the proximal jejunum. Distal jejunum and ileum are less frequently affected. The etiology is unclear, but intestinal dysmotility and high intraluminal pressures are thought to play a role. They are frequently associated with intestinal dysmotility conditions, such as progressive systemic sclerosis, visceral neuropathies, and myopathies(6). In patients with visceral myopathy, atrophy of the jejunal wall and increased luminal pressure may lead to the protrusion of the mucosa through defects in the lamina muscularis mucosae, where the supplying blood vessels, vasa recta, penetrates the bowel wall, resulting in the formation of diverticula on the mesenteric side of the bowel.

Clinical Manifestations:

Most patients with small bowel diverticula are asymptomatic. Patients with small bowel diverticula, particularly jejunoileal diverticula, may present with early satiety, bloating, and chronic upper abdominal discomfort and diarrhea/steatorrhea due to bacterial overgrowth(7). Duodenal diverticulosis most commonly presents with postprandial epigastric abdominal cramping pain and vomiting due to partial or intermittent duodenal obstruction. Extraluminal duodenal diverticula, located 2 to 3 cm adjacent to the ampulla, are also known as juxta-papillary or periampullary diverticula. These are associated with an increased risk of choledocholithiasis with bilirubin-containing pigment stones.

Complications

Jejuno-ileal Diverticulosis are more likely to be develop complications (10%) compared to duodenal diverticula (5%)(8). Common Complications Are;

Acute diverticulitis

Gastrointestinal bleeding

Small bowel obstruction

Obstructive recurrent pancreatitis

Diagnosis

Small bowel diverticulosis is often diagnosed incidentally in patients undergoing upper endoscopy or abdominal imaging for evaluation of upper gastrointestinal symptoms. In endoscopy -Extraluminal small bowel diverticula appear as a blind saccular outpouching of the bowel wall. Intraluminal duodenal diverticula have a polypoid appearance.

Management

Patients with asymptomatic small intestinal diverticulosis do not require any treatment. The management in symptomatic patients is based on the clinical presentation.  Diarrhea and malabsorption due to small intestinal bacterial overgrowth is treated with antibiotic therapy. Management of patients with acute uncomplicated diverticulitis typically includes a restricted diet and antibiotics. Surgical management is reserved for bowel perforation, fistula, or abscess and in patients with refractory gastrointestinal bleeding.

References:

  • Akhrass R, Yaffe M, Fischer C, Ponsky J, Shuck J. Small-bowel diverticulosis: perceptions and reality. J Am Coll Surg. 1997; Apr;184(4):383-8.
  • Transue DL, Hanna TN, Shekhani H, Rohatgi S, Khosa F, Johnson JO. Small bowel diverticulitis: an imaging review of an uncommon entity. Emerg Radiol. 2017 Apr 1;24(2):195–205.
  • Egawa N, Anjiki H, Takuma K, Kamisawa T. Juxtapapillary duodenal diverticula and pancreatobiliary disease. Dig Surg. 2010 Jun;27(2):105–9.
  • Dymarkowski S, De Peuter B, Box I, Vanheste R. Small-bowel Diverticulosis:Imaging Findings and Review of Three Cases. Gastroenterol Res Pract. 2009; 2009:549853. doi: 10.1155/2009/549853.
  • Law R, Topazian M, Baron TH. Endoscopic treatment of intraluminal duodenal (“windsocko”) diverticulum: Varying techniques from five cases. Endoscopy. 2012;44(12):1161–4.
  • 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 Sep 1;85(3):538–47.
  • Palder SB, Frey CB. Jejunal Diverticulosis. Archives of Surgery. 1988 Jul 1;123(7):889–94.
  • Wang LW, Chen P, Liu J, Jiang ZW, Liu XX. Small bowel diverticulum with enterolith causing intestinal obstruction: A case report. World J Gastrointest Surg [Internet]. 2023 Jun 27 ;15(6):1256–61.

Dr-Aravinth

Dr. A. Aravinth
Consultant – Department of Surgical Gastroenterology

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