Diverticula of the small intestine

Diverticular disease is a fairly common condition in developed countries and is characterized by the formation of either single or multiple diverticula in virtually all parts of the digestive tract, as well as in the urinary and gall bladders. Therefore, some authors now more often use the term "diverticular disease" instead of the previously used terms "diverticulosis".

Diverticulum (from the Latin divertere - to turn aside, to separate) is a sac-like protrusion in the wall of a hollow organ. Ruysch first used the term "diverticulum" in 1698 to describe a hernia-like formation in the wall of the ileum. However, Fabricius Hildanus described a similar formation 100 years earlier.

Diverticula and diverticular disease of the small intestine

According to sectional data from various authors, the frequency of diverticula in all sections of the small intestine does not exceed 0.2-0.6%. Diverticula in the duodenum are much more common, mainly in its distal section. In 3% of cases, duodenal diverticula are combined with diverticula in the jejunum and ileum.

A combination of a duodenal diverticulum with a tumor located near it, ganglion cell paraganglioma, has been described. In approximately 1/3 of cases of diverticular disease of the colon, diverticula are also found in the small intestine, most often in the duodenum, and sometimes also in the stomach and esophagus.

The small intestine consists of 3 sections and includes the duodenum, jejunum and ileum, which have their own anatomical and functional features, and therefore some clinical specificity of the manifestation and course of a number of diseases, including diverticula and diverticular disease. Therefore, it is advisable to focus on some features of the clinical anatomy, symptomatology and course of this disease depending on the localization of the pathological process.

Diverticula of the duodenum are quite common. It is believed that the frequency of detection of individual diverticula (or diverticulosis) of the duodenum is second only to diverticulosis of the colon. The frequency of duodenal diverticula, according to various authors, varies from 0.016 to 22% of cases.

Diverticula of the jejunum and ileum. Diverticula of the small intestine can be single or multiple, of different sizes and shapes. The wall of congenital diverticula often does not have a muscular layer (congenital underdevelopment of the muscular membrane of the intestinal wall), unlike acquired diverticula (pulsion and traction), the wall of which has 3 layers: mucous, muscular and serous. As the size of acquired diverticula increases, their muscular layer becomes thinner and the morphological differences between them and congenital ones are practically erased.

The etiology and pathogenesis of the duodenum are basically no different from those of other locations in the digestive tract. However, it should be taken into account, firstly, that in diseases such as peptic ulcer, duodenal dyskinesia, cholelithiasis (especially with frequent attacks of biliary colic), and other diseases of the digestive system, especially with a combination of several of them, the frequency of duodenal diverticula increases significantly.

The causes of development and pathogenesis of small intestinal diverticula are not fully understood. In some cases, they are a congenital anomaly, developing in the weakest areas of the intestinal wall, in others, they are an acquired pathology. These are pulsion and traction diverticula. Pulsion diverticula occur with dyskinesia and intestinal spasms, when areas of "relaxation" appear in areas adjacent to the spasmodic areas, which leads to bulging of the intestinal wall.

Causes of small intestinal diverticula

Clinic of duodenal diverticula. In most cases, duodenal diverticula proceed more or less asymptomatically for a long time or manifest themselves with mild dyspeptic symptoms, mainly arising after disturbances in the usual rhythm and nature of nutrition. However, severe complications are also possible, most often arising suddenly, after gross deviations from normal generally accepted dietary norms, which manifest themselves with pronounced symptoms and often threaten the patient's life: diverticulitis, bleeding, perforation, etc.

Clinic of diverticula of the jejunum and ileum. In most cases, diverticula of the jejunum and ileum are asymptomatic and are detected accidentally during X-ray examination of the gastrointestinal tract or during autopsy. However, if the diverticulum has a narrow lumen connecting it to the intestine and is poorly emptied, chyme stagnates in it, sometimes small foreign bodies (chicken bones, fruit stones, etc.), diverticulitis and peridiverticulitis may develop. In this case, abdominal pain, symptoms of dyspepsia occur, in severe cases the temperature rises, signs of general intoxication appear, and ESR increases. A distinction is made between catarrhal (the most common), purulent (phlegmonous) and gangrenous forms of diverticulitis. In the gangrenous form, perforation is possible due to necrosis of the wall. Sometimes an intestinal diverticulum causes bleeding when a large vessel is damaged.

Symptoms of small intestinal diverticula

The diagnosis of duodenal diverticula is mainly based on the data of contrast radiographic examination (including duodenography when indicated) and the results of gastroduodenoscopy. However, the endoscopist should be warned about the need not to limit himself to examining only the duodenal bulb (as is often the case, since in most cases the main pathological processes, such as peptic ulcers, are most often localized in the duodenal bulb and in the stomach; in addition, endoscopic examination of the entire duodenum requires additional time, complicates, and in some cases complicates the examination), but to try to examine the entire duodenum.

Diagnostics of diverticula of the jejunum and ileum. The main method of detecting diverticular disease of the small intestine is radiographic. It is very difficult to detect a diverticulum of the ileum even in the absence of complications, since it is poorly filled with a contrast mass. In addition, radiographic examination of the small intestine is often difficult due to the peculiarities of its location. If the diverticulum is filled with a suspension of barium sulfate, it has the appearance of a blind appendix extending from the ileum.

Diagnosis of small intestinal diverticula

Treatment of duodenal diverticula in the absence of pronounced symptoms of the disease is limited to medical observation of the patient (initially once every 3-6 months, then, if the disease is “calm”, the patient strictly follows the doctor’s recommendations and there are no signs of a significant increase in the size of the diverticulum or diverticula - 1-2 times a year). Patients should strictly adhere to a 4-5-meal regimen, avoid spicy, fried and too fatty foods (especially considering the frequent combination of duodenal diverticula with gallstones, peptic ulcer disease and pancreatitis), eat slowly and chew food thoroughly.

Treatment of diverticula of the jejunum and ileum. In case of large diverticula, surgical treatment is indicated. Emergency operations are performed in case of perforation of the diverticulum wall, torsion of its stalk, massive intestinal bleeding caused by ulceration of the diverticulum mucosa. In case of uncomplicated single diverticula of small sizes, special treatment is not required. However, patients are recommended to include bran in their diet, chew food thoroughly, avoid hot spices, and monitor bowel movements.

Treatment of small intestinal diverticula

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