Small Intestinal Diverticulosis Clinical Presentation
- Author: Rohan C Clarke, MD; Chief Editor: Julian Katz, MD more...
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 - Obscure, occult gastrointestinal bleed, fatigue, leg swelling
- Biliary tract disease - Biliary colic
- Volvulus - Intestinal obstruction
- Enteroliths - Intestinal obstruction
- Bacterial overgrowth - Flatulence
Physical findings are also related to the complications mentioned above. These findings include abdominal fullness, localized or vague tenderness, rectal bleeding, and melena. Note the following:
- 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, whereas 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 include the following:
- 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 a fenestrated diaphragm that, over time, transforms into a 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 gastrointestinal tract. Incidence at autopsy is approximately 0.3-2%. 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.
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
Harford VH. Diverticula. Feldman M, Scharschmidt BF, Zorab R, Sleisenger MH, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 6th ed. Philadelphia, Pa: WB Saunders; 1998.
Isselbacher KJ, Ebstein A. Diverticular, vascular and other disorders of the intestine and peritoneum. Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill Inc; 1998. 1648-9.
Mark B. Small intestine. Seymour I, Schwartz G, eds. Principles of Surgery. New York: McGraw-Hill Inc; 1999. 1247-9.
Kassir R, Debs T, Boutet C, et al. Intussusception of the Meckel's diverticulum within its own lumen: Unknown complication. Int J Surg Case Rep. 2015 Mar 25. 10:111-4. [Medline].
Pandove PK, Moudgil A, Pandove M, Chandrashekhar, Sharda D, Sharda VK. Meckel's diverticulum mesentery along with its band forming a hernial sac: A rare case of internal herniation. Int J Surg Case Rep. 2015 Mar 7. 10:17-19. [Medline].
Malik AA, Wani KA, Khaja AR. Meckel's diverticulum-Revisited. Saudi J Gastroenterol. 2010 Jan-Mar. 16(1):3-7. [Medline].
Wiesner W, Beglinger Ch, Oertli D, Steinbrich W. Juxtapapillary duodenal diverticula: MDCT findings in 1010 patients and proposal for a new classification. JBR-BTR. 2009 Jul-Aug. 92(4):191-4. [Medline].
Olson DE, Kim YW, Donnelly LF. CT findings in children with Meckel diverticulum. Pediatr Radiol. 2009 Jul. 39(7):659-63; quiz 766-7. [Medline].
He Q, Zhang YL, Xiao B, Jiang B, Bai Y, Zhi FC. Double-balloon enteroscopy for diagnosis of Meckel's diverticulum: comparison with operative findings and capsule endoscopy. Surgery. 2013 Apr. 153(4):549-54. [Medline].
Akhrass R, Yaffe MB, Fischer C. Small-bowel diverticulosis: perceptions and reality. J Am Coll Surg. 1997 Apr. 184(4):383-8. [Medline].
Carey EJ, Fleischer DE. Investigation of the small bowel in gastrointestinal bleeding--enteroscopy and capsule endoscopy. Gastroenterol Clin North Am. 2005 Dec. 34(4):719-34. [Medline].
Dietrich CF, Braden B. Sonographic assessments of gastrointestinal and biliary functions. Best Pract Res Clin Gastroenterol. 2009. 23(3):353-67. [Medline].
Donald JW. Major complications of small bowel diverticula. Ann Surg. 1979 Aug. 190(2):183-8. [Medline].
Eckhauser FE, Zelenock GB, Freier DT. Acute complications of jejuno-ileal pseudodiverticulosis: surgical implications and management. Am J Surg. 1979 Aug. 138(2):320-3. [Medline].
Hartmann D, Schmidt H, Bolz G. A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc. 2005 Jun. 61(7):826-32. [Medline].
Rubesin SE. Simplified approach to differential diagnosis of small bowel abnormalities. Radiol Clin North Am. 2003 Mar. 41(2):343-64, vii. [Medline].
Sanford JP, Gilbert DN, Moellering RC. The Sanford Guide to Antimicrobial Therapy 1999. Sperryville, Va: Antimicrobial Therapy, Inc; 1999. 02-1333. [Full Text].