Skip to content

Small Bowel Diverticulae

Types of Diverticula

  • True Diverticula:
    • Involves all layers of the intestine.
    • Usually congenital.
  • False Diverticula:
    • Involves only the mucosa and submucosa.
    • Usually acquired.

Key Points

  • Duodenal diverticula:
    • The most common (MC) acquired diverticula of the small bowel.
  • Meckel's diverticulum:
    • The most common (MC) true congenital diverticulum of the small bowel.

Duodenal Diverticula

  • First described by Chomel, a French pathologist, in 1710.
  • 2nd MC site for diverticula formation (after the colon).
  • F:M ratio = 2:1, common after 40 years.

Types

  • Extraluminal Diverticula:
    • Acquired, False, and Most common (MC).
    • Locations:
      • D2 (65%),
      • D3 (30%),
      • D4 (8%),
      • D1 (<1%).
    • In D2, locations include:
      • Medial wall (88%),
      • Posterior wall (8%),
      • Lateral wall (4%).

image.png

  • Intraluminal Diverticula:

    • Congenital, True (also known as Wind sock type).

    image.png

Management

  • Incidentally found diverticula: Leave alone.
  • All intraluminal duodenal diverticula: Treatment is necessary as recurrence is certain.
  • Extraluminal diverticula: Resection is indicated if there is symptomatic disease.
  • Most common and effective treatment: Diverticulectomy.

Jejunal & Ileal Diverticulum

  • Incidence: 0.1% to 1.5%.
  • Least common type of diverticula.
  • Most common (MC) type of symptomatic diverticula.
  • Jejunal diverticula:
    • More common and larger than those in the ileum.
    • Typically occur after the 6th decade.
    • Classified as false diverticula.
  • These diverticula are usually multiple and protrude from the mesenteric border of the bowel.

Clinical Manifestations

  • Steatorrhea and megaloblastic anemia may occur due to defective B12 absorption.

Management

  • Incidentally detected diverticula: No treatment needed.
  • Surgical resection: Indicated in symptomatic and complicated cases.

Meckel's Diverticulum

  • Most common (MC) congenital anomaly of the small intestine.
  • Rule of 2s:
    • Located 2 feet (60 cm) from the terminal ileum.
    • 2 inches in length.
    • Occurs in 2% of the general population.
    • 2 times more common in males.
    • 2 types of heterotopic mucosa: Gastric or Pancreatic.
    • Presents in the first 2 decades of life, most commonly in the first 2 years of life.
  • True diverticulum: The only true diverticulum of the small intestine.
  • 60% have heterotopic mucosa:
    • Pancreatic tissue is the most common type of heterotopic tissue.
    • Gastric tissue is the most common type in symptomatic Meckel's diverticulum.
  • Location: The older the patient, the farther away the Meckel diverticulum is from the ileocecal valve.

Symptoms and Complications

  • Symptomatic in 2% to 4% of cases.
  • In children, the most common complication is bleeding, primarily due to heterotopic gastric mucosa.
  • Diverticulitis occurs in approximately 20% of patients.
  • Littre hernia: A Meckel diverticulum located in an inguinal or femoral hernia sac.
  • Tumors: 0.5% to 3.2% of symptomatic Meckel diverticula are tumors, with the most common being carcinoid.

Diagnosis

  • Less than 10% of symptomatic Meckel diverticula are diagnosed preoperatively.
  • In bleeding Meckel's, 99mTc-pertechnetate is the radiopharmaceutical of choice as it localizes to gastric mucosa.

Management

  • Operative intervention is the gold standard in making the diagnosis.
  • Symptomatic Meckel diverticulum: Surgical resection is indicated.
  • In bleeding Meckel diverticulum, an ileal resection is performed.
  • Crohn's disease: Absolute contraindication for surgery in asymptomatic patients.

Table 77.1: Adult Complications From a Meckel Diverticulum

Type of Complication [Adult] Incidence (%)
Intestinal obstruction 37
Intussusception 14
Diverticulitis 13
Hemorrhage 12
Perforation 7
Component of hernia sac 5
Volvulus 3
Neoplasm 3

Table 77.2: Pediatric Complications From a Meckel Diverticulum in Children Younger Than 18 Years of Age

Type of Complication [Pediatric] Incidence (%)
Intestinal obstruction 30.0
Hemorrhage 27.0
Intussusception 19.0
Omphalitis 0.4

Table 77.3: Indications to Resect an Incidentally Found Meckel Diverticulum

INDICATIONS to Resect an Incidentally Found Meckel
Patient < 40 years of age
Meckel diverticulum longer than 2 cm
Presence of a fibrous band
Evidence of heterotopic mucosa

MCQs for Revision

1. A 4-year-old patient presents with profuse lower GI bleed. The investigation to diagnose is?

A) Sigmoidoscopy

B) Barium follow through

C) Tc-99m scan

D) USG Abdomen

Correct Answer: C) Tc-99m scan

(Tc-99m scan is the radiopharmaceutical of choice for diagnosing a bleeding Meckel's diverticulum)

2. The most common site of duodenal diverticula is?

A) Medial wall of D2

B) Lateral wall of D2

C) D3

D) D1

Correct Answer: A) Medial wall of D2

(The medial wall of D2 is the most common site for duodenal diverticula)

3. All are true regarding small bowel diverticula except?

A) <5% duodenal diverticula require surgery for complications

B) The most common and effective treatment is diverticulectomy

C) Jejunal diverticula are more common and are larger than those in the ileum

D) Jejunal diverticula are true diverticula & common after 6th decade

Correct Answer: D) Jejunal diverticula are true diverticula & common after 6th decade

(Jejunal diverticula are false diverticula and occur after the 6th decade)

4. All are true regarding Meckel's diverticulum except?

A) Seen in 2% of the population

B) Usually within 2 feet from the terminal ileum

C) 2 times more common in females

D) Presents in the first 2 decades of life

Correct Answer: C) 2 times more common in females

(Meckel's diverticulum is 2 times more common in males)

5. All are true regarding Meckel's diverticulum except?

A) 60% of Meckel's diverticula have heterotopic mucosa

B) Diverticulitis occurs in approximately 20% of patients

C) Symptoms only occur in 20% to 40% of cases

D) <10% of symptomatic Meckel's diverticula are diagnosed preoperatively

Correct Answer: C) Symptoms only occur in 20% to 40% of cases

(Symptoms occur in 2% to 4% of cases, not 20% to 40%)

6. All are indications to resect an incidentally detected Meckel's diverticulum except?

A) Patient >40 years

B) Meckel's diverticulum >2 cm

C) Fibrous band

D) Heterotopic mucosa found

Correct Answer: A) Patient >40 years

(Patient <40 years is an indication for resection, not >40 years)

7. The most common complication of Meckel's diverticulum in adults is?

A) Intestinal obstruction

B) Bleeding

C) Perforation

D) Malignancy

Correct Answer: A) Intestinal obstruction

(Intestinal obstruction is the most common complication in adults)

8. The most common complication of Meckel's diverticulum in children is?

A) Omphalitis

B) Bleeding

C) Perforation

D) Obstruction

Correct Answer: B) Bleeding

(Bleeding is the most common complication in children with Meckel's diverticulum)

9. Meckel's diverticulum True statement is?

A) It is on the mesenteric border

B) It is a false diverticulum

C) Always has ectopic mucosa

D) Most common congenital abnormality of the small intestine

Correct Answer: D) Most common congenital abnormality of the small intestine

(Meckel's diverticulum is the most common congenital abnormality of the small intestine)

10. The most common symptomatic small bowel diverticulum is?

A) Duodenal diverticula

B) Jejunal diverticula

C) Ileal diverticula

D) All are equally symptomatic

Correct Answer: B) Jejunal diverticula

(Jejunal diverticula are the most common symptomatic small bowel diverticula)

11. The most common complication of jejunal diverticula is?

A) Bleeding

B) Bacterial overgrowth

C) Diverticulitis

D) Perforation

Correct Answer: C) Diverticulitis

(Diverticulitis is the most common complication of jejunal diverticula)