History

Fact Explanation
Upper abdominal fullness and discomfort. Gastric diverticulum (GD) is an outpouching of the gastric wall. GDs are rare and they are commonly detected incidentally during routine diagnostic testing. Most GD are asymptomatic but may present with a vague sensation of fullness or discomfort in the upper abdomen.[1]. Occasionally, the sensation of fullness in the upper abdomen occurs immediately after meals.[2].
Upper abdominal pain Gastric diverticula can be congenital and acquired. The congenital gastric diverticulum is a “true diverticulum” and involves all layers of the gastric wall. It is the most common gastric diverticulum typically located at the posterior wall just below the GOJ. The acquired variety lacks the muscular or serosal layer “false diverticulum” and is mostly located in the distal one third of the stomach, especially in the prepyloric region. [2].Symptoms arise, depending on the size of the diverticular neck, they are most commonly upper abdominal pain, nausea, and emesis, and are described in 18%-30% of cases. Wide-neck diverticula often go unnoticed perhaps because food and digestive juices are less likely to become trapped. It has been suggested that food retention with subsequent distension of the gastric diverticulum may cause pain.[5]. Vague upper abdominal pain is the most common complaint, encountered in 18–30% of symptomatic patients.[4].
Nausea and emisis Most gastric diverticula are asymptomatic. However when symptoms arise, depending on the size of the diverticular neck, they are most commonly upper abdominal pain, nausea, and emesis, and are described in 18%-30% of cases.[5]
Early satiety Symptomatic patients typically present with epigastric pain, dysphagia, belching, and early satiety. The pathophysiology of symptoms is thought to be related to a combination of stasis, obstruction, and bacterial overgrowth.[3].
Dyspepsia and vomiting Dyspepsia and vomiting are less common.[2].
Perforation Ulceration with hemorrhage or perforation are rare complications but have been reported.Diverticula exceeding 4 cm are more prone to produce complications and tend to respond less favorably to medication.[2].
Malignancy Only twice has an invasion with adenocarcinoma been reported.[2]. However accurate diagnosis is essential not only due to complications but also due to association with ectopic mucosa and potential for malignant transformation. Acquired gastric diverticula in contrast are pseudodiverticula, less common and typically located in the antrum. They usually present with a background history of other gastrointestinal pathology, such as peptic ulcer disease, malignancy, pancreatitis, or gastric outlet obstruction.[1].
References
  1. RASHID F, ABER A, IFTIKHAR SY. A review on gastric diverticulum World J Emerg Surg [online] :1 [viewed 09 August 2014] Available from: doi:10.1186/1749-7922-7-1
  2. DONKERVOORT SC, BAAK LC, BLAAUWGEERS JL, GERHARDS MF. Laparoscopic Resection of a Symptomatic Gastric Diverticulum: a Minimally Invasive Solution JSLS [online] 2006, 10(4):525-527 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015748
  3. ZELISKO A, RODRIGUEZ J, EL-HAYEK K, KROH M. Laparoscopic Resection of Symptomatic Gastric Diverticula JSLS [online] 2014, 18(1):120-124 [viewed 09 August 2014] Available from: doi:10.4293/108680813X13693422520648
  4. MUIS MO, LEITAO K, HAVNEN J, GLOMSAKER TB, SøREIDE JA. Gastric diverticulum and halitosis--A case for surgery? Int J Surg Case Rep [online] , 5(7):431-433 [viewed 09 August 2014] Available from: doi:10.1016/j.ijscr.2014.04.029
  5. MARANO L, REDA G, PORFIDIA R, GRASSIA M, PETRILLO M, ESPOSITO G, TORELLI F, COSENZA A, IZZO G, DI MARTINO N. Large symptomatic gastric diverticula: Two case reports and a brief review of literature World J Gastroenterol [online] 2013 Sep 28, 19(36):6114-6117 [viewed 09 August 2014] Available from: doi:10.3748/wjg.v19.i36.6114

Examination

Fact Explanation
Upper GI bleeding and Ulceration Occasionally, patients with gastric diverticula can have dramatic presentations related to massive bleeding or perforation due to food retention with subsequent release of gastric juices within the mucosal sac, causing diverticulitis and possibly ulceration or hemorrhage.[1] The diagnosis may be difficult, as symptoms can be caused by more common gastrointestinal pathologies and only aggravated by diverticula.[1].
Belching and oral fetor Food retention and bacterial overgrowth within the diverticulum have been suggested to explain the belching and oral fetor. However, the true mechanisms of bacterial overgrowth in the gastrointestinal tract are complex.[2].
Left abdominal mass Gastric diverticula are often single, varying in size from 1 to 3 cm. However, multiple and larger diverticula have also been noted. Usually adjacent to the gastroesophageal junction and along the lesser curvature or posterior gastric wall. Gastric cardia diverticula may simulate a left adrenal mass. Those on the posterior wall could herniate through the dorsal mesentery and fuse with the left posterior body wall.[3].
References
  1. MARANO L, REDA G, PORFIDIA R, GRASSIA M, PETRILLO M, ESPOSITO G, TORELLI F, COSENZA A, IZZO G, DI MARTINO N. Large symptomatic gastric diverticula: Two case reports and a brief review of literature World J Gastroenterol [online] 2013 Sep 28, 19(36):6114-6117 [viewed 09 August 2014] Available from: doi:10.3748/wjg.v19.i36.6114
  2. MUIS MO, LEITAO K, HAVNEN J, GLOMSAKER TB, SøREIDE JA. Gastric diverticulum and halitosis--A case for surgery? Int J Surg Case Rep [online] , 5(7):431-433 [viewed 09 August 2014] Available from: doi:10.1016/j.ijscr.2014.04.029
  3. MOHAN P, ANANTHAVADIVELU M, VENKATARAMAN J. Gastric diverticulum CMAJ [online] 2010 Mar 23, 182(5):E226 [viewed 09 August 2014] Available from: doi:10.1503/cmaj.090832

Differential Diagnoses

Fact Explanation
Peptic ulcer disease Present with dyspepsia.[1].Left untreated, peptic ulcer diseases (PUD) will cause major complications, such as hemorrhage, perforation, or obstruction in 20–25% of patients. Among these complications, upper gastrointestinal (UGI) bleeding is the most frequently encountered, accounting for about 70% of cases.[2].Until recently, chronic PUD was almost exclusively due to H. pylori infection with up to 90% of duodenal ulcers and 70% of gastric ulcers attributed to this bacterium.However, NSAIDs and aspirin are now responsible for most ulcer disease in developed countries.[1],[4].
Pancreatitis The most common symptom associated with pancreatitis is pain localized to the upper-to-middle abdomen. Patients often report that their pain radiates to the back. Acute pancreatitis is often associated with nausea or vomiting, and the pain may worsen immediately following a meal.chronic pancreatitis results in abnormal or diminished pancreatic function, patients may also experience issues related to food malabsorption. This leads to steatorrhea, bloating, indigestion, dyspepsia, and diarrhea.[3]. Acquired gastric diverticula in contrast are pseudodiverticula, less common and typically located in the antrum. They usually present with a background history of other gastrointestinal pathology, such as peptic ulcer disease, malignancy, pancreatitis, or gastric outlet obstruction.[4].
Gastric malignancy Gastric carcinoma often produces no specific symptoms when it is superficial and potentially surgically curable, although up to 50% of patients may have nonspecific gastrointestinal complaints such as dyspepsia. In Western countries, even with endoscopic evaluation, gastric cancer is found in only 1% to 2% of patients with dyspepsia. The lack of early pathognomonic symptoms often delays the diagnosis. Consequently, 80% to 90% of patients with gastric cancer present with locally advanced or metastatic tumors that have poor rates of resectability. Patients may present with anorexia and weight loss (95%) as well as abdominal pain that is vague and insidious in nature. Nausea, vomiting, and early satiety may occur with bulky tumors that obstruct the gastrointestinal lumen or infiltrative lesions that impair stomach distension. Ulcerated tumors may cause bleeding that manifest as hematemesis, melena, or massive upper gastrointestinal hemorrhage.[5],[4].
References
  1. HARMON RC, PEURA DA. Evaluation and management of dyspepsia Therap Adv Gastroenterol [online] 2010 Mar, 3(2):87-98 [viewed 12 August 2014] Available from: doi:10.1177/1756283X09356590
  2. HUANG TING-CHUN, LEE CHIA-LONG. Diagnosis, Treatment, and Outcome in Patients with Bleeding Peptic Ulcers and Infections . BioMed Research International [online] 2014 December, 2014:1-10 [viewed 12 August 2014] Available from: doi:10.1155/2014/658108
  3. BANKS PA, CONWELL DL, TOSKES PP. The Management of Acute and Chronic Pancreatitis Gastroenterol Hepatol (N Y) [online] 2010 Feb, 6(2 Suppl 5):1-16 [viewed 12 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886461
  4. RASHID F, ABER A, IFTIKHAR SY. A review on gastric diverticulum World J Emerg Surg [online] :1 [viewed 12 August 2014] Available from: doi:10.1186/1749-7922-7-1
  5. DICKEN BJ, BIGAM DL, CASS C, MACKEY JR, JOY AA, HAMILTON SM. Gastric Adenocarcinoma: Review and Considerations for Future Directions Ann Surg [online] 2005 Jan, 241(1):27-39 [viewed 12 August 2014] Available from: doi:10.1097/01.sla.0000149300.28588.23

Investigations - for Diagnosis

Fact Explanation
esophagogastroduodenoscopy (EGD) Gastric diverticulum is best diagnosed with an UGI contrast study or esophagogastroduodenoscopy (EGD).[2]. These are the most reliable diagnostic tests .But they can give false negative results .Especially for a diverticulum with a narrow neck that precludes entry of the contrast or scope.It is stated that the GD is best identified during UGI study using a right, anterior oblique view with the patient in a supine, slightly left lateral decubitus and Trendelenburg position. Distension of the diverticulum by the scope may mimic the patient's symptoms and this maneuver may indicate which patients would benefit from resection. [1]. But some reports recommend the use of upper endoscopy for diagnosis, as this modality easily confirms the location and size of the diverticulum and provides the opportunity to biopsy any concurrent pathology.[4].
Gastrointestinal contrast radiographic study (UGI). The condition can be diagnosed by radiological or endoscopic examinations.This is usually accomplished with upper gastrointestinal contrast radiographic study (UGI) or Esophagogastroduodenoscopy (EGD).[1]. Upper endoscopy, ultrasound, and upper gastrointestinal barium studies often disclose other upper gastrointestinal pathology. An upper barium study will reveal a posterior wall diverticulum. However, if the diverticulum is not barium filled, it may be missed.[3].
Computer Tomography Scanning (CT scan) Some reports suggest that computer tomography scanning may be effective. However, the accuracy of this imaging modality is not widely accepted because of the possible misdiagnosis.[1]. And also CT is not the primary mode of detection of gastric diverticulum in symptomatic patients.[2].
References
  1. RASHID F, ABER A, IFTIKHAR SY. A review on gastric diverticulum World J Emerg Surg [online] :1 [viewed 11 August 2014] Available from: doi:10.1186/1749-7922-7-1
  2. ZELISKO A, RODRIGUEZ J, EL-HAYEK K, KROH M. Laparoscopic Resection of Symptomatic Gastric Diverticula JSLS [online] 2014, 18(1):120-124 [viewed 11 August 2014] Available from: doi:10.4293/108680813X13693422520648
  3. MCKAY R. Laparoscopic Resection of a Gastric Diverticulum: A Case Report JSLS [online] 2005, 9(2):225-228 [viewed 11 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015582
  4. MARANO L, REDA G, PORFIDIA R, GRASSIA M, PETRILLO M, ESPOSITO G, TORELLI F, COSENZA A, IZZO G, DI MARTINO N. Large symptomatic gastric diverticula: Two case reports and a brief review of literature World J Gastroenterol [online] 2013 Sep 28, 19(36):6114-6117 [viewed 11 August 2014] Available from: doi:10.3748/wjg.v19.i36.6114

Management - General Measures

Fact Explanation
Soft diet There is no specific treatment plan for an asymptomatic diverticulum. The appropriate management for a symptomatic GD depends mainly on the severity of the presenting complaints.[1].Soft diet, antacids, antispasmodics, and proton pump inhibitors have all been reported to relieve symptoms.[2].
Proton pump inhibitors (PPI) Medical treatment with thorough evaluation for other gastrointestinal pathology should be the first line of therapy for suspected symptomatic gastric diverticula.[2]. Proton pump inhibitors therapy for few weeks is reported to resolve the symptoms in proven cases of GD. However it is important to note that this does not resolve the underlying pathology. Some studies report that patients presented again with refractory symptoms of dyspepsia and worsening epigastric pain that did not settle with either proton pump inhibitors or histamine receptor blockers .[1].
References
  1. RASHID F, ABER A, IFTIKHAR SY. A review on gastric diverticulum World J Emerg Surg [online] :1 [viewed 11 August 2014] Available from: doi:10.1186/1749-7922-7-1
  2. ZELISKO A, RODRIGUEZ J, EL-HAYEK K, KROH M. Laparoscopic Resection of Symptomatic Gastric Diverticula JSLS [online] 2014, 18(1):120-124 [viewed 11 August 2014] Available from: doi:10.4293/108680813X13693422520648

Management - Specific Treatments

Fact Explanation
Laparoscopic resection Surgical resection is recommended when the diverticulum is large, symptomatic or complicated by bleeding, perforation or malignancy. Both open and laparoscopic resection yield good results.The laparoscopic approach has been described by different authors. The most favourable approach that provides the necessary exposure is by placing the ports in a similar fashion to laparoscopic Nissen fundoplication. This includes a midline port, right upper quadrant, and 2 left upper quadrant ports. The laparoscopic dissection has been performed by either releasing the gastrocolic/gastrosplenic ligament or by mobilizing the short gastric vessels, thus gaining exposure of the superior posterior wall of the stomach. The latter is the most frequently used approach. Because all diverticula were true and located in the gastric fundus, the most direct approach was by taking down of the short gastric vessels. Simple resection of the diverticulum with a laparoscopic cutting stapler was reported to be successful.[1].
References
  1. RASHID F, ABER A, IFTIKHAR SY. A review on gastric diverticulum World J Emerg Surg [online] :1 [viewed 11 August 2014] Available from: doi:10.1186/1749-7922-7-1