Medical Care
Clinicians must maintain a high index of clinical awareness to avoid missing small intestinal diverticulosis. Therefore, any patient with unresolved symptoms, complications, or recurrent symptoms should be evaluated further.
The general recommendation favors a conservative approach to the management of asymptomatic diverticula. These lesions 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 and 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 a less conservative approach to its management. Capsule endoscopy might be of value, if available, to identify the site of the bleeding. Push enteroscopy or double balloon enteroscopy should be used once a lesion amenable to therapeutic intervention has been identified.
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.
Prehospital care
Acute abdomen and obvious or occult gastrointestinal (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.
When diverticula are secondary to small bowel dysmotility, no specific intervention is warranted, other than surgical if complications arise.
For diverticulitis, patients often require hospitalization because preoperative diagnosis of small bowel diverticulitis is difficult. Initial interventions include the following:
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Bed rest
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Nothing by mouth and/or nasogastric suctioning
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IV fluid
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Broad-spectrum antibiotic coverage
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Surgical consultation: Urgent surgery rarely is indicated unless perforation, abscess, or neoplasm is suspected.
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 and activity
The role of diet is not clear. A high-fiber diet that improves bowel motility and is used in colonic diverticulosis may be beneficial.
No restriction of activity is indicated.
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.
GI bleeding and/or hemorrhage
Note the following:
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Patient is treated with intravenous (IV) fluid and blood products as necessary.
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Diagnostic workup is usually completed in the intensive care setting.
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Most patients stop bleeding, allowing elective surgery.
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Mesenteric angiography with infusion of vasoconstrictors can be used in persistent hemorrhage.
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Laparotomy may be indicated as an emergency therapy for continuing bleeding or as elective treatment if bleeding responds to conservative management. The site of the diverticulum should be identified with angiography and the area should be injected with methylene blue or India ink in order to stain the mesentery involving the bleeding diverticulum.
Intestinal perforation
Early surgery is the treatment of choice for patients with intestinal perforation. Fluid and electrolyte management as well as antibiotics are essential adjuncts.
Intestinal obstruction
Initial management of intestinal obstruction is similar to uncomplicated diverticulitis. Urgent surgical consultation is mandatory.
Intestinal pseudoobstruction
Cautious conservative management is indicated for intestinal pseudoobstruction while excluding mechanical obstruction.
Fistula formation
Fistula formation is a rare complication.
Malabsorption
Malabsorption is often a complication of bacterial overgrowth resulting from blind loop syndrome. It usually responds to antibiotics.
Diverticula
Preoperative diagnosis of diverticula is seldom made. This can present as intussusception, volvulus, or pseudoobstruction.
Flatulence and bloating
Flatulence and bloating are other complications of bacterial overgrowth, which usually responds to antibiotic therapy.
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 continues after conservative management.
Several operative procedures are available depending on the type of diverticulum, site, and nature of complications.
Simple diverticulectomy is most commonly used for a symptomatic diverticulum or a bleeding diverticulum of the duodenum. The diverticulum is simply excised, and the bowel is closed transversely in the Heineke–Mikulicz (H-M) fashion, 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. A bleeding Meckel diverticulum should require resection of a couple inches of small bowel on either end of the Meckel diverticulum, because bleeding is almost always from an adjacent ileal ulceration.
Short segment intestinal resection and end-to-end anastomosis is the preferred approach to jejunoileal diverticulum, which tends to be multiple, irrespective of the type of complication.
Enterotomy 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.
Prevention
Preventive care is not available, although a high-fiber diet may be useful.
Long-Term Monitoring
No special follow-up care is necessary. However, 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.
