Meckel Diverticulum

Background:
Meckel diverticulum is the most common form of
congenital abnormality of the small intestine, resulting
from an incomplete obliteration of the vitelline duct
i.e.: omphalomesenteric duct ( yolk stalk)
Illustration
Illustration
Illustration: vitelline duct remnant
 Meckel Diverticulum
Background:
Although originally described by Fabricus Hildanus
in 1598

It is named after Johann Friedrich Meckel, who

established its embryonic origin between 1808
and 1820

Despite the availability of modern imaging techniques,

the diagnosis of Meckel diverticulum is challenging
 Meckel Diverticulum
Pathophysiology:
Early in embryonic life, the vitelline duct connects
the midgut to the yolk sac

Later on, the duct undergoes progressive narrowing

and usually disappears by the seventh gestational
week

When the duct fails to obliterate, different types

of vitelline duct anomalies appear

Examples of such anomalies include:

 Meckel Diverticulum

Pathophysiology:
1) a patent vitelline sinus beneath the umbilicus
2) an unobliterated bowel portion
3) a fibrous band connecting the ileum to the inner
surface of the umbilicus
4) a vitelline duct cyst
5) a persistent vitelline duct (appearing as a draining
fistula at the umbilicus)
6) prolapse (T-shaped prolapse)
 Meckel Diverticulum

Pathophysiology:
Meckel diverticulum has been reported in 97% of
the vitelline duct anomalies

The tip of the diverticulum can be:

* free in 75% of cases and
* attached to the anterior abdominal wall or
* another structure in the remainder
 Meckel Diverticulum
Pathophysiology:
Meckel diverticulum occurs on the antimesenteric
border of the ileum, usually 60 -100 cm proximal to the
ileocecal valve

On average, the diverticulum is:

2.99 cm long and
1.92 cm wide

Meckel diverticulum is a true diverticulum because it

contains all layers of the intestinal wall
 Meckel Diverticulum

Pathophysiology:
The heterotopic mucosa is likely to be gastric in
origin in 80% of cases of Meckel diverticulum

This is important because peptic ulceration of this or

adjacent mucosa can lead to:
* pain
* bleeding and/or
* perforation
 Meckel Diverticulum
Pathophysiology:
Although jejunal
colonic
rectal
pancreatic
duodenal and
endometrial tissues
have all been found in the diverticulum,
heterotopic gastric mucosa is the most common
tissue observed
 Meckel Diverticulum

Frequency:
In the literature, incidence of Meckel diverticulum is
usually quoted as approximately 2% of the
population, but prevalence can vary from 0.2-4%
 Meckel Diverticulum
Mortality/Morbidity:
(complications)
Sex:
as an incidental finding during operations, males are
more prone to complications than females
Age:
Presentation in infants younger than 2 years has been
considered the classic case

However, in one study, only 45% of infants were younger

than 2 years
 Meckel Diverticulum
CLINICAL
History:
Most patients are asymptomatic

Meckel diverticulum is usually an incidental finding

when a barium study or laparotomy is performed
for other abdominal conditions
 Meckel Diverticulum

CLINICAL
History:
When patients develop symptoms, presence of
complications is almost always indicated

Development of complications is usually rare but

can occur in up to 4% of patients
 Meckel Diverticulum

CLINICAL
History:
Analysis of the literature suggests that complications of Meckel
diverticulum are usually the result of:
attached bands or
ectopic tissue
History
In one study of 830 patients of all ages, complications included:
bowel obstruction (35%)
hemorrhage (32%)
diverticulitis (22%)
umbilical fistula (10%)
and other umbilical lesions (1%)

► In children, bleeding is the most common presenting sign

CLINICAL
History:
Most children younger than 5 years present with acute
lower GI bleeding due to hemorrhage from peptic
ulceration

Such ulceration is a complication of heterotopic gastric

mucosa

and this hemorrhage is usually seen in the form of

painless rectal bleeding
CLINICAL
History:
However, some patients may present only with pain
preceding the onset of hematochezia; this clinical
presentation can often obscure the diagnosis

Not all patients have abdominal pain, but, when

present, it can be significant
CLINICAL
History:
Although intestinal obstruction is not considered a
major presenting clinical sign, it occurs in:
25-40% of pediatric patients and
is the most common complication in adults

Obstruction can occur as a result of various

mechanisms. ►►▼
CLINICAL
History:
1) Omphalomesenteric band (most frequent cause)

2) Internal hernia through vitelline duct remnants

3) Volvulus occurring around vitelline duct remnants

4) T-shaped prolapse of both efferent and afferent

loops of intestine through a persistent vitelline duct
CLINICAL
History:
5) Intussusception is another serious and common
complication of the Meckel diverticulum

The diverticulum may itself act as a lead point for an ileocolic

or ileoileal intussusception

Remember:
None of the clinical features are pathognomonic, and the
diagnosis is rarely made preoperatively
CLINICAL
History:
Like other diverticula in the body, the Meckel
diverticulum can become inflamed

Diverticulitis is seen usually in older patients

Meckel diverticulum is less prone to inflammation

than the appendix because most diverticula:
have a wide mouth and
have very little lymphoid tissue
CLINICAL
History:
The clinical presentation (Meckel diverticulitis)
includes:

abdominal pain in the periumbilical area that

radiates to the right lower quadrant

Abdominal pain is present more in the

periumbilical region than the pain of
appendicitis
CLINICAL
History:
Meckel diverticulitis may be disguised as
appendicitis; the correct diagnosis is usually
established at the laparotomy

History of bleeding per rectum may be helpful in

distinguishing this entity from appendicitis
CLINICAL
History:
Chronic inflammation of Meckel diverticulum is
rare, but a few cases of:
tuberculosis and
Crohn disease
have been reported in the literature
CLINICAL
History:
Even more rarely, the Meckel diverticulum may develop
benign tumors (e.g. leiomyomas, angiomas, neuromas,
lipomas)

or malignant neoplasms (e.g. sarcoma, carcinoid tumor,

adenocarcinomas)

or it may be perforated with a swallowed:

fish bone or
sewing needle
 CLINICAL
Physical
Patients can present with a variety of clinical signs
ranging from:
no symptoms
to acute abdominal pain

The 3 most common presentations are:

1) gastrointestinal bleeding
2) intestinal obstruction and
3) inflammation of the diverticulum
 Meckel diverticulum

CLINICAL
Physical
1) Most of the time, bleeding occurs suddenly and
tends to be massive in younger patients

Bleeding occurs without prior warning and usually

subsides spontaneously
 Meckel diverticulum

CLINICAL
Physical
When a severe bleeding episode occurs, the
patient can present in hemorrhagic shock

Tachycardia is the earliest clinical sign of early

hemorrhagic shock
 Meckel diverticulum

CLINICAL
Physical
The color of the stool often provides physicians
with a clue to determine the site of bleeding
 Meckel diverticulum
CLINICAL
Physical
When bleeding is rapid, stools are:
bright red or
have an appearance like currant jelly

When slow bleeding occurs, the stools are:

black and
tarry
 Meckel diverticulum

CLINICAL
Physical
2) Most patients with intestinal obstruction present
with:
abdominal pain and vomiting
abdominal tenderness
distension and
hyperactive bowel sound
►on examination
CLINICAL
Physical
Patients may sometimes develop a palpable abdominal mass

Occasionally, 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
CLINICAL
Physical
► Children may present with:
abdominal guarding and
rebound tenderness
in addition to abdominal tenderness

Remember
► abdominal distention and
hypoactive bowel sounds are late findings
 Meckel diverticulum
CLINICAL
Physical
Rarely, Meckel diverticulum has been reported to
become incarcerated in the:
Inguinal
Femoral or
Obturator hernial sacs
 Meckel diverticulum

CLINICAL
Physical
Entrapment of Meckel diverticulum in an inguinal hernia is called a
Littre hernia
DIFFERENTIALS
Constipation
Crohn Disease
Gastroenteritis
Hirschsprung Disease
Intussusception
Necrotizing Enterocolitis
Peptic Ulcer Disease
Porphyria, Acute
Sickle Cell Anemia
Urinary Tract Infection
Urolithiasis
Volvulus
WORKUP
Routine laboratory studies, such as :
CBC count
Electrolyte tests
Glucose test
BUN
Creatinine test and
Coagulation screen
are not helpful in establishing the diagnosis but
are helpful in the general workup
 Meckel diverticulum

Imaging Studies:
History and physical examination are of paramount
importance for establishing a clinical diagnosis

Imaging studies are performed to confirm a clinical

suspicion of Meckel diverticulum
Imaging Studies:

Plain radiographs of the abdomen may depict signs of:

intestinal obstruction or
perforation

►When a patient presents:

with bleeding and
with suspicion of Meckel diverticulum
Scintiscan is especially helpful in infants who
present with lower GI bleeding
Imaging Studies
►Scintiscan
Imaging Studies:
Selective arteriography
May be helpful in patients in whom the results from:
scintigraphy and
barium studies
are negative
TREATMENT
Medical Care:
The emergency department evaluation and
treatment of patients depends on the clinical
presentation
Medical Care:
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

If significant bleeding occurs, perform a transfusion

of packed red cells
TREATMENT
Medical Care:
A patient presenting with intestinal obstruction
may require ►nasogastric decompression
Surgical Care:
Treatment is surgical, consisting of a resection of
the affected portion of the bowel

If the patient is bleeding but hemodynamically

stable, a Meckel scan is warranted

On the other hand, the presence of peritoneal signs

or hemodynamic instability demands urgent
surgical intervention
• Illustration
Thanks