Small bowel diverticulosis

Clinical History

A 73-year-old man presented with a history of intermittent abdominal discomfort and bloating or abdominal fullness sensation that go back a few years.
Laboratory test prescribed by his general practitioner was unremarkable, except for iron deficiency anaemia. The patient refused endoscopic investigation.

Imaging Findings

A barium meal examination was performed and shows normal finding of stomach and duodenum. On the small bowel some outpouchings from the intestinal wall are evident.
These are located on the jejunal bowel and are variable in size.
A diagnosis of jejunal diverticulitis was suggested.
The hospital's electronic archive contained a CT examination performed six months before. Our retrospective view of these images allowed to detect only two of the larger diverticula, one of which contained high density material interpreted as food debris.
The diverticular outpouchings of more small dimensions were not detectable.

Discussion

Diverticula are outpouchings of the intestinal wall that affect every segment of the gut. Can be congenital or aquired and composed of all layers of the intestinal wall (True diverticula) or by herniation of the mucosal and submucosal layers (pseudodiverticula). Small bowel diverticula, are aquired pseudodiverticula, usually multiple and more frequently located in the jejunum on mesenteric border of the bowel through the weak spots along the vessels.
First described by Sommering in 1794, they affect about 2% of the population and are very rare [1, 2, 3] if compared with the colon diverticula. The disease presents a peak incidence at the sixth and seventh decades of life with a small male predominance. [3] The size of diverticula varies between few mm. and 3-4 cm. The aetiology is unknown; the most accepted hypothesis is that abnormalities of the smooth muscles or of the myenteric plexus, causing an abnormal peristalsis with segmental intestinal contractions that generate a increased intraluminal pressure, thus favouring the diverticula formation on the weakest point of the bowel. [4] This condition is usually asymptomatic and often casually discovered during radiological investigations. The most common symptoms are a nonspecific epigastric pain, abdominal discomfort, bloating or abdominal fullness sensation. Other symptoms such as fever, melena or chronic bleeding that leads to iron deficiency, malabsorption, diarrhoea, flatulence, weight loss or acute abdomen are associated to complications. These occur in about 15% of cases and the most frequent are usually inflammation and obstruction; less frequent the perforation or haemorrhage.
They may harbor bacteria and cause malabsorption due to deconjugation of gall salts.
The diagnosis of this disease is very difficult because of its rarity and the nonspecificity of symptoms; the use of imaging techniques is fundamental for a correct diagnosis. On barium studies, intestinal diverticula are well recognised as rounded outpouchings of intestinal wall containing contrast material, air, and debris. These features can be recognised also on CT studies, nevertheless this diagnosis is infrequent on abdominal CT. The difficulty to detecting jejunal diverticulosis on CT is probably related to not easy differentiation between diverticula and gas or fluid-filled loops of small bowel. [5] Asymptomatic condition does not require therapy. Medical therapy is helpful in controlling diarrhoea, anaemia and phlogosis. Surgical therapy is mandatory in the presence of perforation jejunal, haemorrhage, abscess formation or failure of medical management.

Differential Diagnosis List

Final Diagnosis

Small bowel diverticulosis

URL:	https://www.eurorad.org/case/10035
DOI:	10.1594/EURORAD/CASE.10035
ISSN:	1563-4086