What are the symptoms of small bowel diverticulitis. How is small bowel diverticulitis diagnosed. What are the treatment options for small bowel diverticulitis. Why is small bowel diverticulitis often missed on conventional CT scans. What are the potential complications of small bowel diverticulitis. How common is small bowel diverticulitis compared to colonic diverticulitis.

Understanding Small Bowel Diverticulitis: A Rare Cause of Abdominal Pain

Small bowel diverticulitis is an uncommon condition that can cause significant abdominal pain, especially in younger adults. Unlike the more common colonic diverticulitis, small bowel diverticulitis affects the small intestine and can be challenging to diagnose. This article explores a case of small bowel diverticulitis in a 34-year-old woman and provides insights into its symptoms, diagnosis, and treatment.

Case Presentation: Stabbing Abdominal Pain in a Young Woman

A 34-year-old woman with no significant medical history presented to the emergency department with severe abdominal pain. The pain was described as sharp and stabbing, localized to the periumbilical region. Interestingly, the pain was exacerbated by body movement and relieved by lying completely still. The patient denied any associated symptoms such as fever, nausea, vomiting, or changes in bowel habits.

Key Observations from the Case

• Patient age: 34 years
• Location of pain: Periumbilical region
• Type of pain: Sharp and stabbing
• Aggravating factor: Body movement
• Relieving factor: Lying still
• Absence of other gastrointestinal symptoms

Diagnostic Challenges in Small Bowel Diverticulitis

Diagnosing small bowel diverticulitis can be challenging due to its rarity and often nonspecific symptoms. In this case, the initial laboratory tests were largely unremarkable, except for an elevated white blood cell count of 14,700/µL. This highlights the importance of advanced imaging techniques in making an accurate diagnosis.

Why is small bowel diverticulitis often missed on conventional CT scans?

Small bowel diverticulitis is frequently overlooked on conventional CT scans due to several factors:

1. The small size of the diverticula
2. The rapid transit of contrast through the small bowel
3. The similarity of findings to other small bowel inflammatory conditions
4. The rarity of the condition, which may not be at the forefront of radiologists’ minds

To improve diagnostic accuracy, magnetic resonance enterography/enteroclysis has shown promise in recent years. These advanced imaging techniques provide better visualization of the small bowel and can help identify the characteristic asymmetric focal or segmental small bowel inflammation associated with small bowel diverticulitis.

Imaging Findings and Diagnosis

In this case, computed tomography (CT) scanning of the abdomen and pelvis with intravenous and oral contrast revealed a moderate to extensive inflammatory reaction involving the left upper quadrant. The findings were consistent with jejunal diverticulitis with contained microperforation.

What are the typical imaging findings in small bowel diverticulitis?

Characteristic CT findings in small bowel diverticulitis include:

• Asymmetric focal or segmental small bowel wall thickening
• Peri-intestinal fat stranding
• Presence of diverticula in the affected segment
• Possible signs of microperforation or abscess formation
• Mesenteric inflammation adjacent to the affected bowel segment

Treatment Approaches for Small Bowel Diverticulitis

The management of small bowel diverticulitis depends on the severity of the condition and the presence of complications. In this case, the patient was treated conservatively with intravenous antibiotics.

What are the treatment options for small bowel diverticulitis?

Treatment options for small bowel diverticulitis include:

1. Conservative management with intravenous antibiotics
2. Bowel rest and gradual reintroduction of oral intake
3. Pain management
4. Surgical intervention in cases of severe disease or complications
5. Long-term dietary modifications to prevent recurrence

In this case, the patient was started on intravenous ciprofloxacin and metronidazole. She was admitted to the surgical service for further evaluation by general surgery and gastroenterology. The patient’s condition improved with conservative management, and she was discharged after three days of hospitalization.

Prevalence and Epidemiology of Small Bowel Diverticulitis

Small bowel diverticulitis is a rare condition compared to its colonic counterpart. Understanding its prevalence and distribution within the small intestine can help clinicians maintain a high index of suspicion when evaluating patients with atypical abdominal pain.

How common is small bowel diverticulitis compared to colonic diverticulitis?

Small bowel diverticulitis is significantly less common than colonic diverticulitis. The prevalence of small bowel diverticulitis ranges from 0.06% to 1.3% of all cases of diverticular disease. In contrast, colonic diverticulosis affects up to 50% of individuals over the age of 60 in Western countries.

Distribution of Small Bowel Diverticulitis

When small bowel diverticulitis does occur, it has a predilection for certain segments of the small intestine:

• Duodenal involvement: 79% of cases
• Jejuno-ileal involvement: 18% of cases
• Other segments: 3% of cases

This distribution highlights the importance of considering small bowel diverticulitis even when the pain is localized to atypical areas, such as the left upper quadrant in this case.

Potential Complications and Long-term Prognosis

While small bowel diverticulitis can often be managed conservatively, it is essential to be aware of potential complications that may require more aggressive intervention.

What are the potential complications of small bowel diverticulitis?

Potential complications of small bowel diverticulitis include:

1. Perforation with peritonitis
2. Abscess formation
3. Bowel obstruction
4. Fistula formation
5. Chronic abdominal pain
6. Malabsorption (in cases of extensive small bowel involvement)

Fortunately, severe complications such as perforation with peritonitis are thought to be rare. However, vigilant monitoring and follow-up are crucial to detect and manage any potential complications early.

Long-term Prognosis

The long-term prognosis for patients with small bowel diverticulitis is generally favorable, especially when diagnosed and treated promptly. Many patients experience resolution of symptoms with conservative management alone. However, recurrence is possible, and patients may benefit from dietary modifications and lifestyle changes to reduce the risk of future episodes.

Differential Diagnosis of Abdominal Pain in Young Adults

The case of small bowel diverticulitis in a 34-year-old woman highlights the importance of considering a broad differential diagnosis when evaluating abdominal pain, especially in younger patients.

What other conditions should be considered in young adults with acute abdominal pain?

The differential diagnosis for acute abdominal pain in young adults includes:

• Appendicitis
• Ovarian cysts or torsion
• Ectopic pregnancy
• Inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
• Gastroenteritis
• Urinary tract infections or kidney stones
• Pancreatitis
• Mesenteric adenitis
• Abdominal wall hernias
• Small bowel obstruction

This case underscores the importance of maintaining a high index of suspicion for less common conditions, such as small bowel diverticulitis, especially when the clinical presentation is atypical or initial investigations are inconclusive.

Implications for Clinical Practice and Future Research

The case of small bowel diverticulitis in a young woman provides several important lessons for clinical practice and highlights areas for future research.

Key Takeaways for Clinicians

1. Consider small bowel diverticulitis in the differential diagnosis of acute abdominal pain, even in younger patients.
2. Recognize that small bowel diverticulitis can present with minimal clinical symptoms and unremarkable laboratory results.
3. Utilize advanced imaging techniques, such as CT with intravenous and oral contrast or MR enterography, when conventional imaging is inconclusive.
4. Initiate prompt antibiotic therapy and consider surgical consultation in cases of suspected small bowel diverticulitis.
5. Monitor patients closely for potential complications, even with conservative management.

Future Research Directions

To improve our understanding and management of small bowel diverticulitis, future research should focus on:

• Developing more sensitive and specific diagnostic criteria for small bowel diverticulitis
• Investigating the long-term outcomes of patients treated conservatively versus surgically
• Exploring the role of minimally invasive surgical techniques in managing complicated cases
• Identifying risk factors for the development of small bowel diverticulitis in younger populations
• Evaluating the effectiveness of dietary and lifestyle interventions in preventing recurrence

By advancing our knowledge in these areas, we can improve the diagnosis, treatment, and long-term management of patients with small bowel diverticulitis, ultimately leading to better outcomes and quality of life.

The Role of Interdisciplinary Collaboration in Managing Complex Abdominal Pain Cases

The successful diagnosis and treatment of small bowel diverticulitis in this case highlight the importance of interdisciplinary collaboration in managing complex abdominal pain presentations. Emergency physicians, radiologists, surgeons, and gastroenterologists all played crucial roles in the patient’s care.

How does interdisciplinary collaboration improve patient outcomes in cases of small bowel diverticulitis?

Interdisciplinary collaboration enhances patient care in several ways:

1. Rapid and accurate diagnosis through expert interpretation of imaging studies
2. Comprehensive evaluation of potential surgical needs and complications
3. Optimized antibiotic therapy based on infectious disease expertise
4. Tailored pain management strategies
5. Coordinated follow-up care to prevent recurrence and manage long-term sequelae

By fostering a collaborative approach, healthcare teams can ensure that patients with rare conditions like small bowel diverticulitis receive the most appropriate and effective care.

Strategies for Enhancing Interdisciplinary Collaboration

To improve interdisciplinary collaboration in the management of complex abdominal pain cases, healthcare institutions can implement the following strategies:

• Regular interdepartmental case conferences to discuss challenging cases
• Development of standardized protocols for the evaluation of atypical abdominal pain
• Implementation of rapid consultation systems between emergency departments and specialty services
• Ongoing education and training on rare abdominal conditions for all team members
• Utilization of electronic health records to facilitate seamless communication between departments

By implementing these strategies, healthcare teams can ensure that patients with rare conditions like small bowel diverticulitis receive prompt, accurate diagnoses and optimal treatment, ultimately leading to improved outcomes and patient satisfaction.

Stabbing Abdominal Pain in a 34-Year-Old Woman

Abdominal Pain

Authors:

Nicholas Tomasello, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Alan Lucerna, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Victor Scali, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

James Espinosa, MD
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Citation: Tomasello N, Lucerna A, Scali V, Espinosa J. Small bowel diverticulitis. Consultant. 2017;57(2):131-132.

A previously healthy 34-year-old woman with no past surgical history presented to the emergency department (ED) reporting abdominal pain.

History and physical examination. The patient stated that she had been in her usual state of health but while resting overnight had developed discomfort localized to the periumbilical region, which she described as sharp and stabbing. She denied radiation of pain elsewhere. The pain was not associated with nor aggravated by meals; however, she did admit to exacerbation of pain with any body movement, relieved by lying completely still in her bed.

She denied any associated fevers, chills, chest pain, nausea, vomiting, constipation, diarrhea, hematochezia, melena, or hematemesis. She denied any excessive use of nonsteroidal anti-inflammatory drugs.

The patient was afebrile at presentation, and her vital signs were stable.

Diagnostic tests. Laboratory data were significant for an elevated white blood cell count of 14,700/µL but were otherwise unremarkable. Computed tomography (CT) scanning of the abdomen and pelvis with intravenous and oral contrast (Figure) revealed moderate to extensive inflammatory reaction involving the left upper quadrant, consistent with jejunal diverticulitis with contained microperforation.

The patient was started on intravenous ciprofloxacin and metronidazole and was admitted to the surgical service for further general surgery and gastroenterology evaluation. The patient was maintained on intravenous antibiotics.

Outcome of the case. The remainder of her hospitalization was uncomplicated, and the patient was discharged 3 days later following clinical improvement in her symptoms.

Discussion. Abdominal pain is one of the most common presenting complaints in emergency medicine, comprising 7% to 11% of all ED visits.^1,2 The differential diagnosis for cases of  undifferentiated abdominal pain is vast; left lower quadrant pain alone can manifest with gastrointestinal, urinary, mesenteric, vascular, or musculoskeletal mechanisms.² Careful evaluation and recognition of less common presentations is therefore important. Diverticular disease, for example, tends to involve the sigmoid colon and presents with tenderness in the left lower quadrant on evaluation in the majority of cases; however, diverticular disease also can involve the small bowel in rare instances,³ such as in our patient’s case.

Diverticulosis and diverticular disease are common causes of abdominal pain, and its incidence is increasing worldwide.³ The mechanism is controversial but is thought to involve acute inflammation of the diverticulum from retained fecal material and fecal microbiota, with resultant abscess formation and microperforation.³ Diverticulitis of the small bowel, however, is an uncommon presentation of diverticular disease, with a prevalence ranging from 0.06% to 1.3%.⁴ The majority of reported cases describe duodenal involvement (79%), followed by jejuno-ileal involvement (18%).⁴

Diverticulitis of the small bowel is often missed on conventional CT scans, although magnetic resonance enterography/enteroclysis has improved diagnostic sensitivity. CT imaging characteristically reveals asymmetric focal or segmental small bowel inflammation.⁵ 

Potential complications include perforation with peritonitis, although this is thought to be rare. Surgical management with resection is a consideration in cases of severe disease; however, long-term resolution of symptoms has been described with intravenous antibiotics alone.⁶

As demonstrated in our patient’s case, small bowel diverticulitis can present with minimal clinical symptoms, and laboratory test results can often be unremarkable.⁶ Imaging studies along with high clinical suspicion are the mainstays of ED diagnosis, particularly in patients younger than 40 years.

References:

1. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797.
2. 2Bodmer NA, Thakrar KH. Evaluating the patient with left lower quadrant abdominal pain. Radiol Clin North Am. 2015;53(6):1171-1188.
3. Elisei W, Tursi A. Recent advances in the treatment of colonic diverticular disease and prevention of acute diverticulitis. Ann Gastroenterol. 2016;​29(1):​24-32.
4. Kassir R, Boueil-Bourlier A, Baccot S, et al. Jejuno-ileal diverticulitis: etiopathogenicity, diagnosis and management. Int J Surg Case Rep. 2015;10:​151-153.
5. Mansoori B, Delaney CP, Willis JE, et al. Magnetic resonance enterography/enteroclysis in acquired small bowel diverticulitis and small bowel diverticulosis. Eur Radiol. 2016;26(9):2881-2891.
6. Levack MM, Madariaga ML, Kaafarani HM. Non-operative successful management of a perforated small bowel diverticulum. World J Gastroenterol. 2014;20(48):18477-18479.

Diverticular Disease: Symptoms and Treatment

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• 
  
  

  Symptoms of diverticular disease include tummy pain, feeling bloated, constipation and/or blood coming out of your rectum (back passage). Pain is often felt on the left side of your tummy, but it can happen on the right. If you have any rectal bleeding, see your GP. For more information, see our section on symptoms.

• 
  
  

  You don’t need to avoid any specific foods. But try to avoid any foods or drinks that could make you constipated, such as coffee, tea or alcohol. Dairy products may also make you constipated, but don’t cut these out of your diet without speaking to a dietitian first. If you notice specific foods are triggering your symptoms, you should also discuss this with your doctor.

  Doctors used to recommend that you shouldn’t eat nuts, seeds, fruit skins, corn or popcorn if you have diverticular disease. This is because they thought little bits of these foods could get stuck in your diverticula pouches and cause complications. But research shows that these foods don’t make diverticular disease worse.

• 
  
  

  Most people who get diverticulitis don’t get it again. You may still notice some tummy pain after your treatment has finished. If your symptoms change or get worse, it’s important to tell your doctor.

  Of those people who do get diverticulitis again, one in two will experience it within a year of their first episode. Around nine in ten people who get it again will get it in the first five years after their first episode. Eating a high-fibre diet will help to keep your diverticular disease under control.

  If you keep getting diverticulitis, you may need to have surgery.

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What is diverticulitis – symptoms, causes and treatment

Diverticulitis is a disease that affects the large intestine. The large intestine is an integral part of the digestive system. The large intestine is located at the end of the digestive tract and plays an important role in the digestive system. The large intestine absorbs water, minerals and nutrients from food and forms stool.

What is diverticulitis

People with diverticulitis develop diverticula, small pockets that form in the intestinal wall of the colon, especially in the lower left side of the colon or colon. Diverticula form due to increased pressure in the colon. These pockets are called diverticula and usually develop at weak points in the colon wall. The presence of diverticula is not uncommon and occurs in about half of the population aged 60 years and older.

The development of diverticula is described by two terms: diverticulosis and diverticulitis. Diverticulosis is used when diverticula in the colon are not inflamed or infected. Diverticulitis occurs when these diverticula become inflamed or infected. Inflammation and infection of the diverticula causes symptoms of diverticulitis, such as abdominal pain.

Symptoms of diverticulitis

In the case of diverticulosis, when infection does not enter the diverticula, symptoms are often absent or mild. In the case of diverticulitis, when the diverticulum becomes infected, the most common symptom is abdominal pain, especially in the lower left abdomen. This pain can range from mild to more severe abdominal pain. Other symptoms of diverticulitis include nausea, fever, constipation, sometimes diarrhea, and rectal bleeding.

Acute diverticulitis may be more severe and cause additional complications. Some of these complications include the development of a blockage in the colon due to scar tissue. There is also a risk of developing a fistula, which is considered a medical emergency. In some cases, infected diverticula can rupture, which is a serious complication leading to leakage of colonic contents into the abdominal cavity. This complication requires immediate medical attention and possibly emergency surgery.

Diagnosis of diverticular disease

Diagnosis of diverticulitis is based on signs and symptoms such as abdominal pain, increased white blood cells and bloody stools. To diagnose diverticulitis, a doctor may do a physical examination, including palpation of the abdomen for pain. A blood test may be done to check the level of white blood cells, and stool samples may be taken to rule out another diagnosis. Imaging techniques, such as computed tomography, are sometimes also used to look for inflamed diverticula. In more chronic cases, a colonoscopy may be done to rule out other possible comorbidities, such as colorectal cancer.

Causes and risk factors for diverticulitis

One possible cause of diverticulitis is nutrition. A diet low in fiber and high in animal fat and red meat may be a risk factor for diverticulitis. A diet low in fiber can cause chronic constipation. Constipation can be the cause of diverticulitis. Other lifestyles that may increase the risk or worsen diverticular disease include lack of exercise, obesity, and smoking. It has also been associated with certain medications, such as steroids, opioids, and non-steroidal anti-inflammatory drugs. A reduced immune system may also be a contributing factor to the development of diverticulitis.

Preventive methods

Some preventive methods can help reduce the risk of diverticulitis. One method is to include more fiber in your diet to improve bowel function, especially if you suffer from constipation. Some dietary changes that increase fiber intake are eating more fruits and vegetables, eating more whole grains, and eating more fiber-rich legumes and grains. Other preventive measures include drinking plenty of water, not smoking, and drinking too much alcohol. Daily exercise and getting enough vitamin D.

Treatment of diverticulitis

Treatment options for diverticulitis depend on the severity of the diverticulitis. Some home treatments can relieve the symptoms of diverticulitis in mild cases of diverticulitis. Some home treatments involve temporarily following a low-fiber or liquid food diet until symptoms become less frequent (as recommended by a doctor). At the same time, the introduction of probiotics and herbal treatment helps to reduce inflammation.

The doctor may also prescribe oral antibiotics to clear the infection. Pain medications may also be prescribed to relieve pain. For more severe diverticulitis, fluid and antibiotics may be given through a drip.

For more complex or severe diverticulitis, surgery may be performed. Surgery may be done if you have repeated episodes of diverticulitis, if you have complications such as intestinal perforation, obstruction, or abscess, or if you have an immune system disorder. Common surgeries include bowel resection, in which parts of the infected intestine are removed and reattached to the healthy intestine. In more severe cases, bowel resection may be combined with a colostomy. In a colostomy, the healthy intestine is connected to an opening in the abdomen called a stoma, and waste is removed into a colostomy bag.

Final Thoughts on Diverticular Disease

Diverticular diseases, including diverticulosis and diverticulitis, are common conditions that many people experience, especially as they age. Diverticulosis occurs when small pockets form in weak areas of the colon wall in the digestive tract, namely the large intestine. If these pockets become infected, the person develops diverticulitis.

A diet low in fiber may contribute to the development of diverticulitis. Other risk factors include genetic predisposition to diverticular disease, smoking, and physical inactivity. To check for diverticulitis, a doctor may do one or more tests, including a physical exam, blood test, or imaging. Diverticulitis can be mild and easily treated at home with prescribed antibiotics, a temporary liquid diet, and probiotics or herbal supplements. With more severe diverticulitis, complications may develop. In such cases, surgery may sometimes be required to treat complications.

It is important to be aware of the risk factors for diverticulitis and take steps to maintain a healthy gastrointestinal tract and colon to prevent diverticular disease.

Diverticulitis FAQ

Can certain foods cause diverticulitis?

• It was previously thought that people prone to diverticulitis should avoid eating nuts, and corn can cause diverticulitis, but studies do not support this theory.
• If you suffer from chronic constipation, eating more high-fiber foods or even fiber supplements to improve bowel function in general can help.
• If you currently have symptoms of diverticulitis, your doctor may recommend that you stick to liquid foods and avoid solid foods until your symptoms improve.

I had diverticulitis; how can i prevent future seizures?

• Despite the genetic link to diverticulitis outbreaks, there are steps you can take to prevent future outbreaks.
• These include a high-fiber diet or fiber supplement, drinking plenty of water, limiting alcohol and smoking, and maintaining a healthy weight.

When should I see a doctor if I think I have diverticulitis?

• If you have not yet been diagnosed with diverticulitis, but think you may have symptoms, you should make an appointment with your doctor.
• If you have already been diagnosed with diverticulitis, some mild symptoms can be treated at home.
• It is important to seek medical attention for possible complications of diverticulitis if your symptoms worsen, such as severe pain, nausea, fever, or bleeding.

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References

Diverticulitis – Symptoms and Causes – Mayo Clinic.

Diverticulitis: Symptoms, Causes, Diagnosis, Treatment, Surgery

Diverticulosis and Diverticulitis: Symptoms, Treatment, Prevention

Diverticular Disease and Diverticulitis – NHS

Symptoms and Causes of Diverticular Disease | NIDDK

https://www.physio-pedia.com/Diverticulitis

Diverticulitis – Diagnosis and Treatment – Mayo Clinic.

Diverticular disease and diverticulitis – NHS.

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Intestinal diverticulosis is a disease in which multiple or single sacs (diverticula) form in the lining of the organ.

This pathology can cause complications such as inflammation and bleeding of the diverticulum.

Causes of intestinal diverticulosis

Intestinal diverticulosis occurs due to weakness of the connective tissue. This condition may be congenital or acquired.

In congenital diverticulosis, multiple sacs are usually observed not only in the intestines, but also in the stomach, bladder and other organs. Acquired intestinal diverticulosis can develop for the following reasons:

• intestinal motility disorders
• malnutrition
• beriberi
• frequent constipation
• overweight
• low physical activity.

Symptoms of intestinal diverticulosis

Often, intestinal diverticulosis is not accompanied by any symptoms at all.

Symptoms of diverticulosis are similar to those of appendicitis and a number of other diseases. The following conditions may indicate the development of intestinal diverticulosis:

• pain in the lower abdomen, aggravated by physical exertion and coughing
• stool disorders (constipation followed by diarrhea)
• traces of blood in the stool
• fever
• nausea and vomiting
• loss of appetite.

Diagnosis of intestinal diverticulosis

For the diagnosis of intestinal diverticulosis in our clinic, the following range of methods is used:

• blood and urine tests
• coprogram
• colonoscopy
• ultrasound of the abdominal cavity
• other methods.

Treatment of intestinal diverticulosis

The doctor selects a method for treating intestinal diverticulosis depending on the characteristics of the course of the disease, the presence of complications and the general condition of the patient.

Diverticulosis can be treated conservatively or surgically.

Drug therapy is aimed at eliminating symptoms, restoring intestinal motility and motility. Surgery is indicated for severe complications, as well as in case of ineffective drug therapy.

Depending on the symptoms of the disease, three types of conservative treatment of intestinal diverticulosis are distinguished:0074

treatment of the symptomatic form of the disease requires not only diet, but also medication to eliminate the main symptoms

treatment of acute diverticulitis involves a special diet and drug therapy aimed at reducing diverticulum inflammation (sulfonamides and antibiotics).