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Small Intestinal Diverticulosis Clinical Presentation

  • Author: Rohan C Clarke, MD; Chief Editor: Julian Katz, MD  more...
 
Updated: Jun 26, 2015
 

History

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
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Physical

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%.[7] 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.
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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
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Contributor Information and Disclosures
Author

Rohan C Clarke, MD Director, Department of Gastroenterology, JPS Health Systems Hospital

Rohan C Clarke, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cubist; <br/>Received reimbursement from Boston Scientific for learning observership for eus; Received honoraria from Optimer pharmaceutical for speaking and teaching.

Coauthor(s)

Oluyinka S Adediji, MD, MBBS Consulting Staff, Department of Adult and General Medicine, Health Services Incorporated, Montgomery, Alabama

Oluyinka S Adediji, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

Lisa Anne Ozick, MD Attending Gastroenterologist, Leumit Health Clinic, Israel

Lisa Anne Ozick, MD is a member of the following medical societies: American College of Gastroenterology, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Rachael M Ferraro, DO Internal Medicine Hospitalist, Torrance Memorial Medical Center, Little Company of Mary Hospital

Rachael M Ferraro, DO is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

David Eric Bernstein, MD Director of Hepatology, North Shore University Hospital; Professor of Clinical Medicine, Albert Einstein College of Medicine

David Eric Bernstein, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, American Gastroenterological Association

Disclosure: Received grant/research funds from Novartis for other; Received grant/research funds from Bayer for other; Received grant/research funds from Otsuka for none; Received grant/research funds from Bristol Myers Squibb for other; Received none from Scynexis for none; Received grant/research funds from Salix for other; Received grant/research funds from MannKind for other.

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