What is the management approach for fecaliths in small bowel diverticula?

Management of Fecaliths in Small Bowel Diverticula

Surgical resection is recommended for small bowel diverticula containing fecaliths, as these represent a high-risk scenario for perforation, obstruction, and other life-threatening complications that cannot be reliably managed conservatively. 1

Understanding the Clinical Context

Small bowel diverticula are uncommon (1-5% prevalence), with most being asymptomatic and discovered incidentally. 2 However, when fecaliths form within these diverticula, the clinical picture changes dramatically. Fecaliths are hard, compacted fecal masses that can cause:

• Perforation (the most serious complication, as demonstrated in case reports of gangrenous and perforated appendix/cecum with fecaliths) 3
• Intestinal obstruction (through inflammatory stenosis, volvulus, or direct mechanical blockage) 4
• Diverticulitis with potential for abscess formation 1
• Bleeding (44.2% of symptomatic cases in one series) 1

Recommended Management Algorithm

Step 1: Initial Assessment and Imaging

• CT imaging with oral and IV contrast is the diagnostic modality of choice to identify the diverticulum, assess for complications (perforation, abscess, obstruction), and characterize the fecalith 5
• Look specifically for: wall thickening, pericolonic inflammation, extraluminal air (perforation), fluid collections (abscess), and bowel dilation (obstruction) 6

Step 2: Risk Stratification

High-risk features mandating urgent surgical intervention:

• Signs of perforation (free air, peritonitis) 6
• Generalized peritonitis or sepsis 6, 7
• Hemodynamic instability 7
• Complete bowel obstruction 4
• Gangrenous changes 3

Moderate-risk features suggesting elective surgical planning:

• Recurrent abdominal pain episodes 1
• Partial obstruction 4
• Large diverticulum (>5 cm) with fecalith 5
• History of diverticulitis 5

Step 3: Surgical Approach

For symptomatic or complicated cases:

• Segmental resection is preferred over simple diverticulectomy (performed in 53.7% vs 43.8% of symptomatic cases) 1
• Segmental resection ensures complete removal of diseased bowel and prevents recurrence 1
• Primary repair may be considered for isolated perforation in stable patients, but carries risk of recurrence 3

For incidentally discovered small bowel diverticula with fecaliths:

• Surgical resection is still recommended because most small bowel diverticula (except duodenal) can be removed without significant morbidity or mortality, and removal prevents future complications 1
• The rationale: fecaliths indicate stasis and dysfunction that will likely lead to complications over time 5

Step 4: Special Considerations by Location

Duodenal diverticula:

• Have higher morbidity and mortality rates 1
• Require more cautious surgical approach due to proximity to pancreaticobiliary structures 1
• May warrant observation if truly asymptomatic and without fecalith-related complications 2

Jejunal/ileal diverticula:

• More amenable to straightforward resection 1
• Lower surgical risk profile 1
• Should be removed when fecaliths are present, even if incidental 1

Conservative Management: When Is It Appropriate?

Conservative management with laxatives and enemas may be attempted only in highly selected cases: 3

• Fecalith in colon (not small bowel) without obstruction 5
• No signs of perforation, peritonitis, or sepsis 6
• Patient can tolerate oral intake 6
• Close monitoring available with low threshold for surgery 6

However, this approach does not prevent recurrence and should not be applied to small bowel diverticula with fecaliths. 3

Critical Pitfalls to Avoid

1. Assuming conservative management is adequate: Unlike colonic fecal impaction, small bowel diverticula with fecaliths have high complication rates and require definitive surgical management 1

2. Delaying surgery in symptomatic patients: Postoperative complications occur more commonly in symptomatic patients (25.6%) than incidental cases (8.1%), suggesting earlier intervention is preferable 1

3. Performing simple diverticulectomy instead of segmental resection: Segmental resection provides more definitive treatment and lower recurrence risk 1

4. Overlooking duodenal diverticula complications: These have uniquely high morbidity/mortality and require specialized surgical expertise 1

5. Missing the diagnosis entirely: Small bowel diverticula should be considered in any patient with unexplained abdominal pain or GI bleeding, especially if recurrent 1

Postoperative Management

• Standard postoperative care with early mobilization 1
• No specific dietary restrictions beyond standard post-bowel surgery recommendations 1
• Long-term follow-up to monitor for recurrence (though rare after complete resection) 5
• In one case series, no recurrence occurred during 33 months of follow-up after appropriate surgical resection 5