EDITOR’S QUIZ: GI SNAPSHOT
From question on page 418
Radiographic enteroclysis showed multiple large duodenal and jejunoileal diverticula (fig 1). The proximal small intestine was found to have normal resorptive capacities suggested by a normal d-xylose test while intestinal bacterial overgrowth was indicated by a H2 breath test with glucose. Extended diverticulosis of the small bowel with subsequent bacterial overgrowth was assumed to be the most likely cause of the patient’s malabsorption and weight loss. Bacterial overgrowth of the small intestine was treated with a rotating antibiotic regimen of ciprofloxacin for 10 days, metronidazole for a further 10 days, followed by tetracycline for 10 days. Simultaneously, a high calorie diet and vitamin B12 supplementation was started. This therapy was well tolerated and the patient gained 10 kg in weight within six weeks. A follow up H2 breath test two weeks after completing the rotating antibiotic regimen was also normal, thus indicating that bacterial overgrowth had been successfully treated. Subsequently, the patient reached his initial body weight and maintained a normal weight for more than 18 months.
Small bowel diverticulosis is rare, and in most cases an asymptomatic course of disease is observed. The highest incidence of small intestinal diverticula is observed in the duodenum, followed by the proximal jejunum with decreasing prevalence in the distal small bowel.1 Assessment by enteroclysis has shown an incidence of approximately 2.0–2.3%; in autopsy series the incidence has ranged from 0.06% to 4.6%.2,3 Both duodenal and jejunoileal diverticula are thought to be acquired pulsion diverticula containing outpouchings of mucosa and submucosa. Due to the relative stasis of the intestinal contents within the diverticulum, bacterial overgrowth, malabsorption, steatorrhoea, and megaloblastic anaemia may develop. Other complications of diverticulosis of the small bowel may include abdominal pain, bleeding, diverticulitis, perforation, abscess formation, obstruction, and bile stasis.1
Excluding patients with acute abdomen who need surgical intervention, the treatment of symptomatic diverticulosis should aim to correct the cause of the malabsorption by eliminating bacterial overgrowth with cyclic use of broad spectrum antibiotics. The use of antispasmodics, antacids, analgesics, and vitamin B12 supplementation may result in symptomatic improvement in most patients. Resection of the involved segment of the small bowel should be considered only as a last resort and should be reserved for those patients not responding to conservative treatment.1