Diverticular Disease of the Stomach and Small Bowel

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 a 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. Proton pump inhibitors for several weeks can alleviate dyspepsia in some patients (1).

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 approximately 22% of people and are often periampullary (1, 2). A diverticulum that arises within 2- to 3-cm of the ampulla is called a juxtapapillary diverticulum. Patients are asymptomatic or have 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 multi-slice spiral computed tomography (MSCT) and upper endoscopy can also be used (3). 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.

These small-bowel diverticula are uncommon and can arise in the jejunum (80%), ileum (15%), or both (5%) (1). They are usually multiple, and their sizes range from only a few millimeters to 10 cm in diameter. 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 enteroscopy (anterograde or retrograde), barium small-bowel series, CT enterography, MRI enterography, or capsule endoscopy.

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