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Meckel's Diverticulitis
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Meckel's Diverticulitis
, Meckel's Diverticulum, Meckel Diverticulum
See Also
Appendicitis
Epidemiology
Most common cause of significant
Gastrointestinal Bleeding
in children
Meckel's Diverticulum occurs equally in both genders
Complications are more common in males by ratio of 3:2
Lifetime complication rate: 4%
More than 50% of complications occur before age 10
History
Initial report by Hildanus in 1598
Detailed description by Johann Meckel in 1809
Pathophysiology
Meckel's Diverticulum
Meckel's Diverticulum is the most common congenital malformation of the
Gastrointestinal Tract
Incomplete closure of vitelline duct (omphalomesenteric remnant)
Omphalomesenteric duct (vitelline duct) connects primitive gut to
Yolk Sac
in early fetal development
Duct typically closes and obliterates when the placenta replaces the
Yolk Sac
at 7 weeks gestation
Incomplete elimination of the Omphalomesenteric duct (vitelline duct) results in various remnants
Meckel's Diverticulum
Enterocyst
Fibrous Cord
Fistula
Characteristics
Meckel's Diverticulum contains all intestinal wall layers (serosa,
Muscle
, submucosa, mucosa)
Meckel's Diverticulum may be lined with gastric mucosa (85%) and other heterotopic tissue
Ectopic tissue occurs most often at the diverticulum tip
Gastric mucosa acid secretion may lead to ulceration, bleeding
Other heterotopic tissue
Pancreatic tissue
Brunner's glands
Duodenal mucosa
Colonic mucosa
Hepatobiliary mucosa
Endometrial mucosa
Blood supply is ultimately from superior
Mesenteric Artery
(derived from omphalomesenteric artery)
Location
Proximal to ileocecal valve by 100 cm
Usually within 45 to 60 cm of ileocecal valve
Follows the rule of 2's (roughly)
Affects 2% of the population (range 0.4 to 4%)
Often presents before age 2 years
May contain two types of ectopic tissue, such as gastric (85%) and pancreatic tissue
Symptomatic presentations or complications affect 2-4% of those with Meckel's Diverticulum
If symptoms are to occur, they occur by age 2 years in 50% of cases (age 10 in some references)
Occurs 2 feet (up to 100 cm) proximal to the ileocecal valve
Meckel's Diverticulum is 2 cm wide and 2 cm long
Findings
Episodic
Rectal Bleeding
Painless intermittent bleeding is the most common presentating symptom in children
Bleeding may occur from ulceration of gastric or pancreatic ectopic tissue, or from intermittent intussception
Acute Meckel's Diverticulitis and other complications (e.g. obstruction)
Abdominal Pain
Intractable
Vomiting
Tachycardia
Differential Diagnosis
Meckel's Diverticulitis
See
Appendicitis
Viral Gastroenteritis
Constipation
Intussusception
Inflammatory Bowel Disease
Complications
Meckel's Diverticulum
Meckel's Diverticulum has an overall complication rate of 4%
GI Bleed
ing (25-50% of complications)
Often associated with ectopic gastric mucosa
Profuse
Hemorrhage
may occur
Hemorrhage
is most common presentation under age 2
Resolves spontaneously in most cases
Meckel's Diverticulitis (10 to 20% of complications)
Similar in presentation to
Appendicitis
Bowel Obstruction
(14 to 53% of cases, esp. adults)
Volvulus
at fibrotic band attached to abdominal wall
Intussusception
Incarcerated
Inguinal Hernia
(Littre's
Hernia
)
Bowel
Perforation
Malignancy
Carcinoid Tumor
Sarcoma
Stromal Tumor
Intraductal Papillary Mucinous Adenoma of Pancreatic Tissue
Miscellaneous tumors and adenocarcinomas
Imaging
Radionuclide Scintigraphy (Meckel's Scan)
Performed via IV injection of
Sodium
Tc-pertechnetate
Preferential uptake by gastric tissue
Detects ectopic gastric mucosa
Most accurate test in Meckel's Diverticulum
Test Sensitivity
: 85% in children
Test Specificity
: 95% in children
Less accurate in adults
Cimetidine
increases accuracy in adults
Small Bowel
enema
Indicated for negative scintigraphy in adults
Arteriography (indicated for acute
Hemorrhage
)
Tests to evaluate differential diagnosis (but not typically useful in diagnosis of Meckel's Diverticulum or
Diverticulitis
)
Abdominal XRay
Abdominal Ultrasound
May show blind-ended thick-walled loop eminating from
Small Bowel
Evaluates for other diagnosis (e.g. intussception,
Appendicitis
)
CT Abdomen and Pelvis
with oral and IV contrast
Excludes other
Abdominal Pain
causes (e.g.
Appendicitis
,
Small Bowel Obstruction
)
Meckel's Diverticulum or
Diverticuli
ts is missed unless perforation or other complications are present
Evaluation
Maintain a high index of suspicion
Delayed diagnosis is common
Management
Meckel's Diverticulum
Symptomatic (e.g. Meckel's Diverticulitis)
Prompt surgical resection of Meckel's Diverticulum
Segmental bowel resection indications
Perforation
Intestinal Ischemia
Ectopic tissue extends to diverticulum junction or into intestinal mucosa
Asymptomatic incidental finding on other surgery
Resect all symptomatic cases (as above)
Prophylactic resection of Meckel's Diverticulum indications
Age <8 years old (some guidelines recommend <40 years old)
Male gender (higher complication rate)
Meckel's Diverticulum >2 cm
References
Thompson and Ruttan (2021) Crit Dec Emerg Med 35(5):12-3
Townsend (2001) Sabiston Surgery, Saunders, p. 907-9
Cullen (1994) Ann Surg 220:564-9 [PubMed]
Kuru (2018) 110(11): 726-32 [PubMed]
Rossi (1996) AJR 166:567-73 [PubMed]
Yahchouchy (2001) J Am Coll Surg 192:658-62 [PubMed]
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