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. 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 can be

Extraluminal diverticula of the duodenum are common and are seen in about 25% of patients > 50 years of age who are undergoing endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) Imaging is essential for accurately diagnosing biliary tract disorders and is important for detecting focal liver lesions (eg, abscess, tumor). It is limited in detecting and diagnosing diffuse... read more ; they are periampullary in 75% 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 Overview of Gastrointestinal Bleeding Gastrointestinal (GI) bleeding can originate anywhere from the mouth to the anus and can be overt or occult. The manifestations depend on the location and rate of bleeding. (See also Varices... read more , diverticulitis Colonic Diverticulitis Diverticulitis is inflammation with or without infection of a diverticulum, which can result in phlegmon of the bowel wall, peritonitis, perforation, fistula, or abscess. The primary symptom... read more , and perforation Acute Perforation of the Gastrointestinal Tract Any part of the gastrointestinal tract may become perforated, releasing gastric or intestinal contents into the peritoneal space. Causes vary. Symptoms develop suddenly, with severe pain followed... read more . Diarrhea and malabsorption Overview of Malabsorption Malabsorption is inadequate assimilation of dietary substances due to defects in digestion, absorption, or transport. Malabsorption can affect macronutrients (eg, proteins, carbohydrates, fats)... read more due to bacterial overgrowth Small Intestinal Bacterial Overgrowth (SIBO) Small intestinal bacterial overgrowth can result from alterations in intestinal anatomy or gastrointestinal motility, or lack of gastric acid secretion. This condition can lead to vitamin deficiencies... read more can occur if multiple diverticula are present. Duodenal obstruction is extremely rare. Juxtapapillary diverticula may cause complications such as cholangitis Choledocholithiasis and Cholangitis Choledocholithiasis is the presence of stones in bile ducts; the stones can form in the gallbladder or in the ducts themselves. These stones cause biliary colic, biliary obstruction, gallstone... read more , recurrent pancreatitis Acute Pancreatitis Acute pancreatitis is acute inflammation of the pancreas (and, sometimes, adjacent tissues). The most common triggers are gallstones and alcohol intake. The severity of acute pancreatitis is... read more , choledocholithiasis Choledocholithiasis and Cholangitis Choledocholithiasis is the presence of stones in bile ducts; the stones can form in the gallbladder or in the ducts themselves. These stones cause biliary colic, biliary obstruction, gallstone... read more (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.

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 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 Small Intestinal Bacterial Overgrowth (SIBO) Small intestinal bacterial overgrowth can result from alterations in intestinal anatomy or gastrointestinal motility, or lack of gastric acid secretion. This condition can lead to vitamin deficiencies... read more . Surgery may be necessary for patients with perforation Acute Perforation of the Gastrointestinal Tract Any part of the gastrointestinal tract may become perforated, releasing gastric or intestinal contents into the peritoneal space. Causes vary. Symptoms develop suddenly, with severe pain followed... read more or diverticulitis Colonic Diverticulitis Diverticulitis is inflammation with or without infection of a diverticulum, which can result in phlegmon of the bowel wall, peritonitis, perforation, fistula, or abscess. The primary symptom... read more . Surgery is usually avoided in patients with chronic intestinal pseudo-obstruction.