Small Bowel Diverticulitis

Small bowel diverticulitis is inflammation of an acquired jejunal or ileal diverticulum. Jejunal disease predominates and occurs mainly in older adults.

Inflammation can remain localised or progress to abscess, perforation, peritonitis or fistulation.

Because symptoms are nonspecific, it is often mistaken for appendicitis, colonic diverticulitis or other causes of acute abdomen.

Patients typically develop localised or poorly localised abdominal pain with fever, nausea and tenderness.

Jejunal diverticulitis often produces central or left sided pain.

Perforation causes increasing guarding, diffuse pain, ileus and systemic toxicity.

CT abdomen with IV contrast: identify an inflamed mesenteric border small bowel diverticulum and determine whether perforation or abscess is present.

A stable patient with localised uncomplicated inflammation and no free perforation can be managed initially with bowel rest, analgesia and antibiotics.

A practical regimen is:

Ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 12 hours.

An accessible localised abscess may undergo percutaneous drainage.

Operate for:

• Generalised peritonitis
• Free perforation
• Uncontrolled sepsis
• Failed conservative treatment
• Bowel obstruction
• Significant recurrent complications

For perforated jejunal diverticulitis, perform segmental small bowel resection with primary anastomosis when the patient is stable and bowel perfusion is satisfactory. Simple diverticulectomy through inflamed mesenteric tissue is generally less reliable than removing the diseased segment.

After adequate source control, approximately 4 days of antibiotics is generally sufficient for secondary intra abdominal infection.