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 10 to 22% of people (1, 2). Most duodenal diverticula are solitary and occur in the second portion of the duodenum adjacent to or involving the ampulla of Vater (periampullary) (3). In the remainder of the small bowel (jejunum and ileum), diverticula occur in up to 1 to 2% of people (4), occur most commonly in the jejunum, and are more common among patients with disorders of intestinal motility (5). 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 gastrointestinal (GI) symptoms (eg, dyspepsia) because the diverticulum may not be the cause of the symptoms.
References
1. Ackermann W. DIVERTICULA AND VARIATIONS OF THE DUODENUM. Ann Surg. 1943;117(3):403-413. doi:10.1097/00000658-194303000-00007
2. Egawa N, Anjiki H, Takuma K, et al. Juxtapapillary duodenal diverticula and pancreatobiliary disease. Dig Surg. 2010;27(2):105-109. doi:10.1159/000286520
3. Thorson CM, Paz Ruiz PS, Roeder RA, et al. The perforated duodenal diverticulum. Arch Surg. 2012;147(1):81-88. doi:10.1001/archsurg.2011.821
4. Longo WE, Vernava AM 3rd. Clinical implications of jejunoileal diverticular disease. Dis Colon Rectum. 1992;35(4):381-388. doi:10.1007/BF02048119
5. Kongara KR, Soffer EE. Intestinal motility in small bowel diverticulosis: a case report and review of the literature. J Clin Gastroenterol. 2000;30(1):84-86. doi:10.1097/00004836-200001000-00017
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 10 to 22% of people; they are often periampullary (1, 2, 3). A diverticulum that arises within 2- to 3-cm of the ampulla is called a juxtapapillary diverticulum (4). 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 (4). 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 (4). 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.
This endoscopic image shows a duodenal diverticulum.
GASTROLAB/SCIENCE PHOTO LIBRARY
These diverticula can be diagnosed with upper GI barium studies, but CT and upper endoscopy can also be used (5). 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.
Duodenal diverticula references
1. Thorson CM, Paz Ruiz PS, Roeder RA, Sleeman D, Casillas VJ. The perforated duodenal diverticulum. Arch Surg. 2012;147(1):81-88. doi:10.1001/archsurg.2011.821
2. Egawa N, Anjiki H, Takuma K, Kamisawa T. Juxtapapillary duodenal diverticula and pancreatobiliary disease. Dig Surg. 2010;27(2):105-109. doi:10.1159/000286520
3. Ackermann W. DIVERTICULA AND VARIATIONS OF THE DUODENUM. Ann Surg. 1943;117(3):403-413. doi:10.1097/00000658-194303000-00007
4. Rangan V, Lamont JT. Small Bowel Diverticulosis: Pathogenesis, Clinical Management, and New Concepts. Curr Gastroenterol Rep. 2020;22(1):4. Published 2020 Jan 15. doi:10.1007/s11894-019-0741-2
5. Li Z, Wang D, Hu J, Zhang G, Sun J. Multi-slice spiral computed tomography diagnosis of juxta-papillary duodenal diverticulum and its relationship with biliopancreatic diseases. Technol Health Care. 2024;32(1):1-8. doi:10.3233/THC-220742
Jejunal Diverticula and Ileal Diverticula
These small-bowel diverticula are uncommon and can arise in the jejunum (80%), ileum, or both (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 (2). Antibiotics can be prescribed for small intestinal bacterial overgrowth. Surgery may be necessary for patients with perforation or diverticulitis. Bleeding may be controlled endoscopically or surgically. Surgery is usually avoided in patients with chronic intestinal pseudo-obstruction related to jejunal diverticulosis (3).
Jejunal diverticula and ileal diverticula references
1. Ghrissi R, Harbi H, Elghali MA, Belhajkhlifa MH, Letaief MR. Jejunal diverticulosis: a rare case of intestinal obstruction. J Surg Case Rep. 2016;2016(2):rjv176. Published 2016 Feb 1. doi:10.1093/jscr/rjv176
2. Rangan V, Lamont JT. Small Bowel Diverticulosis: Pathogenesis, Clinical Management, and New Concepts. Curr Gastroenterol Rep. 2020;22(1):4. Published 2020 Jan 15. doi:10.1007/s11894-019-0741-2
3. Downes TJ, Cheruvu MS, Karunaratne TB, et al. Pathophysiology, Diagnosis, and Management of Chronic Intestinal Pseudo-Obstruction. J Clin Gastroenterol. 2018;52(6):477-489. doi:10.1097/MCG.0000000000001047
Gastric Diverticula
Gastric diverticula are typically discovered as incidental findings during endoscopy or imaging studies (eg, upper GI barium studies, CT with contrast) (1). Diverticula are classified as either true or false. True diverticula involve all layers of the wall and are typically congenital. False diverticula (or pseudodiverticula) do not involve the muscular layer and are acquired over time due to intraluminal pressure. The predominant location is along the dorsal wall of the fundus.
Gastric diverticula are usually asymptomatic (1), but some patients report a vague sensation of fullness and dyspepsia. Complications such as bleeding, perforation, and cancer are unusual. Diagnosis may be with a combination of contrast radiography, CT scanning, and upper endoscopy.
No specific treatment is necessary for an asymptomatic diverticulum; management depends on the severity of symptoms (1). Proton pump inhibitors for several weeks can alleviate dyspepsia in some patients. Surgery is indicated for large or symptomatic gastric diverticula, or those with hemorrhage, ulceration, perforation, or malignant transformation.
Gastric diverticula reference
1. Shah J, Patel K, Sunkara T, Papafragkakis C, Shahidullah A. Gastric Diverticulum: A Comprehensive Review. Inflamm Intest Dis. 2019;3(4):161-166. doi:10.1159/000495463
Key Points
Diverticula are common in the duodenum, and rarer in the jejunum, ileum, and stomach.
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 gastrointestinal symptoms (eg, dyspepsia).
