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A1-G Surg Note Small Bowel > Small Bowel Diverticulosis > Flashcards

Small Bowel Diverticulosis Flashcards

1
Q

What is the most common site for small bowel diverticula?

A

The duodenum is the most common site.

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2
Q

Which type of small bowel diverticula is the most well-known?

A

Meckel’s diverticula are the most well-known

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3
Q

How are small bowel diverticula classified?

A

They can be congenital or acquired and are classified as true or false based on whether all three walls of the bowel are involved.

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4
Q

What symptoms can symptomatic Meckel’s diverticula present with?

A

They can present with bleeding or diverticulitis and rarely as a cause of obstruction or perforation.

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5
Q

How are small bowel diverticula further classified?

A

They are classified by location (duodenal or jejunoileal) and by whether they are asymptomatic or symptomatic.

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6
Q

What percentage of small bowel diverticula cases are duodenal diverticula?

A

Duodenal diverticula comprise 45% to 79% of small bowel diverticula cases.

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7
Q

What is the only known risk factor for duodenal diverticula?

A

Age

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8
Q

Where are duodenal diverticula most commonly located?

A

In the second portion of the duodenum (60% to 95% of cases).

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9
Q

Are duodenal diverticula typically symptomatic or asymptomatic?

A

much more commonly asymptomatic.

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10
Q

What is the difference between congenital and acquired duodenal diverticula?

A

Congenital diverticula are rare and intraluminal (e.g., windsock diverticula), while the vast majority are acquired and extraluminal

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11
Q

What is the mechanism thought to cause acquired duodenal diverticula?

A

It relates to weakness in the bowel wall where perforating vessels are found.

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12
Q

What are windsock diverticula, and how do they form?

A

Windsock diverticula are rare congenital duodenal diverticula lined with duodenal mucosa inside and outside, formed from failure of canalization of the embryonal foregut

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13
Q

How is the diagnosis of duodenal diverticula typically made?

A

By cross-sectional imaging, fluoroscopic contrast studies, endoscopy, or during abdominal surgery.

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14
Q

Is treatment required for asymptomatic duodenal diverticula?

A

No

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15
Q

Are most jejunoileal diverticula symptomatic or asymptomatic?

A

The vast majority are asymptomatic.

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16
Q

Where are jejunoileal diverticula most commonly located?

A

80% are in the jejunum
15% in the ileum
5% found in both

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17
Q

What type of diverticula are most common in the jejunoileal region?

A

False diverticula.

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18
Q

What is the likely cause of jejunoileal diverticula?

A

Gradual weakening of the intestinal wall from increased intraluminal pressure, often related to dysfunction of the migrating motor complexes

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19
Q

What is the most widely reported risk factor for jejunoileal diverticula?

A

Age
Intestinal dysmotility disorders.

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20
Q

What is the most common location for jejunoileal diverticula?

A

proximal jejunum.

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21
Q

What is the best radiographic study to evaluate jejunoileal diverticula?

A

Enteroclysis.

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22
Q

Which other imaging techniques are increasingly used for diagnosing jejunoileal diverticula?

A

CT and MR enterography

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23
Q

Can capsule endoscopy be used to diagnose jejunoileal diverticula?

A

Yes

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24
Q

Is surgical management recommended for incidentally discovered jejunoileal diverticula?

A

No

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25
Q

What are the most common congenital diverticula of the small bowel?

A

Meckel’s diverticula.

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26
Q

What percentage of small bowel diverticula do Meckel’s diverticula account for?

A

25%.

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27
Q

What embryologic structure do Meckel’s diverticula represent?

A

A remnant vitelline (omphalomesenteric) duct

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28
Q

What type of diverticulum is a Meckel’s diverticulum, and what does that imply?

A

It is a true diverticulum, meaning it involves all three layers of the bowel wall

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29
Q

Where are Meckel’s diverticula always located?

A

On the antimesenteric side of the ileum

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30
Q

What is the “rule of two” for Meckel’s diverticula?

A

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.

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31
Q

What are the two main types of symptoms associated with Meckel’s diverticula?

A

Bleeding and obstruction.

32
Q

Are Meckel’s diverticula commonly found on axial imaging?

A

No, they are less frequently found on axial imaging.

33
Q

Is there an indication for surgical resection of an incidentally discovered Meckel’s diverticulum in adults?

A

No, there is generally no compelling indication for surgical resection in adults

34
Q

Under what conditions might some authors advocate for prophylactic resection of a Meckel’s diverticulum?

A

-in children, or in adults with palpable ectopic tissue
-a prior history of diverticulitis
-hemorrhage
-intussusception
-the presence of a mesodiverticular band.

35
Q

What is the most commonly reported symptom of duodenal diverticula?

A

Postprandial epigastric abdominal pain, often associated with nausea and vomiting.

36
Q

How can large duodenal diverticula cause obstruction?

A

By extraluminal compression of the duodenum.

37
Q

What complications can arise from extrinsic compression by duodenal diverticula?

A

Obstructive jaundice or recurrent pancreatitis due to compression of the biliary tree or pancreatic duct.

38
Q

What are common infectious complications associated with duodenal diverticula?

A

Diverticulitis with or without abscess, perforation, and rarely, fistula.

39
Q

How can bleeding occur in cases of duodenal diverticula?

A

Through inflammatory erosion into a neighboring vessel, presenting as hematemesis and melena.

40
Q

What is the initial management for duodenal obstruction?

A

Nasogastric tube decompression

41
Q

What imaging modalities are helpful for diagnosing duodenal diverticula?

A

CT scans, upper GI contrast studies, and endoscopy.

42
Q

What are the characteristic imaging findings of duodenal diverticulitis?

A

Findings similar to colonic diverticulitis, usually diagnosed with CT.

43
Q

What should be done if a bleeding vessel related to a duodenal diverticula needs to be identified?

A

CT angiography or endoscopy may be performed, with potential intervention by mesenteric angiography.

44
Q

What surgical interventions may be necessary for duodenal obstruction due to diverticula?

A

Options include
resection with transverse closure
Thal patch
Roux-en-Y duodenojejunostomy
or segmental duodenal resection.

45
Q

What condition would require a pancreaticoduodenectomy for duodenal obstruction?

A

Involvement of the medial side of the duodenum.

46
Q

What is the preferred initial management for biliary or pancreatic obstruction due to duodenal diverticula?

A

Endoscopic stenting.

47
Q

When should surgical resection be considered for biliary or pancreatic obstruction?

A

Only if endoscopic management fails

48
Q

How are most cases of duodenal diverticulitis with contained perforation managed?

A

Conservatively with nil per os, nasogastric tube placement, antibiotics, and possibly percutaneous drainage

49
Q

What is the approach to managing bleeding from a duodenal diverticulum?

A

Similar to other causes of upper GI bleeding, with endoscopy or interventional radiology; surgical management is rarely needed.

50
Q

What nonspecific symptoms can patients with jejunoileal diverticula present with?

A

Abdominal pain, early satiety, bloating, and malabsorption (diarrhea and/or steatorrhea).

51
Q

What condition often leads to malabsorption in patients with jejunoileal diverticula?

A

Small intestinal bacterial overgrowth (SIBO)

52
Q

What are the complications that can arise from jejunoileal diverticula?

A

Diverticulitis, bleeding, obstruction, and perforation

53
Q

Where is the pain typically located in patients with symptomatic jejunoileal diverticula?

A

Epigastric or periumbilical.

54
Q

What is the most common means of detecting jejunoileal diverticula?

A

Cross-sectional imaging.

55
Q

How is SIBO treated in patients with jejunoileal diverticula?

A

With antibiotics.

56
Q

What is the treatment for jejunoileal diverticulitis?

A

Bowel rest, intravenous fluids, and antibiotics, similar to the treatment for colonic diverticulitis.

57
Q

When is surgical intervention indicated for jejunoileal diverticulitis?

A

For recurrent or complicated episodes, or if conservative management fails.

58
Q

How is a perforated jejunoileal diverticulum managed?

A

Conservative management for walled-off perforations with minimal symptoms, or urgent exploration and resection for critically ill patients.

59
Q

What should be considered if both esophagogastroduodenoscopy and colonoscopy are negative in cases of GI bleeding?

A

A bleeding jejunoileal diverticulum

60
Q

What diagnostic tools can be used to find a bleeding jejunoileal diverticulum?

A

Push or double-balloon enteroscopy and capsule endoscopy

61
Q

Is interventional radiology angioembolization typically used for bleeding jejunoileal diverticula?

A

No, it is not typically attempted.

62
Q

How are small bowel obstructions due to jejunoileal diverticula managed?

A

Like adhesive small bowel obstructions, with resection if conservative management fails

63
Q

How are bowel obstructions from an impacted fecalith treated?

A

Surgically, through enterotomy and stone extraction.

64
Q

What is the most common mechanism of a symptomatic Meckel’s diverticulum?

A

Acid production by heterotopic gastric mucosa within the diverticulum leading to ulceration

65
Q

What are the common symptoms/complications of a symptomatic Meckel’s diverticulum?

A

Bleeding, obstruction, or abdominal pain

66
Q

In which population are Meckel’s diverticulum complications most common?

A

Pediatric population

67
Q

What were the most common presentations of Meckel’s diverticulum in pediatric patients according to a single-center series?

A

35% with gastrointestinal bleeding
20% with diverticulitis or perforation
14% with obstruction
12% with intussusception

68
Q

What condition is often associated with gastrointestinal bleeding from a Meckel’s diverticulum

A

The presence of heterotopic gastric mucosa

69
Q

In which patients should suspicion of a bleeding Meckel’s diverticulum be higher?

A

Young patients without evidence of an inflammatory explanation for bleeding and adults under 30 with a negative GI bleeding workup.

70
Q

What is the test of choice for detecting a bleeding Meckel’s diverticulum in a young, hemodynamically stable patient?

A

A Meckel’s scan (scintigraphic study).

71
Q

What role does CT angiography play in diagnosing a bleeding Meckel’s diverticulum?

A

It is an increasingly used, sensitive test for detecting GI bleeding.

72
Q

What are some advanced endoscopic techniques used to localize a bleeding Meckel’s diverticulum?

A

Double-balloon enteroscopy and capsule endoscopy.

73
Q

What types of small bowel obstruction can a Meckel’s diverticulum cause in children?

A

Volvulus and intussusception.

74
Q

What is the recommended treatment for a small bowel obstruction secondary to a Meckel’s diverticulum?

A

Nasogastric tube decompression, volume resuscitation, followed by surgical resection

75
Q

What type of surgical resection is recommended for a broad-based Meckel’s diverticulum or one with a palpable abnormality?

A

Segmental bowel resection and reconstruction

76
Q

Why is segmental resection recommended for bleeding secondary to a Meckel’s diverticulum?

A

Because the ulcer is often on the mesenteric side of the ileum, sometimes downstream of the diverticulum.

77
Q

What additional procedure do some authors advocate for during surgery for a symptomatic Meckel’s diverticulum?

A

Appendectomy, to avoid diagnostic dilemmas in the future

A1-G Surg Note Small Bowel (10 decks)

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