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Meckel Diverticulum

Meckel diverticulum is one of the most common congenital malformations of the gastrointestinal tract and occurs in the distal ileum. The majority of patients are asymptomatic, but symptoms may include rectal bleeding, abdominal pain, and vomiting. The diagnosis is made through imaging techniques, most commonly radionuclide scanning and surgical treatment is the method of choice for managing patients.


Presentation

The majority of patients are asymptomatic and the diagnosis is often made incidentally. However, symptoms may be present, and most commonly include bleeding, abdominal pain, nausea, vomiting and cramping [9]. Rectal bleeding is one of the most important signs and may range from minimal bleeding to significant hemorrhage that may lead the patient to anemia and possibly shock. Findings can include either fresh blood in stools or melena in some cases. Intestinal obstruction manifests with abdominal pain and constipation, while vomiting may also be reported. Inflammatory complications, such as acute diverticulitis, is of striking resemblance to appendicitis because symptoms that are reported include diarrhea, fever, abdominal pain and cramping, as well as tenderness in the periumbilical area. In very rare cases, an intestinal perforation may occur, leading to symptoms such as hypotension and severe pain. Because the clinical presentation of Meckel diverticulum includes nonspecific symptoms related to the gastrointestinal tract, a careful and detailed diagnostic workup should be conducted to identify this condition as the underlying cause, particularly in the pediatric population.

Asymptomatic
  • Meckel diverticulum is more commonly detected in symptomatic patients than in asymptomatic patients, and detection is related to the amount of peritoneal fat.[ncbi.nlm.nih.gov]
  • Complications were experienced by two asymptomatic females, one asymptomatic male, and a symptomatic male. There were no mortalities. CONCLUSIONS: Meckel diverticulum is found infrequently in the adult population.[ncbi.nlm.nih.gov]
  • Hence we strongly recommend resection of MD in asymptomatic patients.[saudijgastro.com]
  • Although the majority of patients are asymptomatic and less than 10% of patients exhibit symptoms.[symptoma.com]
Anemia
  • You may need to take iron supplements to treat anemia. You may need a blood transfusion if you have a lot of bleeding, Most people recover fully from surgery and will not have the problem come back. Complications from the surgery are also unlikely.[nlm.nih.gov]
  • This test checks for anemia or infection. A stool sample may be checked for blood. Barium enema and small bowel series. This procedure is done to examine the large intestine for abnormalities.[stanfordchildrens.org]
  • When the intestine develops an ulcer, significant bleeding can result, causing anemia (low numbers of red blood cells in the bloodstream). If enough blood is lost, a child may go into shock, which is a life-threatening situation.[beaumont.org]
  • Blood test: This is done to determine if anemia or infection is present. A stool sample may also be obtained to check for frank (obvious) or occult (hidden) blood.[cincinnatichildrens.org]
  • Persistent bleeding can eventually lead to iron deficiency anemia, which may be the first sign of the problem.[uvahealth.com]
Anorexia
  • A 65-year-old woman presented with a nonradiating, constant pain in the right groin with associated nausea and anorexia. Physical examination revealed a tender, irreducible lump in the right groin area.[ncbi.nlm.nih.gov]
  • One point is given to the migration of pain to the right hypogastrium, anorexia, nausea/vomiting, Rovsing’s sign, subfebrility, and shift of the leukocytes to the left side.[portal.lf.upjs.sk]
  • Illustrative Case A 60-year-old woman presented to the emergency department with a complaint of nonradiating, waxing and waning epigastric abdominal pain of two to three hours' duration, with associated nausea and anorexia.[aafp.org]
  • CASE REPORT A 39 years old man, was admitted to the emergency unit of diffuse abdominal pain of 3 days of evolution, associated with anorexia, nausea and vomiting. He had history of epilepsy and mental deficit.[scielo.org.pe]
Pallor
  • A 12-year-old boy presented with bloody diarrhoea and abdominal pain in association with a long-standing history of black stools and progressive pallor.[ncbi.nlm.nih.gov]
  • Clinical Presentation and Intervention: A 12-year-old boy presented with bloody diarrhoea and abdominal pain in association with a long-standing history of black stools and progressive pallor.[doi.org]
Pediatric Disorder
  • Get the comprehensive coverage you need - from pertinent historical factors and examination techniques to visual and diagnostic methods - with over 2,500 practical, clinical photographs to help identify and diagnose hundreds of pediatric disorders.[books.google.ro]
Abdominal Pain
  • RESULTS: The presenting complaints represented a variety of common GI presentations, including nausea, vomiting, and acute abdominal pain (n 3); acute abdominal pain with peritonitis (n 2); crampy abdominal pain lasting several weeks (n 1); and rectal[ncbi.nlm.nih.gov]
  • Our subjective experience is that we see children with Meckel diverticulum who present with abdominal pain and are evaluated by CT.[ncbi.nlm.nih.gov]
  • The majority of patients are asymptomatic, but symptoms may include rectal bleeding, abdominal pain, and vomiting.[symptoma.com]
  • Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception.[ncbi.nlm.nih.gov]
  • In this paper, we present a 10-month-old boy who suffered from abdominal pain, persistent vomiting, and mild fever for 2 days. Abdominal sonography, plain abdomen X-ray, and computed tomography merely showed mechanical ileus and partial malrotation.[ncbi.nlm.nih.gov]
Rectal Bleeding
  • BACKGROUND: Complicated Meckel diverticulum (MD) in children does not always present with painless rectal bleeding and its presentation can then produce a difficult diagnostic dilemma.[ncbi.nlm.nih.gov]
  • Abstract Meckel diverticulum was diagnosed preoperatively as the cause of recurrent rectal bleeding in a 2-year-old child by means of a sodium pertechnetate Tc 99m scan.[ncbi.nlm.nih.gov]
  • The majority of patients are asymptomatic, but symptoms may include rectal bleeding, abdominal pain, and vomiting.[symptoma.com]
  • Four cases had significant rectal bleeding, three had acute diverticulitis, and two had intussusception caused by the diverticulum.[ncbi.nlm.nih.gov]
Nausea
  • RESULTS: The presenting complaints represented a variety of common GI presentations, including nausea, vomiting, and acute abdominal pain (n 3); acute abdominal pain with peritonitis (n 2); crampy abdominal pain lasting several weeks (n 1); and rectal[ncbi.nlm.nih.gov]
  • The diagnosis of Meckel's diverticulum should be considered in patients with unexplained abdominal pain, nausea and vomiting, or intestinal bleeding. Major complications include bleeding, obstruction, intussusception, diverticulitis and perforation.[ncbi.nlm.nih.gov]
  • A 65-year-old woman presented with a nonradiating, constant pain in the right groin with associated nausea and anorexia. Physical examination revealed a tender, irreducible lump in the right groin area.[ncbi.nlm.nih.gov]
  • Three weeks following drain removal the patient reported recurrent nausea and abdominal pain. A CT scan demonstrated a 3.7-cm rim-enhancing air-fluid level with dependent contrast consistent with persistent enteric fistula and abscess.[ncbi.nlm.nih.gov]
  • Symptoms may include: Pain in the abdomen that can be mild or severe Blood in the stool Nausea and vomiting Symptoms often occur during the first few years of life. However, they may not start until adulthood.[nlm.nih.gov]
Acute Abdomen
  • This is a prospective study of 1332 patients who were operated upon for acute abdomen during the period August 1999 to July 2009 in a single surgical unit.[ncbi.nlm.nih.gov]
  • Laboratory and radiological findings showed signs of an acute abdomen with differential diagnosis between an infectious and an obstructive cause. Owing to the rapid and progressive toxic condition, an emergency laparoscopy was performed.[ncbi.nlm.nih.gov]
  • Materials and Methods: This is a prospective study of 1332 patients who were operated upon for acute abdomen during the period August 1999 to July 2009 in a single surgical unit.[saudijgastro.com]
  • A Meckel diverticulum should be suspected when the work-up of a patient with lower gastrointestinal bleed or acute abdomen reveals no abnormalities.[amboss.com]
Melena
  • It can cause melena, right lower quadrant pain, intussusception , volvulus , or obstruction near the terminal ileum.[osmosis.org]
  • He denied nausea, vomiting, hematochezia, melena or urinary tract symptoms; he had however experienced several recent episodes of brown diarrhea.[intjem.springeropen.com]
  • There is an increased incidence of the Meckel diverticulum in Crohn patients compared to the general population: gastrointestinal hemorrhage (melena/hematochezia): most common complication and may account for 30% of symptomatic cases 2 .[radiopaedia.org]
  • Findings can include either fresh blood in stools or melena in some cases. Intestinal obstruction manifests with abdominal pain and constipation, while vomiting may also be reported.[symptoma.com]
  • The patients may present with abdominal mass, distension, pain, vomiting, melena, perforation or obstruction. [7], [8] We encountered a similar case in our study.[saudijgastro.com]

Workup

The diagnosis of Meckel diverticulum is often made after invasive surgical procedures are performed and presents a challenge for the physicians. History of rectal bleeding in the pediatric population should always include Meckel diverticulum in the differential diagnosis and the most common and most specific diagnostic method is radionuclide scanning with 99m technetium pertechnetate [10]. This procedure has a very high diagnostic accuracy because the radioactive isotope binds to ectopic sites of gastric mucosa, most commonly in the Meckel diverticulum. Alternative methods include computed tomography (CT scan) with oral contrast since plain CT does not show hollow organs on regular scans. CT scans may reveal intussusception, volvulus, or neoplasms [11], but in the majority of cases, surgical exploration and laparoscopy are techniques that provide a definite diagnosis. Since the symptomatology is quite similar to acute appendicitis, explorative surgery is commonly performed. Additional diagnostic methods include abdominal X-rays, barium enema, and angiography.

In addition to imaging techniques, a complete blood count (CBC) should be performed, since bleeding may lead to anemia that sometimes necessitates blood transfusion.

Microcytic Anemia
  • Meckel's diverticulum revealed by microcytic anemia: the contribution of CT enteroclysis Diagn Interv Imaging 2014 ; 95 : 625-627 [inter-ref] [10] Platon A., Gervaz P., Becker C.D., Morel P., Poletti P.A.[em-consulte.com]

Treatment

In virtually all cases, surgical resection is the method of choice. Surgical procedures include diverticulectomy or bowel resection with anastomosis if the intestinal perforation is observed.

Because surgery is the main treatment strategy, its use in asymptomatic patients has been discussed extensively. Because the diverticulum can cause complications, prophylactic surgery has been established as a beneficial method of treatment [12] [13], especially in male patients, in whom complications are much more common [14].The symptomatic patients are always treated surgically.

In the case when diverticulitis is present, antibiotic therapy may be indicated. Agents of choice include trimethoprim-sulfamethoxazole double-strength tablet q12h or ciprofloxacin 750 mg q24h, or levofloxacin 750 mg q24h combined with metronidazole 500 mg q6h [15]. All of these drugs are taken orally, and the duration of therapy is usually 7-10 days. Alternatives include moxifloxacin and amoxicillin-clavulanic acid, while patients with more severe diverticulitis may receive piperacillin-tazobactam, ertapenem or imipenem intravenously.

Prognosis

The prognosis for patients with Meckel diverticulum is generally good, as this congenital intestinal abnormality is often diagnosed incidentally, while a minority of patients develop symptoms. Both preoperative and postoperative complications may occur, most commonly development of adhesions that can cause bowel obstruction [8], but various malignant tumors have been identified in these patients, including carcinoid tumor, pancreatic adenomas, sarcoma and other. Fortunately, they are rare and occur in less than 5% of patients.

Etiology

Meckel diverticulum develops during the early fetal development, as the foregut remains connected with the yolk sac through the vitelline or omphalomesenteric duct. Normally, the connection between the two structures is achieved during the 3rd week of gestation and is terminated between the 7th and the 9th week. But for unknown reasons, the connection persists and leads to the development of a true diverticulum [3]. True diverticulum implies that all layers of the intestinal wall are present, while ectopic mucosal cells may be present, such as gastric parietal cells that secrete hydrochloric acid.

Epidemiology

Meckel diverticulum is estimated to be the most common congenital intestinal malformation, being present in 1-3% of the population [4]. The majority of patients are asymptomatic through life, and 4-6% of patients develop symptoms, which is usually during childhood, but symptoms may occur at any age [5]. Although gender predilection has not been established, various studies indicate that male patients are much more prone to developing complications. No known risk factors are established so far.

Sex distribution
Age distribution

Pathophysiology

During early fetal life, the foregut and the yolk sac become connected via the vitelline duct at the 3 rd week of gestation. For reasons that are still not understood, the vitelline duct does not close during the 8th week of gestation when it should, which results in permanent connection of the yolk sac and the foregut. Eventually, the part of the sac that is connected transforms into intestinal tissue, with all cellular layers - a true diverticulum. In addition to intestinal cells, the heterotropic mucosa may be present [6], most commonly gastric parietal cells. Pancreatic, duodenal, endometrial mucosa have been described in the diverticulum as well. It is established that the secretion of acid leads to intestinal injury, which is assumed to be responsible for intestinal bleeding, which is one of the most common manifestations of this syndrome, but for other symptoms as well [7].

Intestinal obstruction commonly occurs in patients with Meckel diverticulum, mainly due to intussusception, but other mechanisms are described as well, including hernial incarceration (also known as Littre's hernia), volvulus, and tumors in rare cases.

Meckel diverticulum may also result in the development of acute diverticulitis, which may lead to abscess formation and significant inflammatory changes and it is seen predominantly in younger patients.

Prevention

The majority of patients with Meckel diverticulum are asymptomatic and the diagnosis is often incidental. Preventive measures should be oriented toward identifying the presence of this congenital anomaly while it does not cause any symptoms and treat accordingly. Although lifetime complications and risk of developing symptoms are small, prophylactic surgical resection is recommended by the majority of studies, for the reason of preventing potential complications.

Summary

Meckel diverticulum is estimated to be prevalent in up to 3% of the population, making this congenital malformation of the intestine the most common gastrointestinal anomaly around the world. It has been described more than 200 years ago [1], and the cause is the incomplete closure of the vitelline duct that connects the foregut and the yolk sac during early fetal life. As a result, the part of the yolk sac becomes intestinal tissue with all mucosal and submucosal layers, which illustrates that this is a "true" diverticulum [2]. In addition, it may contain heterotrophic cells, most commonly the parietal cells of the gastric mucosa, which secrete hydrochloric acid and damage the surrounding intestinal mucosa, thus producing intestinal injury. This syndrome equally affects both genders, but for unknown reasons, complications are more frequently observed among males. Characteristic symptoms of rectal bleeding and abdominal pain are most commonly reported. Although the majority of patients are asymptomatic and less than 10% of patients exhibit symptoms. Complications are rare and may include intestinal perforation, severe obstruction, acute diverticulitis, and development of tumors, which is why it is very important to establish the diagnosis in its asymptomatic stages. Imaging techniques are initial diagnostic methods, and the most commonly used is radionuclide scanning with technetium 99m pertechnetate scan, which comprises isotope binding to the ectopic gastric mucosa. However, because acute symptoms of the abdomen indicate exploratory surgery, this method usually confirms the diagnosis. Treatment includes diverticulectomy, and in cases of intestinal perforation, bowel resection, and anastomosis. Surgery is indicated in both symptomatic and asymptomatic patients, primarily to reduce the risk of developing further complications.

Patient Information

Meckel diverticulum is a malformation of the intestine that occurs during early fetal life, and it is the most common congenital intestinal anomaly encountered in medical practice. It is present in approximately 2-3% of the population, and the majority of patients are asymptomatic. During early development of the fetus, the yolk sac is connected with the foregut through a duct during the 3rd week of life, and this connection should be terminated around the 8th week. However, for unknown reasons, this connection persists, and the part of the yolk sac together with the vitelline duct is transformed into intestinal tissue, known as Meckel diverticulum. This disorder is equally diagnosed in both genders, but for some reason, male patients much more commonly develop complications. The diagnosis is often made incidentally because it rarely causes complaints, but symptoms that occur in patients are a consequence of intestinal injury in this segment. Injury occurs because cells of the gastric mucosa may be present in the diverticulum, and acid production leads to the damage. Symptoms that are most commonly reported include rectal bleeding, abdominal pain, cramping, nausea, vomiting, and fever. The diagnosis can be made using imaging studies, most notably through the use of a radionuclide scan (known as the technetium 99m pertechnetate scan). The principle includes the introduction of an isotope that will bind to the cells of the gastric mucosa outside the stomach and can identify their presence in the diverticulum. However, the clinical presentation can be strikingly similar to appendicitis, and because significant complications, such as intestinal perforation and severe bleeding may occur, surgery is often the main diagnostic method, but it is also the principal form of treatment. The diverticulum is often removed, or if severe damage to the segments of the intestine that are close, a bowel resection may be performed. Patients with Meckel diverticulum have a good prognosis, the majority of patients do not develop any complications during their lifetime. However, in some patients, intestinal perforation, and severe bleeding may occur and pose significant risks, which is why a diagnosis of this congenital anomaly almost always indicates surgery.

References

Article

  1. Meckel JF. Uber die divertikel am darmkanal. Arch Physiol. 1809;9:421-453.
  2. Sagar J, Kumar V, Shah DK. Meckel's diverticulum: a systematic review. J R Soc Med. 2006;99:501.
  3. Turgeon DK, Barnett JL. Meckel's diverticulum. Am J Gastroenterol. 1990;85:777-781.
  4. Whang EE, Ashley SW, Zinner MJ. Small intestine. In: Brunicardi FC, Andersen DK, Billiar TR, et al., eds. Schwartz's principles of surgery. 8th ed. New York, NY: McGraw-Hill; 2005:1043-1045.
  5. Yahchouchy EK, Marano AF, Etienne JC, et al. Meckel's diverticulum. J Am Coll Surg. 2001;192:658-662.
  6. Cserni G. Gastric pathology in Meckel's diverticulum. Review of cases resected between 1965 and 1995. Am J Clin Pathol 1996;106:782-785.
  7. Soltero MJ, Bill AH. The natural history of Meckel's diverticulum and its relation to incidental removal: a study of 202 cases of diseased Meckel's diverticulum found in King County, Washington, over a fifteen year period. Am J Surg. 1976;132:168-173.
  8. Cullen JJ, Kelly KA, Moir CR, et al. Surgical management of Meckel's diverticulum: an epidemiologic, population-based study. Ann Surg. 1994;220:564-568.
  9. Evers MB. Meckel's diverticulum. In: Townsend CM Jr, Beauchamp RD, Evers BM, et al., eds. Sabiston textbook of surgery, 18th ed. Philadelphia, PA: Saunders Elsevier; 2007:1321-1323.
  10. Kiratli PO, Aksoy T, Bozkurt MF, et al; Detection of ectopic gastric mucosa using 99mTc pertechnetate: review of the literature. Ann Nucl Med. 2009;23(2):97-105.
  11. Levy AD, Hobbs CM. Meckel diverticulum: radiologic features with pathologic Correlation. Radiographics. 2004;24(2):565-87.
  12. Zani A, Eaton S, Rees CM, et al. Incidentally detected Meckel diverticulum: to resect or not to resect? Ann Surg. 2008;247:276-281.
  13. Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg. 2005;241: 529-533.
  14. Matsagas MI, Fatouros M, Koulouras B, et al. Incidence, complications, and management of Meckel's diverticulum. Arch Surg. 1995;130:143-146.
  15. Gilbert DN, Chambers HF, GM Eliopoulos, MS Saag. The Sanford Guide to Antimicrobial Therapy 2015. 45th ed. Antimicrobial Therapy, Inc, Sperryville, VA; 2015.

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Last updated: 2018-06-22 04:38