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* This is the Professional Version. *

Diverticular Disease of the Stomach and Small Bowel

By Joel A. Baum, MD, Assistant Professor of Medicine, Chairman, Icahn School of Medicine at Mount Sinai ; Rafael Antonio Ching Companioni, MD, Icahn School of Medicine, Elmhurst Hospital Center

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Diverticula are saclike mucosa-lined pouches that protrude from a tubular structure (see also Definition of Diverticular Disease).

Diverticula rarely involve the stomach but are present in the duodenum in up to 25% of people. Most duodenal diverticula are solitary and occur in the second portion of the duodenum adjacent to or involving the ampulla of Vater (periampullary). In the remainder of the small bowel (jejunum and ileum), diverticula occur in up to 5% of patients, occur most commonly in the jejunum, and are more common among patients with disorders of intestinal motility. Meckel diverticulum occurs in the middle to distal ileum.

Most diverticula of the stomach and small bowel are asymptomatic and are detected incidentally. Complications of diverticula include bleeding, perforation, and diarrhea with malabsorption resulting from bacterial overgrowth. Asymptomatic diverticula require no treatment. Caution should be used when recommending surgery for patients who have a diverticulum and vague GI symptoms (eg, dyspepsia) because the diverticulum may well not be the cause of symptoms.

Gastric diverticula

Gastric diverticula are typically discovered as incidental findings during endoscopy or imaging studies (eg, upper GI barium studies, CT with contrast). The predominant location is the proximal portion of the stomach along the greater curvature. The size of the diverticulum ranges from 1 to 3 cm in diameter. Gastric diverticula are formed by a projection of the stomach mucosa through the muscularis but not through the entire stomach wall (perhaps due to the thickness of the muscular layers in the stomach) and are thus referred to as intramural or partial diverticula.

Gastric diverticula are usually asymptomatic, but some patients report a vague sensation of fullness and dyspepsia. Complications such as bleeding, perforation, and cancer are unusual.

No specific treatment is necessary for an asymptomatic diverticulum; management depends on the severity of symptoms. Some studies have reported that use of proton pump inhibitors for several weeks can alleviate dyspepsia. However, other data show that symptoms may be unresponsive to proton pump inhibitors or H2 blockers.

Duodenal diverticula

Duodenal diverticula can be

  • Extraluminal (which protrude outside the duodenal wall)

  • Intraluminal (which protrude into the duodenal lumen)

Extraluminal diverticula of the duodenum are common and are seen in about 25% of patients > 50 yr undergoing ERCP; they are periampullary in three quarters of these patients. A diverticulum that arises within 2- to 3-cm of the ampulla is called a juxtapapillary diverticulum. Patients are asymptomatic or complain of nonspecific abdominal symptoms.

Complications of extraluminal diverticula include bleeding, diverticulitis, and perforation. Diarrhea and malabsorption due to bacterial overgrowth can occur if multiple diverticula are present. Duodenal obstruction is extremely rare. Juxtapapillary diverticula may cause complications such as cholangitis, recurrent pancreatitis, choledocholithiasis (even after cholecystectomy), and sphincter of Oddi dysfunction.

Intraluminal diverticula or windsock diverticula are diverticula that occur entirely within the lumen. They are rare and are due to a developmental anomaly that results in a diaphragm or web across the lumen. Over time, peristalsis can pull the web and the bowel wall to which it is attached into the lumen. The invaginated bowel wall then is in effect an intraluminal pouch or diverticulum. Intraluminal diverticula typically occur in the second portion of the duodenum, the majority occurring near the ampulla of Vater. They may involve the entire circumference or only a part of the wall of the duodenum and may project as far distally as the fourth part of the duodenum. There is often a second opening located eccentrically in the diverticulum. They are usually asymptomatic, but some patients develop incomplete duodenal obstruction, perforation, or bleeding.

These diverticula can be diagnosed with upper GI barium studies, but CT with oral contrast and upper endoscopy can also be used. During upper endoscopy, a diverticulum may be incorrectly interpreted as the duodenal lumen or a large polyp. Treatment options include surgical resection when obstruction or bleeding occurs. There are a few case reports of successful endoscopic treatment where the diverticulum is unroofed to prevent food from collecting.

Jejunal and ileal diverticula

These small-bowel diverticula occur in up to 5% of the general population, and can arise in the jejunum (80%), ileum (15%), or both (5%). They are usually multiple, and their sizes range from only a few millimeters in diameter to 10 cm in length. Small-bowel diverticula lack a true muscular wall and usually are located on the mesenteric border. These diverticula may be caused by intestinal motility disorders.

Many patients are asymptomatic or report nonspecific symptoms such as recurrent abdominal pain, early satiety, bloating, loud borborygmi, and intermittent diarrhea. Complications include bleeding, diverticulitis, and perforation. Some patients can develop bacterial overgrowth and subsequent malabsorption or small-bowel volvulus which can cause obstruction.

Small-bowel diverticula are usually diagnosed by barium small-bowel series, CT enterography, or capsule endoscopy.

Conservative management is usually recommended for asymptomatic patients. Antibiotics can be prescribed for bacterial overgrowth syndrome. Surgery may be necessary for patients with perforation or diverticulitis. Surgery is usually avoided in patients with chronic intestinal pseudo-obstruction.

Key Points

  • Diverticula rarely involve the stomach but are common in the duodenum and small bowel.

  • Most diverticula are asymptomatic and are detected incidentally.

  • Complications include bleeding, perforation, and malabsorption resulting from bacterial overgrowth.

  • Asymptomatic diverticula require no treatment.

  • Be cautious about recommending surgery for patients who have a diverticulum and vague GI symptoms (eg, dyspepsia).

* This is the Professional Version. *