Meckel’s diverticulum presentiMeckel’s diverticulum presenting as small bowel obstructionng as small bowel obstruction

振興醫院小兒科 振興醫院小兒科 Dr. Dr. 程美美程美美

Clinical CourseClinical Course

At ward At ward NG: coffee-ground with bile contain (160ml) NG: coffee-ground with bile contain (160ml) Low urine output with dropping BP: 86/42 despite NS Low urine output with dropping BP: 86/42 despite NS

challenge challenge Use three combined antibiotics (Ampicillin, GM, MetroUse three combined antibiotics (Ampicillin, GM, Metro

nidazole)nidazole) Follow Abdominal echo: persistent bowel distension, Follow Abdominal echo: persistent bowel distension,

bowel wall thickening, no target sign, bowel wall thickening, no target sign, increase ascites increase ascites amount amount

Consult Pediatric surgeon: suggest operationConsult Pediatric surgeon: suggest operation Sent to OR 12 hours laterSent to OR 12 hours later

OP Findings and OP Findings and pathological report pathological report

Dilated distal half of small bowelDilated distal half of small bowel Meckel’s diverticulum ( 5 x 3 x 1 cm ) which was Meckel’s diverticulum ( 5 x 3 x 1 cm ) which was

30cm away from ileocecal valve with fecal obstr30cm away from ileocecal valve with fecal obstruction 5cm in length uction 5cm in length

Resection 15cm of ileum, Clear ascites: ±100mlResection 15cm of ileum, Clear ascites: ±100ml1.1. Diverticulum lined by small intestine mucosa witDiverticulum lined by small intestine mucosa wit

h focal lymphocyte infiltration.h focal lymphocyte infiltration.2.2. The muscular wall of diverticulum is thin.The muscular wall of diverticulum is thin.3.3. No ectopic gastric or pancreatic tissueNo ectopic gastric or pancreatic tissue4.4. Surrounding ileal mucosa is unremarkableSurrounding ileal mucosa is unremarkable

Discussion Discussion

Intestinal obstructionIntestinal obstruction

Meckel’s diverticulum Meckel’s diverticulum

Cause of gastrointestinal Cause of gastrointestinal obstruction–small intestine obstruction–small intestine Nelson 17thNelson 17th

Congenital Congenital 1.1. Duodenal atresiaDuodenal atresia2.2. Annular pancreasAnnular pancreas3.3. Malrotation / volvulusMalrotation / volvulus4.4. Malrotation / Ladd bandsMalrotation / Ladd bands5.5. Ileal atresiaIleal atresia6.6. Meconium ileus Meconium ileus 7.7. Meckel’s diverticulum with volvulus or intussusceptionMeckel’s diverticulum with volvulus or intussusception8.8. Inguinal herniaInguinal hernia9.9. Intestinal duplicationIntestinal duplication

Cause of gastrointestinal Cause of gastrointestinal obstruction–small intestine obstruction–small intestine Nelson 17thNelson 17th

AcquiredAcquired

1.1. Postsurgical adhesionsPostsurgical adhesions

2.2. Crohn’s diseaseCrohn’s disease

3.3. IntussusceptionIntussusception

4.4. Distal ileal obstruction syndrome ( cystic fibrosiDistal ileal obstruction syndrome ( cystic fibrosis )s )

5.5. Duodenal hematomaDuodenal hematoma

6.6. Superior mesenteric artery syndromeSuperior mesenteric artery syndrome

Differentiation between simple Differentiation between simple and strangulating obstructionand strangulating obstruction

Signs of shock, acidosis, and peritonitis, aSigns of shock, acidosis, and peritonitis, and abdominal wall often doughy and erythnd abdominal wall often doughy and erythematousematous

Fever, feculent vomiting, absent bowel souFever, feculent vomiting, absent bowel sound, localized abdominal tenderness, and lend, localized abdominal tenderness, and leukocytosisukocytosis

Meckel’s diverticulumMeckel’s diverticulum

Meckel’s diverticulum Meckel’s diverticulum

Lifetime complication around Lifetime complication around 4 %4 % including including perforation, obstruction, inflammation, hemperforation, obstruction, inflammation, hemorrhage, herniation, neoplasm, umbilical fiorrhage, herniation, neoplasm, umbilical fistula, ulcerationstula, ulceration

Half of them occur before Half of them occur before 2 years old2 years oldLonger ( 4 cm ), broad base ( 2 cm )Longer ( 4 cm ), broad base ( 2 cm )

Obstruction in Meckel’s diverticuObstruction in Meckel’s diverticulumlum

Meckel’s diverticulum may be associated Meckel’s diverticulum may be associated with partial or complete bowel obstructiowith partial or complete bowel obstruction. n.

1.1. Act as a lead point of anAct as a lead point of an intussusception intussusception ( more common in older male children )( more common in older male children )

2.2. Intraperitoneal Intraperitoneal bands bands connecting residual connecting residual omphalomesenteric duct remnants to the omphalomesenteric duct remnants to the ileum and umbilicusileum and umbilicus

Nelson 17th edition Nelson 17th edition

Meckel’s diverticulum causing intesMeckel’s diverticulum causing intestinal obstruction tinal obstruction

The American journal of gastroenterology December 2001The American journal of gastroenterology December 2001

31 y/o man with recurrent vomiting and abdomin31 y/o man with recurrent vomiting and abdominal painal pain

The apex of the Meckel’s diverticulum adhesion tThe apex of the Meckel’s diverticulum adhesion to the mesentery, making an o the mesentery, making an obstructing foldobstructing fold in th in the adjacent small bowele adjacent small bowel

Bowel loops proximal to the obstruction were dilBowel loops proximal to the obstruction were dilated, adhesive band was lysed, unfolding the boated, adhesive band was lysed, unfolding the bowel and diverticulectomy was performed wel and diverticulectomy was performed

10 different ways for Meckel’s diverticulum c10 different ways for Meckel’s diverticulum can cause bowel obstructionan cause bowel obstruction

1.1. IntussusceptionIntussusception2.2. Fibrous band persisting between the MD and tFibrous band persisting between the MD and t

he umbilicus causing a volvulushe umbilicus causing a volvulus3.3. Internal hernia caused by a loop of bowel trappInternal hernia caused by a loop of bowel trapp

ed between the mesentery and the mesodivertied between the mesentery and the mesodiverticular band, mechanically compress the ileumcular band, mechanically compress the ileum

4.4. Litter’s hernia where MD obstructed in an exterLitter’s hernia where MD obstructed in an external hernianal hernia

5.5. MD causing inflammatory reaction and adhesioMD causing inflammatory reaction and adhesion with surrounding bowel cause obstructionn with surrounding bowel cause obstruction

10 different ways for Meckel’s diverticulum c10 different ways for Meckel’s diverticulum can cause bowel obstructionan cause bowel obstruction

6. Obstruction of the neck of MD enlargement and 6. Obstruction of the neck of MD enlargement and compress the bowel lumencompress the bowel lumen

7. Obstruction by a large enterolith in the MD7. Obstruction by a large enterolith in the MD8. Torsion of MD on its own axis8. Torsion of MD on its own axis9. Extrusion of the ileum through a persistent omp9. Extrusion of the ileum through a persistent omp

halomesenteric duct out of the abdomenhalomesenteric duct out of the abdomen10. True knot involving MD and another hollow vis10. True knot involving MD and another hollow vis

cus cus

Thank you for attention Thank you for attention