eMedicine Specialties > Gastroenterology > Intestine

Diverticulosis, Small Intestinal

Lisa Ozick, MD, Chief, Division of Gastroenterology, Harlem Hospital Center
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

Updated: Apr 12, 2006

Introduction

Background

Small intestinal diverticulosis refers to the clinical entity characterized by the presence of multiple saclike mucosal herniations through weak points in the intestinal wall. Small intestinal diverticula are far less common than colonic diverticula. The singular form is diverticulum, and the plural form is diverticula.

Pathophysiology

The resulting diverticula emerge on the mesenteric border, ie, sites where mesenteric vessels penetrate the small bowel. Diverticula are classified as true and false. True diverticula are composed of all layers of the intestinal wall, whereas false diverticula are formed from the herniation of the mucosal and submucosal layers. Meckel diverticulum is a true diverticulum.

Diverticula can be classified as intraluminal or extraluminal. Intraluminal diverticula and Meckel diverticulum are congenital. Extraluminal diverticula may be found in various anatomic locations and are referred to as duodenal, jejunal, ileal, or jejunoileal diverticula.

Frequency

United States

Duodenal diverticula are approximately 5 times more common than jejunoileal diverticula. The actual incidence of both types of diverticula is not known because these lesions are usually asymptomatic. The incidence at autopsy of duodenal diverticula is 6-22%. Jejunal diverticula are less common, with a reported incidence of less than 0.5% on upper GI radiographs and a 0.3-1.3% autopsy incidence.

International

Incidence parallels that in the United States.

Mortality/Morbidity

Small bowel diverticula are generally asymptomatic, with the exception of Meckel diverticulum. Major complications include diverticulitis, GI hemorrhage, intestinal obstruction, acute perforation, and pancreatic and/or biliary disease in duodenal diverticula. Mortality is influenced by patients' age, nature of complications, and timeliness of intervention.

Race

No racial predilection exists.

Sex

Duodenal diverticula occur in equal numbers of men and women, while a slight male preponderance exists in jejunoileal diverticula.

Age

Most cases of duodenal diverticula are observed in patients older than 50 years, while jejunoileal diverticula are commonly observed in patients aged 60-70 years. Reports of this condition in young adults exist as well.

Clinical

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 - Fatigue, leg swelling
• Biliary tract disease - Biliary colic
• Volvulus - Intestinal obstruction
• Enteroliths - Intestinal obstruction

Physical

Physical findings are also related to the complications mentioned above. These findings include abdominal fullness, localized or vague tenderness, rectal bleeding, and melena.

• 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, while 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
  • 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 fenestrated diaphragm that, over time, transforms into 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 GI tract. Incidence at autopsy is approximately 25%. 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.

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

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.

Treatment

Medical Care

The general recommendation favors a conservative approach to the management of asymptomatic diverticula. They are generally left alone unless they can be related to diseases. In certain locations, diverticula are associated with special complications. For example, periampullary diverticula can be associated with pancreatitis, cholangitis, or recurrent choledocholithiasis after cholecystectomy. Intraluminal diverticula are observed in the duodenum. They can be complicated by intestinal obstruction and biliary and pancreatic diseases. A higher complication rate is associated with jejunoileal diverticulosis and, as such, may justify less conservative approach to its management. Capsule endoscopy might be of value if available to identify the site of the bleed. Push enteroscopy should be used once a lesion amenable to therapeutic intervention has been identified.

• Prehospital care: Acute abdomen and obvious and occult GI hemorrhage are the clinical scenarios that necessitate prehospital intervention. Vascular access, intravenous fluid, oxygen, and prompt transport to the hospital are all that is required in the field.
• Medical management
  • Abdominal pain without clinical evidence of diverticulitis or intestinal obstruction requires no specific treatment. Patients benefit from the use of bulk-forming agents, such as fiber, bran, and cellulose products. Intractable pain associated with anemia and jejunal loop dilatation on radiograph should heighten concern for jejunal diverticulosis.
  • For diverticulitis, patients often require hospitalization because preoperative diagnosis of small bowel diverticulitis is difficult. Initial interventions include the following:
    • Bed rest
    • Nothing by mouth and/or nasogastric suctioning
    • IV fluid
    • Broad-spectrum antibiotic coverage
    • Surgical consultation: Urgent surgery rarely is indicated unless perforation, abscess, or neoplasm is suspected.
• Management of complications: The approach to management of complicated small bowel diverticula involves initiation of medical and supportive management. Surgical consultation must be performed promptly. Patients can present with the following complications:
  • GI bleeding and/or hemorrhage
    • Patient is treated with IV fluid and blood products as necessary.
    • Diagnostic workup is usually completed in the intensive care setting.
    • Most patients stop bleeding, allowing elective surgery.
    • Mesenteric angiography with infusion of vasoconstrictors can be used in persistent hemorrhage.
    • Laparotomy may be indicated as an emergency therapy for continuing bleeding or as elective treatment if bleeding responds to conservative management.
  • Intestinal perforation: Early surgery is the treatment of choice. Fluid and electrolyte management as well as antibiotics are essential adjuncts.
  • Intestinal obstruction: Initial management is similar to uncomplicated diverticulitis. Urgent surgical consultation is mandatory.
  • Intestinal pseudoobstruction: Cautious conservative management is indicated while excluding mechanical obstruction.
  • Fistula formation: This is a rare complication.
  • Malabsorption: This is often a complication of bacterial overgrowth resulting from blind loop syndrome. It usually responds to antibiotics.
  • Preoperative diagnosis of diverticula is seldom made. This can present as intussusception, volvulus, or pseudoobstruction.

Surgical Care

• Complications of small bowel diverticulosis, such as massive bleeding or diverticulitis with perforation, require surgery. Diagnosis is seldom made preoperatively. The aim is to control complications when present and/or to prevent future complications.
• Emergency surgery is indicated for severe diverticulitis, intestinal perforation, intestinal obstruction, and hemorrhage that continue after conservative management.
• Several operative procedures are available depending on the type of diverticulum, site, and nature of complications.
• Simple diverticulectomy
  • This is most commonly used for symptomatic diverticulum or bleeding diverticulum of the duodenum. The diverticulum is simply excised, and the bowel is closed longitudinally or transversely, ensuring minimal luminal stenosis.
  • This procedure requires modification in cases involving a diverticulum that is embedded deep in the head of the pancreas or is associated with the ampulla of Vater, is perforated, or is intraluminal in location. It can be technically difficult in the presence of common duct obstruction. These patients benefit more from choledochoduodenostomy.
  • Meckel diverticulum can also be removed by this technique.
• Intestinal resection and end-to-end anastomosis: This is the preferred approach to jejunoileal diverticulum, which tends to be multiple, irrespective of types of complications.
• Enterotomy: This can be performed solely to remove enterolith of diverticular origin causing distal obstruction.
• Caveats of surgical management: Perforated duodenal diverticulum requires a special approach. Simple excision and closure may be complicated by obstruction; therefore, consider complete diversion of the bowel from the duodenum, then perform vagotomy, antrectomy, closure of the duodenal loop, and Billroth II anastomosis. Dysmotility alone without obstruction is not an indication for bowel resection because resection would not prevent propagation of motility disorder.

Consultations

• Consultation with a general surgeon is indicated for all patients requiring surgical management.
• A gastroenterologist assists with diagnosis and follow-up strategy and performs both diagnostic and therapeutic endoscopy.

Diet

The role of diet is not clear. A high-fiber diet that improves bowel motility and is used in colonic diverticulosis may be beneficial.

Activity

No restriction of activity is indicated.

Medication

Antibiotics are important in the management of diverticulitis and related complications.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting. Antibiotic combinations are usually recommended for serious gram-negative bacillary infections. This approach ensures coverage for a broad range of organisms and polymicrobial infections. In addition, it prevents resistance from bacterial subpopulations and provides additive or synergistic effects. Once organisms and sensitivities are known, the use of antibiotic monotherapy is then recommended. Antibiotics can be administered PO in mild disease and unambiguous diagnosis, otherwise administer IV.

Metronidazole (Flagyl)

Active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells and the intermediate metabolized compounds that are formed, binding DNA and inhibiting protein synthesis, which causes cell death.

Dosing

Adult

15 mg/kg IV loading dose, followed by 500 mg PO/IV q6h

Pediatric

Not established

Interactions

Cimetidine may increase toxicity of metronidazole; may increase effects of anticoagulants; may increase toxicity of lithium and phenytoin; disulfiramlike reaction may occur with orally ingested ethanol

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Clindamycin (Cleocin)

Effective against aerobic and anaerobic streptococci but not enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where it preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.

Dosing

Adult

300-900 mg IV/IM q6h

Pediatric

Not established

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment is necessary in renal insufficiency; associated with severe and possibly fatal colitis; caution in neonates

Ampicillin (Marcillin, Omnipen, Polycillin, Principen, Totacillin)

Interferes with bacterial cell wall synthesis during active multiplication, causing bactericidal activity against susceptible organisms.

Dosing

Adult

1-2 g PO divided qid
2-8 g IV/IM divided qid

Pediatric

Not established

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Amoxicillin (Trimox, Amoxil, Biomox)

Can be used PO when outpatient treatment is indicated. Interferes with the synthesis of cell wall mucopeptide during active multiplication, resulting in a bactericidal activity against susceptible bacteria.

Dosing

Adult

500 mg PO tid

Pediatric

Not established

Interactions

Reduces efficacy of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in renal impairment

Ciprofloxacin (Cipro)

Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.

Dosing

Adult

250-500 mg PO q12h
200-400 mg IV q12h

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants; monitor PT

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Imipenem and cilastin (Primaxin)

Used for treatment of multiple organism infections as in peritonitis when other agents are not appropriate.

Dosing

Adult

250-500 mg IV q6h

Pediatric

<12 years: Not recommended
>12 years: Not established

Interactions

Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Adjust dose in renal insufficiency

Cefoxitin (Mefoxin)

Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative bacteria may respond to cefoxitin.

Dosing

Adult

1-2 g IV/IM q6-8h or 1-2 g IV/IM q4h in severe cases

Pediatric

Not established

Interactions

Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis

Ticarcillin and clavulanate potassium (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most gram-negative bacteria and most anaerobes.

Dosing

Adult

3 g ticarcillin and 0.1 g clavulanate IV over 30 min q4-6h

Pediatric

Not established

Interactions

Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels

Contraindications

Documented hypersensitivity; severe pneumonia; bacteremia; pericarditis; emphysema; meningitis; treatment of purulent or septic arthritis with oral penicillin during acute stage

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Perform CBC count prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; exercise caution in patients diagnosed with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions

Ampicillin and sulbactam sodium (Unasyn)

Drug combination antimicrobial agents consisting of a beta-lactamase inhibitor and ampicillin. Active against skin, enteric flora, and anaerobes.

Dosing

Adult

1 g ampicillin and 0.5 g sulbactam IV q6h or 2 g ampicillin and 1 g sulbactam IV q6h

Pediatric

Not established

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Follow-up

Further Inpatient Care

• Inpatient treatment is indicated only in patients presenting with complications. The duration of such admission depends on the nature of the complication and the interventions rendered. Once inflammation/infection has resolved, endoscopic modalities may be employed to further evaluate and treat, if possible.

Further Outpatient Care

• No special follow-up care is necessary.
• Educate patients concerning the likely complications of small intestinal diverticulosis. Recommend a high-fiber diet posthospitalization.
• Patients should know that symptoms must be promptly reported to their physician.

Deterrence/Prevention

• Preventive care is not available. A high-fiber diet may be useful.

Complications

• Chronic abdominal pain
• Diverticulitis
• Intestinal obstruction
• Intestinal hemorrhage
• Malabsorption

Prognosis

• Prognosis is good even with complications.

Patient Education

• Patients should understand the benign nature of the disease.
• Patients should know where to seek help if complications develop.
• Patients should know that no definitive cure for this entity exists.
• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Diverticulosis and Diverticulitis.

Miscellaneous

Medicolegal Pitfalls

• A high index of clinical awareness is needed to avoid missing this condition. Therefore, any patient with unresolved symptoms, complications, or recurrent symptoms should be evaluated further. The diagnosis can still be missed.

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].

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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

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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