eMedicine Specialties > Gastroenterology > Intestine

Diverticulosis, Small Intestinal: Differential Diagnoses & Workup

Author: Lisa Ozick, MD, Chief, Division of Gastroenterology, Harlem Hospital Center
Coauthor(s): Rohan C Clarke, MD, Attending Gastroenterologist, JPS Health Systems Hospital, Fort Worth, Texas; Oluyinka S Adediji, MD, Consulting Staff, Department of Adult and General Medicine, Health Services Incorporated, Montgomery, Alabama
Contributor Information and Disclosures

Updated: Apr 12, 2006

Differential Diagnoses

Upper Gastrointestinal Bleeding
Upper Gastrointestinal Bleeding: Surgical Perspective

Other Problems to Be Considered

Bowel Obstruction, Small
Pancreatitis

Workup

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.

Imaging Studies

  • Plain abdominal radiograph and/or chest radiograph demonstrates evidence of perforation, including air under the diaphragm; free peritoneal air; evidence of intestinal obstruction; or evidence of ileus, including multiple air-fluid levels and bowel dilatation.
  • Abdominal CT scan with contrast provides more information in complicated as well as uncomplicated cases. Phlegmon can be identified, especially in the retroperitoneal space, providing the initial clue to the possibility of small intestinal diverticular disease.
  • A double contrast barium meal and enteroclysis is useful in diagnosis but is contraindicated in acute diverticulitis or perforation.

Other Tests

  • Bleeding scan: This is used to determine the site of bleeding if the patient is hemodynamically stable. It is helpful in localizing bleeding sites, detecting bleeding as slow as 0.5 cc/min.
  • Mesenteric angiography: This is used for brisk hemorrhages to identify the bleeding site and offers the opportunity for mesenteric occlusion therapy.

Procedures

  • 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.

Histologic Findings

See Pathophysiology.

More on Diverticulosis, Small Intestinal

Overview: Diverticulosis, Small Intestinal
Differential Diagnoses & Workup: Diverticulosis, Small Intestinal
Treatment & Medication: Diverticulosis, Small Intestinal
Follow-up: Diverticulosis, Small Intestinal
References
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References

  1. Akhrass R, Yaffe MB, Fischer C. Small-bowel diverticulosis: perceptions and reality. J Am Coll Surg. Apr 1997;184(4):383-8. [Medline].

  2. Carey EJ, Fleischer DE. Investigation of the small bowel in gastrointestinal bleeding--enteroscopy and capsule endoscopy. Gastroenterol Clin North Am. Dec 2005;34(4):719-34. [Medline].

  3. Donald JW. Major complications of small bowel diverticula. Ann Surg. Aug 1979;190(2):183-8. [Medline].

  4. Eckhauser FE, Zelenock GB, Freier DT. Acute complications of jejuno-ileal pseudodiverticulosis: surgical implications and management. Am J Surg. Aug 1979;138(2):320-3. [Medline].

  5. Harford VH. Diverticula. In: 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 and Co;1998.

  6. 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. Jun 2005;61(7):826-32. [Medline].

  7. Isselbacher KJ, Ebstein A. Diverticular, vascular and other disorders of the intestine and peritoneum. In: Fauci A, ed. Harrison's Principles of Internal Medicine. New York, NY:. McGraw-Hill Inc;1998:1648-1649.

  8. Mark B. Small Intestine. In: Seymour I, Schwartz G, eds. Principles of Surgery. New York, NY:. McGraw-Hill Inc;1999:1247-1249.

  9. Rubesin SE. Simplified approach to differential diagnosis of small bowel abnormalities. Radiol Clin North Am. Mar 2003;41(2):343-64, vii. [Medline].

  10. Sanford JP, Gilbert DN, Moellering RC. The Sanford Guide to Antimicrobial Therapy 1999. USA Antibiotic Therapy Incorporation. 1999;02-1333. [Full Text].

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Further Reading

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Keywords

diverticular disease of the small bowel, mucosal herniations, abnormalities in peristalsis, intestinal dyskinesis, high segmental intraluminal pressures, true diverticula, false diverticula, Meckel's diverticulum, intraluminal diverticula, extraluminal diverticula, duodenal diverticula, jejunal diverticula, ileal diverticula, jejunoileal diverticula, diverticulitis, GI hemorrhage, intestinal obstruction, acute perforation, pancreatic disease, biliary disease

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Contributor Information and Disclosures

Author

Lisa Ozick, MD, Chief, Division of Gastroenterology, Harlem Hospital Center
Lisa Ozick, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Rohan C Clarke, MD, Attending Gastroenterologist, JPS Health Systems Hospital, Fort Worth, Texas
Rohan C Clarke, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Oluyinka S Adediji, MD, Consulting Staff, Department of Adult and General Medicine, Health Services Incorporated, Montgomery, Alabama
Oluyinka S Adediji, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

David Eric Bernstein, MD, Chief, Section of Hepatology, North Shore University Hospital, Director, Associate Professor, Department of Internal Medicine, Division of Hepatology, New York University School 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, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Douglas M Heuman, MD, FACP, Director of Hepatology, McGuire Veterans Affairs Medical Center, Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Douglas M Heuman, MD, FACP is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
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 and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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