Diverticula of the Alimentary Tract Aaron Sinclair MD

Diverticula of the Alimentary Tract Aaron Sinclair, MD

Learning Objectives • Differentiate between true and false diverticula. • Review pathophysiologic development of different diverticula. • Evaluate the locations of common diverticula of the alimentary tract. • Assess different diagnostic modalities for diverticula. • Discuss when treatment is indicated for diverticula.

Normal Anatomy

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Diverticula of the Esophagus • Upper Esophagus – Zenker’s • Middle Esophagus – Traction • Lower Esophagus – Epiphrenic

Upper Esophagus – Zenker’s Diverticulum • False Diverticulum • Upper Posterior Esophagus – Killian’s Triangle

Upper Esophagus – Zenker’s Diverticulum • Etiology – unknown, ? Acid and Swallowing dysfunction. • Age predominately > 60 Incidence 2/100, 000 http: //emedicine. medscape. com/article/3741 53 -overview

Upper Esophagus – Zenker’s Diverticulum • Diagnosis – preferred barium swallow • Caution with endoscopy due to perforation risk http: //www. gastrolab. net/y 0157. jpg

Upper Esophagus – Zenker’s Diverticulum • Treatment – Traditional Surgical Management – Endoscopic Cricopharyngeal Myotomy • Symptom Improvement as high as 90% • Recurrence in up to 35% Zenker's Diverticulum Ryan Law, David A. Katzka, Todd H. Baron Published Online: September 19, 2013 http: //dx. doi. org/10. 1016/j. cgh. 2013. 09. 016

Middle Esophagus – Traction Diverticulum • True Diverticulum • Mediastinal lymphadenopathy scarring traction

Middle Esophagus – Traction Diverticulum • Usually < 2 cm in size • Treatment rarely needed unless complications occur – Fistulas – Occlusion http: //www. gastrohep. com/i mages/image. asp? id=720

Lower Esophagus – Epiphrenic Diverticulum • False Diverticula • Rare =. 015% of the population • Occurs within 10 cm of Lower Esophageal Stricture

Lower Esophagus – Epiphrenic Diverticulum • Etiology = GERD + Motility Dysfunction ? • Treatment = typically not indicated if < 5 cm & asymptomatic • Therapy: – Fundoplication (GERD) – Open Resection or Laparoscopic

Gastric Diverticulum • True Diverticulum • Rare -. 04% • Usually asymptomatic but can lead to complications: – Bleeding – Dyspepsia – Emesis

Gastric Diverticulum • Treatment – conservative for symptomatic patients only – Proton Pump Inhibitors • Definitive Treatment – Gastrectomy of the Diverticulum http: //www. eurorad. org/eurorad/view_figu re. php? pubid=11721&figid=36787&nr=1&la ng=en

Duodenal Diverticula • • True or False Diverticula Common – 22% of population Most common location is 2 nd part Can lead to complications due to location – Obstuction Sphincter of Oddi – Impingement of Hepato- http: //www. gastrolab. fi/videos/vid 3065. jpg biliary tree

• Diagnosis – – Duodenal Diverticula Endoscopy Small Bowel Follow Through MRI or CT scan Endoscopy http: //posterng. netkey. at/esr/viewing/index. p hp? module=viewing_poster&task=viewsection &pi=105730&ti=324613&searchkey= • Treatment – Asymptomatic – nothing – Dependent on symptoms http: //www. gastrolab. fi/videos/vid 3063. jpg

Jejunal and Ileal Diverticula • False Diverticula • Occur anywhere along the Jejunum or Ileum • Typically on the mesenteric side of the bowel at blood vessel penetration • Most are found incidentally • Symptoms may include – Bleeding – Obstruction – Infection • ? Bacterial overgrowth. • Diverticulitis http: //openi. nlm. nih. gov/imgs/512/211/29888 64/2988864_crg 0004 -0492 -f 03. png Jejunal Diverticulitis: A Rare Case of Severe Peritonitis. Sakpal SV, Fried K, Chamberlain RS - Case R Gastroenterol (2010)

Jejunal and Ileal Diverticula • Diagnosis: – Capsule Endoscopy – Small Bowel Barium Contrast Follow Through • Treatment – Antibiotics Jejunal Diverticulosis: Findings on CT in 28 Patients – Promotility Agents Florian Fintelmann 1 Marc S. Levine – Resection Stephen E. Rubesin http: //pillcamkorea. co. kr/boa d/image_viw. asp? key=106&p age=5 http: //www. ajronline. org/doi/pdfplus/10. 2214/AJR. 07. 3 087 AJR: 190, May 2008

Meckel’s Diverticula • True Diverticula • Rule of 2’s • Symptoms may include – Bloody Mucoid stools – Abdominal pain – 2% of the population – 2 feet from the ileocecal – Nausea and vomiting under age 6 valve – 2: 1 male predominance – 2% are symptomatic • May have ectopic tissues http: //emedicine. medscape. com/article/1947 76 -overview#a 2

• Diagnosis: Meckel’s Diverticula – Adults – high degree of suspicion – technectium 99 m scan – Children • Ultrasound – Can fix intussusception - 90% • CT Scan • Treatment – Based on Age and Symptoms • 5 fold increase in complications – Bowel Obstruction – Infection – Asymptomatic – remove • Age <50 or young children • Palpable abnormality • Size >2 cm (length or base)

Colonic Diverticula • False Diverticula • Arteries penetrate the muscularis to reach the submucosa and mucosa – weak point

Colonic Diverticula • Decreased fiber leads to an increase in colonic wall pressures. • Low fiber colonic wall hypertrophy • La. Place’s Law – Increased pressure at smaller diameter (sigmoid)

• Incidence – Age 40 – Age 80 • • Colonic Diverticula 20% of all people 60% of all people 80% asymptomatic with diverticulosis 15% to 20% diverticulitis 5% to 10% diverticular bleeding http: //www. drugs. com/healthguide/diverticulosis-and. Diagnosis – – CT Scan Endoscopy Radionucleide Imaging Barium Enema diverticulitis. html

• Treatment Colonic Diverticula – Strong Associations • Fiber – A Harvard study of 47, 888 men demonstrates the role of dietary fiber. Men who consumed the most fiber were 42% less likely to develop symptomatic diverticular disease than their peers who consumed the least fiber. – Weak Associations • Increasing Exercise • Increasing Water Intake • Decreasing Low Fat/High Meat Diet

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