Small Bowel Diverticulosis Flashcards
What is the most common site for small bowel diverticula?
The duodenum is the most common site.
Which type of small bowel diverticula is the most well-known?
Meckel’s diverticula are the most well-known
How are small bowel diverticula classified?
They can be congenital or acquired and are classified as true or false based on whether all three walls of the bowel are involved.
What symptoms can symptomatic Meckel’s diverticula present with?
They can present with bleeding or diverticulitis and rarely as a cause of obstruction or perforation.
How are small bowel diverticula further classified?
They are classified by location (duodenal or jejunoileal) and by whether they are asymptomatic or symptomatic.
What percentage of small bowel diverticula cases are duodenal diverticula?
Duodenal diverticula comprise 45% to 79% of small bowel diverticula cases.
What is the only known risk factor for duodenal diverticula?
Age
Where are duodenal diverticula most commonly located?
In the second portion of the duodenum (60% to 95% of cases).
Are duodenal diverticula typically symptomatic or asymptomatic?
much more commonly asymptomatic.
What is the difference between congenital and acquired duodenal diverticula?
Congenital diverticula are rare and intraluminal (e.g., windsock diverticula), while the vast majority are acquired and extraluminal
What is the mechanism thought to cause acquired duodenal diverticula?
It relates to weakness in the bowel wall where perforating vessels are found.
What are windsock diverticula, and how do they form?
Windsock diverticula are rare congenital duodenal diverticula lined with duodenal mucosa inside and outside, formed from failure of canalization of the embryonal foregut
How is the diagnosis of duodenal diverticula typically made?
By cross-sectional imaging, fluoroscopic contrast studies, endoscopy, or during abdominal surgery.
Is treatment required for asymptomatic duodenal diverticula?
No
Are most jejunoileal diverticula symptomatic or asymptomatic?
The vast majority are asymptomatic.
Where are jejunoileal diverticula most commonly located?
80% are in the jejunum
15% in the ileum
5% found in both
What type of diverticula are most common in the jejunoileal region?
False diverticula.
What is the likely cause of jejunoileal diverticula?
Gradual weakening of the intestinal wall from increased intraluminal pressure, often related to dysfunction of the migrating motor complexes
What is the most widely reported risk factor for jejunoileal diverticula?
Age
Intestinal dysmotility disorders.
What is the most common location for jejunoileal diverticula?
proximal jejunum.
What is the best radiographic study to evaluate jejunoileal diverticula?
Enteroclysis.
Which other imaging techniques are increasingly used for diagnosing jejunoileal diverticula?
CT and MR enterography
Can capsule endoscopy be used to diagnose jejunoileal diverticula?
Yes
Is surgical management recommended for incidentally discovered jejunoileal diverticula?
No
What are the most common congenital diverticula of the small bowel?
Meckel’s diverticula.
What percentage of small bowel diverticula do Meckel’s diverticula account for?
25%.
What embryologic structure do Meckel’s diverticula represent?
A remnant vitelline (omphalomesenteric) duct
What type of diverticulum is a Meckel’s diverticulum, and what does that imply?
It is a true diverticulum, meaning it involves all three layers of the bowel wall
Where are Meckel’s diverticula always located?
On the antimesenteric side of the ileum
What is the “rule of two” for Meckel’s diverticula?
Located 2 feet from the ileocecal valve
contain two types of heterotopic tissue (gastric or pancreatic)
occur twice as commonly in males
found in 2% of the population
symptomatic in about 2% of cases
diagnosed within the first 2 years of life
and can extend over 2 inches in length.
What are the two main types of symptoms associated with Meckel’s diverticula?
Bleeding and obstruction.
Are Meckel’s diverticula commonly found on axial imaging?
No, they are less frequently found on axial imaging.
Is there an indication for surgical resection of an incidentally discovered Meckel’s diverticulum in adults?
No, there is generally no compelling indication for surgical resection in adults
Under what conditions might some authors advocate for prophylactic resection of a Meckel’s diverticulum?
-in children, or in adults with palpable ectopic tissue
-a prior history of diverticulitis
-hemorrhage
-intussusception
-the presence of a mesodiverticular band.
What is the most commonly reported symptom of duodenal diverticula?
Postprandial epigastric abdominal pain, often associated with nausea and vomiting.
How can large duodenal diverticula cause obstruction?
By extraluminal compression of the duodenum.
What complications can arise from extrinsic compression by duodenal diverticula?
Obstructive jaundice or recurrent pancreatitis due to compression of the biliary tree or pancreatic duct.
What are common infectious complications associated with duodenal diverticula?
Diverticulitis with or without abscess, perforation, and rarely, fistula.
How can bleeding occur in cases of duodenal diverticula?
Through inflammatory erosion into a neighboring vessel, presenting as hematemesis and melena.
What is the initial management for duodenal obstruction?
Nasogastric tube decompression
What imaging modalities are helpful for diagnosing duodenal diverticula?
CT scans, upper GI contrast studies, and endoscopy.
What are the characteristic imaging findings of duodenal diverticulitis?
Findings similar to colonic diverticulitis, usually diagnosed with CT.
What should be done if a bleeding vessel related to a duodenal diverticula needs to be identified?
CT angiography or endoscopy may be performed, with potential intervention by mesenteric angiography.
What surgical interventions may be necessary for duodenal obstruction due to diverticula?
Options include
resection with transverse closure
Thal patch
Roux-en-Y duodenojejunostomy
or segmental duodenal resection.
What condition would require a pancreaticoduodenectomy for duodenal obstruction?
Involvement of the medial side of the duodenum.
What is the preferred initial management for biliary or pancreatic obstruction due to duodenal diverticula?
Endoscopic stenting.
When should surgical resection be considered for biliary or pancreatic obstruction?
Only if endoscopic management fails
How are most cases of duodenal diverticulitis with contained perforation managed?
Conservatively with nil per os, nasogastric tube placement, antibiotics, and possibly percutaneous drainage
What is the approach to managing bleeding from a duodenal diverticulum?
Similar to other causes of upper GI bleeding, with endoscopy or interventional radiology; surgical management is rarely needed.
What nonspecific symptoms can patients with jejunoileal diverticula present with?
Abdominal pain, early satiety, bloating, and malabsorption (diarrhea and/or steatorrhea).
What condition often leads to malabsorption in patients with jejunoileal diverticula?
Small intestinal bacterial overgrowth (SIBO)
What are the complications that can arise from jejunoileal diverticula?
Diverticulitis, bleeding, obstruction, and perforation
Where is the pain typically located in patients with symptomatic jejunoileal diverticula?
Epigastric or periumbilical.
What is the most common means of detecting jejunoileal diverticula?
Cross-sectional imaging.
How is SIBO treated in patients with jejunoileal diverticula?
With antibiotics.
What is the treatment for jejunoileal diverticulitis?
Bowel rest, intravenous fluids, and antibiotics, similar to the treatment for colonic diverticulitis.
When is surgical intervention indicated for jejunoileal diverticulitis?
For recurrent or complicated episodes, or if conservative management fails.
How is a perforated jejunoileal diverticulum managed?
Conservative management for walled-off perforations with minimal symptoms, or urgent exploration and resection for critically ill patients.
What should be considered if both esophagogastroduodenoscopy and colonoscopy are negative in cases of GI bleeding?
A bleeding jejunoileal diverticulum
What diagnostic tools can be used to find a bleeding jejunoileal diverticulum?
Push or double-balloon enteroscopy and capsule endoscopy
Is interventional radiology angioembolization typically used for bleeding jejunoileal diverticula?
No, it is not typically attempted.
How are small bowel obstructions due to jejunoileal diverticula managed?
Like adhesive small bowel obstructions, with resection if conservative management fails
How are bowel obstructions from an impacted fecalith treated?
Surgically, through enterotomy and stone extraction.
What is the most common mechanism of a symptomatic Meckel’s diverticulum?
Acid production by heterotopic gastric mucosa within the diverticulum leading to ulceration
What are the common symptoms/complications of a symptomatic Meckel’s diverticulum?
Bleeding, obstruction, or abdominal pain
In which population are Meckel’s diverticulum complications most common?
Pediatric population
What were the most common presentations of Meckel’s diverticulum in pediatric patients according to a single-center series?
35% with gastrointestinal bleeding
20% with diverticulitis or perforation
14% with obstruction
12% with intussusception
What condition is often associated with gastrointestinal bleeding from a Meckel’s diverticulum
The presence of heterotopic gastric mucosa
In which patients should suspicion of a bleeding Meckel’s diverticulum be higher?
Young patients without evidence of an inflammatory explanation for bleeding and adults under 30 with a negative GI bleeding workup.
What is the test of choice for detecting a bleeding Meckel’s diverticulum in a young, hemodynamically stable patient?
A Meckel’s scan (scintigraphic study).
What role does CT angiography play in diagnosing a bleeding Meckel’s diverticulum?
It is an increasingly used, sensitive test for detecting GI bleeding.
What are some advanced endoscopic techniques used to localize a bleeding Meckel’s diverticulum?
Double-balloon enteroscopy and capsule endoscopy.
What types of small bowel obstruction can a Meckel’s diverticulum cause in children?
Volvulus and intussusception.
What is the recommended treatment for a small bowel obstruction secondary to a Meckel’s diverticulum?
Nasogastric tube decompression, volume resuscitation, followed by surgical resection
What type of surgical resection is recommended for a broad-based Meckel’s diverticulum or one with a palpable abnormality?
Segmental bowel resection and reconstruction
Why is segmental resection recommended for bleeding secondary to a Meckel’s diverticulum?
Because the ulcer is often on the mesenteric side of the ileum, sometimes downstream of the diverticulum.
What additional procedure do some authors advocate for during surgery for a symptomatic Meckel’s diverticulum?
Appendectomy, to avoid diagnostic dilemmas in the future
