What is the workup and treatment for a female patient with abdominal pain and pressure suspected to have a gastric diverticulum?

Workup and Treatment for Suspected Gastric Diverticulum

Initial Diagnostic Approach

For a female patient with abdominal pain and pressure suspected to have a gastric diverticulum, obtain CT abdomen with IV contrast as the primary diagnostic modality, followed by upper endoscopy for confirmation and to exclude alternative diagnoses. 1, 2

Primary Imaging: CT Abdomen with IV Contrast

• CT with IV contrast is the gold standard for diagnosing gastric diverticula, providing superior anatomic detail, ability to assess for complications (perforation, bleeding), and evaluation of alternative diagnoses that may present similarly 3, 1
• CT should be performed with neutral oral contrast (water or dilute barium) to optimize gastric distention and delineate the intraluminal space from the diverticulum 3
• IV contrast enhances detection of inflammatory changes, wall thickening, and vascular complications that may require urgent intervention 3, 4

Confirmatory Testing: Upper Endoscopy

• Esophagogastroduodenoscopy (EGD) should be performed after CT imaging to directly visualize the diverticulum, assess for mucosal abnormalities, exclude peptic ulcer disease or gastric malignancy, and evaluate for active bleeding if hematemesis is present 1, 4
• Endoscopy is particularly important because symptoms of gastric diverticula overlap significantly with more common pathologies (gastritis, peptic ulcer disease, gastric cancer) that require different management 1, 2

Alternative Imaging Considerations

• Upper GI series with barium can demonstrate the diverticulum as an outpouching, typically in the gastric fundus, but provides less information about complications and surrounding structures compared to CT 3, 5
• Plain radiography has extremely limited utility and should not be used as initial imaging 3

Clinical Presentation to Assess

• Most gastric diverticula are asymptomatic and discovered incidentally during imaging for other indications 1, 2
• When symptomatic, look for: upper abdominal/epigastric pain, nausea, vomiting, dyspepsia, and postprandial discomfort 1, 2
• Red flag symptoms requiring urgent evaluation: hematemesis, melena, signs of perforation (peritonitis, free air), or severe acute abdominal pain suggesting complications 1, 4

Treatment Algorithm

Asymptomatic or Incidentally Discovered Diverticula

• No specific treatment is required for asymptomatic gastric diverticula 1, 2
• Conservative management with observation is appropriate 1
• Antacids or proton pump inhibitors provide only temporary symptom relief and do not address the underlying anatomic abnormality 1

Symptomatic Uncomplicated Diverticula

• Trial of conservative medical management with acid suppression therapy (PPIs) and dietary modifications may be attempted initially 1
• If symptoms persist despite medical therapy or if the diverticulum is large (>4 cm), surgical resection should be considered 1, 2

Complicated or Large Symptomatic Diverticula

• Surgical resection is the definitive treatment for diverticula that are large, persistently symptomatic despite medical therapy, or complicated by bleeding, perforation, or suspected malignancy 1, 2
• Laparoscopic resection combined with intraoperative endoscopy is the preferred surgical approach, offering excellent outcomes with minimal invasiveness 1
• Over two-thirds of patients remain symptom-free after surgical resection 1

Critical Pitfalls to Avoid

• Do not assume symptoms are from the diverticulum without excluding more common pathologies (peptic ulcer disease, gastritis, gastric cancer) through endoscopy, as these conditions frequently coexist and may be the primary cause of symptoms 1, 2
• Do not perform barium enema or contrast enema studies if gastric diverticulum is suspected, as these are inappropriate for upper GI pathology and carry perforation risk in colonic diverticula 3, 6
• Do not delay surgical consultation if the patient presents with hematemesis, signs of perforation, or hemodynamic instability, as these complications can be life-threatening 1, 4
• Do not rely on plain radiography alone, as it has extremely limited sensitivity for detecting gastric diverticula and their complications 3