Small Intestine Diverticulae

DEFINITION

Outpouchings of the small intestine
True = include all layers of the bowel wall
False = only mucosa, submucosa and serosa; not musclaris


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EPIDEMIOLOGY

Relatively uncommon ~1%
Maybe 5% cause symptoms

Because they are uncommon the literature and evidence base is fairly poor.

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AETIOLOGY

Can be congenital or acquired

Acquired
Thought to be related to dysmotility associated with the MMC, where spastic contractions result in prolonged intraluminal pressures
- leads to 'false' diverticulae development over many years of malfunction.



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BIOLOGICAL BEHAVIOUR

Most are discovered while asymptomatic

Asymptomatic

Duodenal
Most common site; ~half
Perhaps 1% of these become symptomatic, which is good because management is difficult
Congenital forms typically arise from 2nd to 4th segments
- may be associated with other abnormalities, e.g. malrotation, omphalocoele, annular pancreas, congenital biliary cysts, cardiac and urinary congenital abnormalities.
Symptoms vary depending on size and location
- especially notable is proximity to the ampulla of Vater

Jejunoileal
25% of diverticulae. 
Most likely to become symptomatic, though <10% will.

Meckel's
Remaining 25% of divertics
A 'true' divertic
See Meckel's notes

Symptomatic

Present as:
- inflammation / infection
- obstruction
- perforation
- bleeding

Meckel's
See Meckel's notes
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MANIFESTATIONS

As above, present as:
- inflammation / infection
- obstruction
- perforation
- bleeding

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INVESTIGATIONS

Duodenal
CT with multiplanar reconstructions
Image by OGD and ERCP
Important to clarify relationship with, and proximity to, the Ampulla of Vater, and biliary and pancreatic structures
MRCP may help

Jejunual
Small bowel contrast series / fluoroscopy
Push enteroscopy, double-balloon enteroscopy
Expanding role for capsule endoscopy

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MANAGEMENT

Asymptomatic

Duodenal diverticulae are unlikely to become symptomatic and should be left alone.
Jejunoileal diverticulae should also be left alone despite higher risk of symptoms
- no proven role for resection.
Meckel's
See Meckel's notes

Symptomatic

Duodenal
Difficult to manage
Usually include or are adjacent to the Ampulla of Vater and bile duct
Operative management reserved for when patient cannot undergo simple endoscopic therapy, or after failure of ERCP, sphincterotomy and stenting.
Operative treatment principles:
- should be done by experienced upper GI surgeon; difficult and associated with high morbidity and mortality
- wide Kocher Maneuver
- clarification of anatomy and relationships to biliary and pancreatic structures; must identify all structures
- liberal use of duct stenting
- transverse or oblique closure of the duodenum and sometimes a patch
- cholecystectomy.

Jejunal
Depends on symptoms
May be managed non-operatively on a selected basis
Segmental resection when necessary, prevents SB narrowing

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REFERENCES
Cameron 10th