Small Bowel Diverticulosis: Does Location Matter?

Abstract

Small intestinal diverticulosis is characterized by the presence of multiple sac-like mucosal herniations through weak points in the intestinal wall which are far less common than colonic diverticula. Terminal ileal diverticulosis is extremely rare with a reported prevalence on conventional barium studies of 0.3-1.9%. They are most commonly observed in the duodenum (45%) followed by the jejunum (16%) and ileum (5%). We report a case of an 82 year old male with a history of hypertension, diabetes mellitus, coronary artery disease, heart failure, and cerebrovascular accident who was admitted for shortness of breath secondary to symptomatic anemia. He was found to have a microcytic anemia and dark stools with no signs of active bleeding. An esophagogastroduodenoscopy (EGD) was grossly unremarkable and biopsies revealed mild, chronic, inactive gastritis that was negative for Helicobacter pylori and intestinal metaplasia. A colonoscopy revealed severe diverticulosis throughout the entire colon as well as the terminal ileum without signs of active or recent bleeding (figure 1). Although no active bleeding was seen on ileo-colonoscopy it was presumed that the source of bleeding was either from an ileal or colonic diverticular bleed. The patient was conservatively managed and remained hemodynamically stable with no further episodes of black stools and was subsequently discharged home. Small bowel diverticulosis is a rare clinical entity. Most cases are diagnosed incidentally upon abdominal computed tomography (CT) or endoscopy. However, Gross and Katz (2003) recommend that any patient with a triad of anemia, abdominal pain, and an abdominal radiograph with dilated loops of small bowel merits small bowel diverticulosis in the differential diagnosis [4]. Furthermore, clinicians should be aware that small bowel diverticulosis can be associated with complications such as pseudo-obstruction, blind loop syndrome, dyskinesia, chronic diverticulitis, enterolith, perforation, peritonitis, bleeding, fistula formation, volvulus, and malabsorptive diarrhea [2-5]. Since gastrointestinal bleeding is a known complication of small intestinal diverticulosis, terminal ileum intubation at time of colonoscopy should always be performed especially if an upper endoscopy and colonoscopy fail to identify a source of bleeding and in the appropriate clinical context.2531 Figure 1. Diverticulosis in the terminal ileum.