DR SYED FAHAD ALI ZAIDI

RESIDENT SU II BBH

MECKEL’S DIVERTICULUM:A CASE PRESENTATION

Asma, D/O tanveer , 12 years female CR No 7995Resident of rawalpindiPresented to ER On 09-04-2012

BIODATA

Presented to ER with C/OPain abdomen 3 daysConstipation; 2 daysVomiting 2 days

Pain was initially mild and peri-umblical; later became generalized and severe. It was associated with nausea, anorexia and multiple episodes of vomiting.No associated history of fever, no h/O bleeding PR

PRESENTING COMPLAINTS

On examination patient had tachycardia, mild fever and she had generalized abdominal tenderness, and guarding, suggestive of peritonitis.

AXR erect showed free gas under diaphragm

Hb was 14, and TLC was 15900/mm3

Clinical findings

Patient was resuscitated with wide bore IV lines, using crytalloids.

NG tube and foley’s catheter was passed.

After resuscitation she was shifted to COT for exploration

MANAGEMENT

SINGLE 2x2 cm perforation in jejunum, in proximity of a diverticulum at anti-mesenteric border of the bowel.

Omentum was sealing the perforation150-200 ml free fluid in the abdomenAppendix secondarily inflammed.

OPERATIVE FINDINGS…

Resection of perforated gut, and Primary closure, followed by appendectomy and abdominal lavage was done.

Diverticulum was left in situ as it was broad based

Abdomen was closed en mass with vicryl 1.

PROCEDURE

Patient did not have a smooth post op course, and pain abdomen , along with signs of toximea were present.

Wound had sero-sanguinous discharge, with early features of dehiscence

On 2nd post op day, an USG abdomen was done to rule out free fluid. No free fluid was reported.

On 4th post op day, a decision was made to re-explore the patient.

POST OP COURSE

OP FINDINGS showed A diverticulum in proximity of the anastomosisA new perforation in the jejunum, 6 “ distal to

previous anastomosis.

The diverticulum was excised, and perforation exteriorized as tube jejunostomy.

Post operatively patient remained stable

RE-EXPLORATION….

A segment of gut was resected in both laparotomies; histopathology specimen were sent to two different labs.

Both specimen reported presence of MECKEL’S DIVERTICULUM with gastric mucosa, and perforation

HISTOPATHOLOGY

Meckel diverticulum (also referred to as Meckel's Diverticulum) is the most common congenital abnormality of the small intestine; it is caused by an incomplete obliteration of the vitelline duct (ie, omphalomesenteric duct).

Although originally described by Fabricius Hildanus in 1598, it is named after Johann Friedrich Meckel, who established its embryonic origin in 1809.[1]

MECKEL ‘S DIVERTICULUM

Early in embryonic life, the fetal midgut receives its nutrition from the yolk sac via the vitelline duct. The duct then undergoes progressive narrowing and usually disappears by 7 weeks' gestation.

When the duct fails to fully obliterate, different types of vitelline duct anomalies appear.

EMBRYOLOGY

Examples of such anomalies include1) A persistent vitelline duct (appearing as a draining fistula at

the umbilicus); 2) A fibrous band that connects the ileum to the inner surface of

the umbilicus;3) A patent vitelline sinus beneath the umbilicus4) A an obliterated bowel portion;5) A vitelline duct cyst; and, most commonly (97%)

Meckel diverticulum, which is a blind-ending true diverticulum that contains all of the layers normally found in the ileum.

 The tip of the diverticulum is free in 75% of cases and is attached to the anterior abdominal wall or another structure in the remainder of cases.

EMBRYOLOGY

Meckel diverticulum occurs on the antimesenteric border of the ileum, usually 40-60 cm proximal to the ileocecal valve.

On average, the diverticulum is 3 cm long and 2 cm wide. Slightly more than one half contain ectopic mucosa.

Meckel diverticulum is typically lined by ileal mucosa, but other tissue types are also found with varying frequency.

ANATOMY

The heterotopic mucosa is most commonly gastric. This is important because peptic ulceration of this or adjacent mucosa can lead to painless bleeding, perforation, or both.

Second most common heterotopic mucosa in meckel diverticulum is pancreatic

Rarely, colonic, rectal, endometrial, and hepatobiliary tissues have been noted.

THE MUCOSAL LINING

Found in 2 % of populationFound at 2 feet proximal to ICJ in most casesIt is 2 inches longHas two types of heterotopic mucosaIn pediatric group; presentation is common

around 2 years of age

“THE RULE OF 2”

Most patients are asymptomatic. Meckel diverticulum is most frequently diagnosed as an incidental finding when a barium study or laparotomy is performed for other abdominal conditions.

Symptomatic Meckel diverticulum is virtually synonymous with a complication.

Patients can present with various clinical signs, including peritonitis or hypovolemic shock

The 3 most common symptomatic presentations are GI bleeding, intestinal obstruction, and acute inflammation of the diverticulum.

CLINICAL PRESENTATION

In children, hematochezia is the most common presenting sign. Bleeding in adults is much less common.

Acute lower GI bleeding is secondary to hemorrhage from peptic ulceration. Such ulceration occurs when acid secreted by heterotopic gastric mucosa damages contiguous vulnerable tissue, often times resulting in direct erosion of a vessel.

BLEEDING PR

Intestinal obstruction is the most common complication in adults. Obstruction can be the result of various mechanisms.Omphalomesenteric band (most frequent cause)Internal hernia through vitelline duct remnantsVolvulus occurring around vitelline duct remnantsT-shaped prolapse of both efferent and afferent

loops of intestine through a persistent vitelline duct fistula at the umbilicus in a neonate

Intussusception (when Meckel diverticulum itself acts as a lead point for an ileocolic or ileoileal intussusception)

OBSTRUCTION

Most patients with intestinal obstruction present with abdominal pain, bilious vomiting, abdominal tenderness, distension, and hyperactive bowel sounds upon examination.

Patients may develop a palpable abdominal mass.

When patients do not present early or if the diagnosis is missed, the obstruction can progress to intestinal ischemia or infarction. The latter manifests with acute peritoneal signs and lower GI bleeding.

Like other diverticula in the body, Meckel diverticulum can become inflamed. Diverticulitis is usually seen in older patients.

The clinical presentation includes abdominal pain in the peri-umbilical area that radiates to the right lower quadrant. Usually, abdominal tenderness is more marked in the periumbilical region than the pain of appendicitis.

Persistence of peri-umbilical pain or a history of bleeding per rectum may be helpful in distinguishing this entity from appendicitis.

DIVERTICULITIS

Clinical history resembles that of perforated appendix.

Patient may present with peritonitis or shock

History of persistant abdominal pain and bleeding PR may help differentiate it from perf appendix.

PERFORATION

DIFFERENTIAL DIAGNOSISAppendicitisColitisColonic Vascular

MalformationsConstipationCrohn DiseaseGastroenteritisGastrointestinal DuplicationsHenoch-Schoenlein PurpuraHirschsprung Disease Intestinal duplication Intestinal

PolyposisSyndromes

Intussusception Juvenile PolypsNecrotizing

EnterocolitisPeptic Ulcer DiseasePeutz-Jeghers SyndromePostoperative AdhesionsUlcerative ColitisUrolithiasisVolvulus

Routine laboratory findings, including CBC count, electrolyte levels, glucose test results, BUN levels, creatinine levels, and coagulation screen results, are not helpful in establishing the diagnosis of Meckel diverticulum but are necessary to manage a patient with GI bleeding along with a type and cross.

Hemoglobin and hematocrit levels are low in the setting of anemia or bleeding.

INVESTIGATIONS

On BARIUM STUDIES, Meckel diverticulum may appear as a blind-ending pouch on the antimesenteric side of the distal ileum. If filling defects are visualized, the diverticulum may contain a tumor.

MECKEL SCAN is a more useful and specific investigation.

SMA angiogram may help in some patientsCapsule Endoscopy may be useful in some

cases.

SPECIFIC INVESTIGATIONS

When a patient has GI bleeding suggestive of Meckel diverticulum, the diagnostic evaluation should focus on Meckel scanning, a technetium-99m pertechnetate scintiscan

The pertechnetate is taken up by gastric mucosa. Because bleeding from the Meckel diverticulum is related to acid induced damage of mucosa adjacent to the parietal cell containing tissue, it is always included early in the work-up.

MECKEL’S SCAN

After intravenous injection of the isotope, the gamma camera is used to scan the abdomen. This procedure usually lasts approximately 30 minutes.

Gastric mucosa secretes the radioactive isotope; thus, if the diverticulum contains this ectopic tissue, it is recognized as a hot spot.

In children the Meckel scan has a reported sensitivity of 80-90%, a specificity of 95% and an accuracy of 90%.

The emergency department evaluation and treatment of patients depends on the clinical presentation of Meckel diverticulum.

Because most symptomatic patients are acutely ill, establish an intravenous line immediately, start crystalloid fluids, and keep the patient on nothing by mouth (NPO) status. Obtain the blood investigations suggested above with a type and cross match.If significant bleeding occurs, perform a transfusion of packed red cells.

Broad spectrum antibiotics should be startedA patient who presents with intestinal obstruction usually

requires nasogastric decompression; also perform plain radiography of the abdomen.

MANAGEMENT

Decision of further management depends on the patient’s condition and clinical findings.

If the patient is bleeding but is hemodynamically stable, a Meckel scan is warranted.

On the other hand, the presence of peritoneal signs or hemodynamic instability demands urgent surgical intervention. Signs of small bowel obstruction also require surgical intervention.

Four possible surgical procedures are as follows:

Diverticulectomy with suture closure of the base Wedge resection of the intestinal wall containing the diverticulum

with suture closure Segmental resection of the intestine, including the diverticulum,

and end-to-end anastomosis Division of the fibrous band with or without diverticulectomy

Adjacent ileum should be included in the resection because ulcers frequently develop in the adjacent part of the ileum.

Successful resection of a Meckel diverticulum, even in children and infants, can also be accomplished through laparoscopy, using an endoscopically designed autostapling device.

SURGERY OPTIONS….

Most surgeons prefer to leave a broad based and asymptomtaic meckel diverticulum in situ as such, assuming a 6% mortality rate from Meckel diverticulum complications, 400 asymptomatic diverticula would have to be excised to save one patient

Another faction favors prophylactic removal of a diverticulum, which is a simple operation. This view is supported by data that demonstrate that managing a complication of Meckel diverticulum is associated with high morbidity and mortality rates.

ASYMPTOMATIC MECKEL?????

Complicated Meckel diverticulum can lead to significant morbidity and mortality, most often because of a delay in diagnosis.

Causes of mortality include strangulation, perforation, and exsanguination because of delay in resuscitation.

Once a complication arises and surgery is required, the operative mortality and morbidity rates have both been estimated at 12%.

If the Meckel diverticulum is removed as an incidental finding, the risk of mortality and morbidity and long-term complications are much less (1%, 2%, and 2%, respectively).

As many as 5% of complicated Meckel diverticulum contain malignant tissue.

COMPLICATIONS