Clinics and Practice 2011; volume 1:e51

Meckel’s diverticulitis causing 92.8% neutrophils), raised serum amylase (468 U/L) and raised urinary amylase (769 Correspondence: Vishalkumar Shelat, small bowel obstruction by a U/L). Serum lipase, electrolytes, creatinine Department of General Surgery, Tan Tock Seng novel mechanism and liver function tests were unremarkable. Hospital, 11 Jalan Tan Tock Seng, Singapore Chest and abdominal films were unremark - 308433, Singapore. E-mail: [email protected] Vishalkumar G. Shelat, Kaiwen Kelvin Li, able. The patient underwent computed tomog - Anil Rao, Tay Sze Guan raphy (CT) scan of her abdomen/pelvis on the Key words: Meckel’s diverticulum; Meckel’s diver - first day of admission which showed mild Department of General Surgery, Tan Tock ticulitis; small bowel obstruction. dilatation of the small bowels, particularly in Seng Hospital, Singapore, Singapore the distal jejunum and proximal with Received for publication: 4 May 2011. thickening of the bowel wall and submucosal Accepted for publication: 21 June 2011. oedema. No transition point was seen on the CT scan (Figure 1). This work is licensed under a Creative Commons Abstract Attribution NonCommercial 3.0 License (CC BY- She received symptomatic treatment. NC 3.0). However, her abdomen became increasingly Meckel’s diverticulum occurs in 2% of the distended and she developed vomiting over ©Copyright V.G. Shelat et al., 2011 general population and majority of patients next three days. A repeat CT scan of the Licensee PAGEPress, Italy remain asymptomatic. Gastrointestinal bleed - abdomen/pelvis was performed on the fourth Clinics and Practice 2011; 1:e51 ing is the most common presentation in the day of admission and this showed interval doi:10.4081/cp.2011.e51 paediatric population. While asymptomatic and worsening of small bowel dilatation along with incidentally found Meckel’s diverticulum may a transition point in the distal ileum (Figure be left alone, surgery is essential for treating a 2). She underwent emergency exploratory ing all layers of the intestinal wall and is usu - symptomatic patient. Despite advances in laparotomy. Intra-operatively, gangrenous 6 cm ally situated 60-100 cm from the ileocecal valve imaging and technology, pre-operative diagno - long Meckel’s diverticulum was found with on the anti-mesenteric border of the terminal sis is often difficult. We present a first report of omentum adherent at its tip (Figure 3). The ileum. The apex of the diverticulum may be an unusual mechanism of small bowel obstruc - small bowel loop was obstructed secondary to free or attached by a fibrous band to the tion due to Meckel’s diverticulitis in a paedi - the omental band. The terminal ileum distal to umbilicus or to the mesentery, in which case it atric patient. The diagnosis was only apparent the band was collapsed. The small bowel was can cause intestinal obstruction. As the cells at laparotomy. otherwise viable. A short segment of the termi - lining the vitelline duct are pluripotent, it is nal ileum containing the Meckel’s diverticu - not uncommon to find heterotopic tissue with - lum and adhesion band was resected and sta - in a Meckel’s diverticulum. In one study, het - pled anastamosis with linear staples was per - erotopic gastric mucosa was found in 62% of Introduction formed. The histology showed an infracted cases, pancreatic tissue was found in 6% while Meckel’s diverticulum lined by - pancreatic tissue and gastric mucosa were Meckel’s diverticulum is the most common type mucosa. No gastric-type mucosa or pan - found in 5%. 7 The raised serum amylase levels 1 congenital abnormality of the small intestine. creatic tissue was identified. Her recovery was in our patient were reflective of intestinal It arises due to an incomplete obliteration of prolonged due to ileus. She was discharged on ischaemia rather than ectopic pancreatic tis - the omphalomesenteric duct. The majority of post-operative day 8 and was well at her clinic sue. Most people with Meckel’s diverticulum patients remain asymptomatic; with only 4- follow-up visit. remain asymptomatic with only 4-16% develop - 16% of patients experiencing symptoms. 2 ing symptoms arising from complications such Gastrointestinal bleeding is the most common as intestinal obstruction, gastrointestinal presentation in the paediatric population bleeding, and diverticulitis. 2,8 In a large series while intestinal obstruction is the most com - Discussion of 1476 cases of Meckel’s diverticulum found mon complication in adults. We present a first intra-operatively in a single institution over a report of an unusual mechanism of small Meckel’s diverticulum was first described by span of 52 years, it was found that 16% were bowel obstruction due to Meckel’s diverticulitis Fabricus Heldanus in 1650, 3 then reported by symptomatic with a mean age of 31 years and in a paediatric patient. Levator in 1671 4 and by Ruysch in 1730. 5 a male:female ratio of 3:1. 8 In the paediatric However, its embryonic origin was established patient population, the commonest complica - by Johann Friedrich Meckel much later in 1809 tion is gastrointestinal bleeding arising from and since then bears his name. 6 peptic ulceration due to acid secreted by het - Case Report During the first few weeks of gestation, the erotopic gastric mucosa. 9 On the other hand, loop remains in open connection with intestinal obstruction is the most frequent A 15-year-old girl presented with one day the by way of the vitelline duct. complication in the adult patient population. history of colicky central abdominal pain asso - Normally, the vitelline duct obliterates. Our case is an infrequent case where intestin - ciated with loss of appetite and nausea. There Meckel’s diverticulum represents a common al obstruction occurred in a paediatric patient. was no other history to note. She was afebrile vestigial remnant of the omphalomesenteric Intestinal obstruction occurs by various mech - with normal hemodynamic parameters. She duct (also known as the vitelline duct). anisms: omphalomesenteric band, internal was mildly dehydrated and abdominal exami - Persistence of the duct may also rarely lead to hernia through vitelline duct remnants, volvu - nation revealed tenderness over the periumbil - (i) fistula between umbilicus and ileum when lus around vitelline duct remnant, intussus - ical and suprapubic regions. Bowel sounds the entire duct remains patent; (ii) umbilical ceptions, incarceration within a hernia sac were active and the abdomen was not distend - sinus when the umbilical end of the duct is not (Littre’s hernia) or chronic Meckel’s divertic - ed. Digital rectal examination was unremark - obliterated and (iii) fibrous cord between the ulitis. 2 Enteroliths formed in the diverticulum able. Laboratory tests showed leukocytosis umbilicus and the ileum representing an oblit - causing intestinal obstruction have also been with left shift (16,600 white blood cells/mm3, erated duct. It is a true diverticulum contain - reported. 10,11 The small bowel obstruction in

[page 102 ] [Clinics and Practice 2011; 1:e51] Case Report our patient was not explained by any of the ing with symptoms other than per-rectal bleed - omphalomesenteric remnant without any pal - above mechanisms. This is the first report of ing. In a study of 776 patients, 88% of patients pable mass in the lumen may be treated with a an omental band adherent to Meckel’s divertic - with Meckel’s diverticulum presenting with simple wedge resection of the diverticulum ulum causing intestinal obstruction. per-rectal bleeding had a correct preoperative and closure of the ileal defect. 28 In cases where Charles Mayo once remarked Meckel’s diagnosis while only 11% of patients who pre - the diverticulum has a wide base or palpable diverticulum is frequently suspected, often sented with other symptoms were rightly diag - ectopic tissue or where there is inflammatory looked for and seldom found. 12 Preoperative nosed preoperatively. 13 Plain X-ray, CT scans or ischemia changes in adjacent ileum, it is diagnosis of symptomatic Meckel’s diverticu - and barium studies are rarely useful in pre- preferable to resect the involved bowel with lum is difficult, especially in patients present - operative diagnosis of Meckel’s. In our patient, end-to-end bowel anatamosis. 24,29 Segmental CT scan was done twice and it failed to recog - ileal resection is also required for treatment of nize the presence of inflamed Meckel’s diver - patients with gastrointestinal bleeding as the ticulum on two occasions. Hence pre-operative site of bleeding is usually in the adjacent diagnosis is many times not possible and a ileum. Involvement of the diverticulum by high index of suspicion is essential in dealing benign tumors can be dealt with a simple with an undiagnosed abdominal pain. When diverticulectomy, depending on the site and the patient presents with gastrointestinal size of the lesion. Where malignant tumors are bleeding, technetium-99m pertechnate scan is involved, wide intestinal and mesenteric a useful non-invasive investigation. In chil - resection would be required. 30,31 dren, it has a sensitivity of 80-90%, specificity In conclusion, Meckel’s diverticulum is not of 95% and accuracy of 90% 14 but in the adults, uncommon and hence should be considered as it is less reliable with a sensitivity of 62.5%, a differential diagnosis in a patient with an specificity of 9% and accuracy of 46%. 15 As the unestablished cause of intestinal obstruction. Figure 1. Computed tomography scan technetium-99 m pertechnate scan is specific showing dilated small bowel loops and to ectopic gastric mucosa and not specifically mucosal oedema. The bowel wall is well to Meckel’s diverticulum, it may be positive in enhancing. gut duplication cysts with ectopic gastric References mucosa. 16 Management of incidentally detected 1. Anderson DJ. Carcinoid tumour in Meckel’s diverticulum is controversial. Meckel’s diverticulum: laparoscopic treat - Resection of incidentally found Meckel’s diver - ment and review of literature. J Am ticulum has been justified due to a potential Osteopath Assoc 2000;100:432-4. for morbidity and mortality throughout life. 17-20 2. Prall RT, Bannon MO, Bharucha AE. In 1976, Soltero et al . first opposed routine Meckel’s diverticulum causing intestinal resection of incidentally found Meckel’s diver - obstruction. Am J Gastroenterol 2001;96: ticulum, demonstrating that there was only a 3246-7. small chance of a truly asymptomatic Meckel’s 3. Chaudhuri TK, Christie JH. False positive diverticulum causing disease in later life. 21 Meckel’s diverticulum scan. Surgery 1972; Peoples et al. also discouraged the resection of 71:313. incidentally found Meckel’s diverticulum as 4. Dalinka MK, Wunder JF. Meckel’s divertic - they found that the lifetime risk of developing ulum and its complications, with emphasis Figure 2. Computed tomography scan symptoms from a Meckel’s diverticulum do not on roentgenologic demonstration. Radio - showing worsening small bowel dilatation significantly outweigh the surgical morbidity logy 1973;106:295-8. and a transition point (green arrow) at the and mortality of resection. 22 Many others advo - 5. Duszynski DO. Radionuclide imaging of ileum. cate a case-specific approach. Incidentally gastrointestinal disorders. Semin Nucl found Meckel’s diverticulum with a broad base Med 1972;2:383-6. or of a short length should be left in situ 23,24 6. Opitz JM, Schultka R, Gobbel L. Meckel on while the palpability of mucosal heterotopia developmental pathology. Am J Med Genet would steer a surgeon towards resection. 9,25,26 A 2006;140:115-28. Park et al . also recommend a selective 7. Elsayes KM, Menias CO, Harvin HJ, approach, advising resection of incidentally Francis IR. Imaging manifestations of detected Meckel’s diverticulum in the follow - Meckel’s diverticulum. AJR Am J Roentge - ing cases: (i) patients younger than 50 years of nol 2007;189:81-8. age; (ii) male patients; (iii) diverticulum 8. Park JJ, Wolff BG, Tollefson MK, et al. longer than 2 cm; (iv) detection of abnormal Meckel diverticulum: the Mayo Clinic features inside the diverticulum. 8 A recent experience with 1476 patients (1950- meta-analysis does not support routine resec - 2002). Ann Surg 2005;241:529-33. tion of incidentally detected Meckel’s divertic - 9. St-Vil D, Brandt ML, Panic S, et al. ulum. 27 Meckel’s diverticulum in children: a 20- The definitive treatment of symptomatic year review. J Pedatr Surg 1991;26:1289- Meckel’s diverticulum is surgery, via laparoto - 92. Figure 3. Intra-operative photograph my, laparoscopic or laparoscopic-assisted 10. Srinivas GN, Cullen P. Intestinal obstruc - showing normal appendix and gangrenous approaches. The extent of resection is guided tion due to meckel’s diverticulum: a rare Meckel’s diverticulum. Miniature photo - by the type of complication encountered and presentation. Acta Chir Belg 2007;107:64- graph of resected specimen. the intra-operative findings. A narrow-base 6.

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11. Trésallet C, Renard-Penna R, Nguyen- lum: a ten-year experience. Am Surg heterotopic mucosa. ANZ J Surg Thanh Q, et al. Intestinal obstruction by an 1997;63:354-5. 2004;74:869-72. enterolith from a perforated giant Meckel’s 18. Bani-Hani KE, Shatnawi NJ. Meckel’s 25. Simms MH, Corkery JJ. Meckel’s diverticu - diverticulum: diagnosis with CT recon - diverticulum: comparison of incidental lum: its association with congenital mal - structed images. Int Surg 2007;92:125-7. and symptomatic cases. World J Surg formation and the significance of atypical 12. Russell RCG, Williams NS, Bulstrode CJK. 2004;28:917-20. morphology. Br J Surg 1980;67:216–9. The small and large intestines. In: Russell 19. Michas CA, Cohen SE, Wolfman EF Jr. 26. Groebli Y, Bertin D, Morel P. Meckel’s RCG, Williams NS, Bulstrode CJK, eds. Meckel’s diverticulum: should it be excised diverticulum in adults: retrospective Bailey and Love’s Short Practice of incidentally at operation? Am J Surg 1975; analysis of 119 cases and historical review. Surgery. 23rd ed. London: Arnold; 2000. p. 129:682-5. Eur J Surg 2001;167:518-24. 1033. 20. Cullen JJ, Kelly KA, Moir CR, et al. Surgical 27. Zani A, Eaton S, Rees CM, Pierro A. 13. Higaki S, Saito Y, Akazawa A, et al. management of Meckel’s diverticulum. An Incidentally detected Meckel diverticulum: Bleeding Meckel’s diverticulum in an epidemiologic, population-based study. to resect or not to resect? Ann Surg adult. Hepatogastroenterology 2001;48: Ann Surg 1994;220:564-9. 2008;247:276-81. 1628-30. 21. Soltero MJ, Bill AH. The natural history of 28. Sharma RK, Jain VK. Emergency surgery 14. Kong MS, Chen CY, Tzen KY, et al. Meckel’s Diverticulum and its relation to for Meckel’s diverticulum. World J Emerg Technetium-99m pertechnetate scan for incidental removal. A study of 202 cases of Surg 2008;3:27. ectopic gastric mucosa in children with diseased Meckel’s diverticulum found in 29. Mukai M, Takamatsu H, Noguchi H, et al. gastrointestinal bleeding. J Formos Med King County, Washington, over a fifteen Does the external appearance of a Assoc 1993;92:717-20. year period. Am J Surg 1976;132:168-173. Meckel’s diverticulum assist in choice of 15. Lin S, Suhocki PV, Ludwig KA, Shetzline 22. Peoples JB, Lichtenberger EJ, Dunn MM. the laparoscopic procedure? Pediatr Surg MA. Gastrointestinal bleeding in adult Incidental Meckel's diverticulectomy in Int 2002;18:231-3. patients with Meckel’s diverticulum: the adults. Surgery 1995;118:649-52. 30. Sutter PM, Canepa MG, Kuhrmeier F, et al. role of technetium 99m pertechnetate 23. Robijn J, Sebrechts E, Miserez M. Mana - [Carcinoid tumor in Meckel’s diverticu - scan. South Med J 2002;95:1338-41. gement of incidentally found Meckel’s lum: case presentation and review of liter - 16. Kumar R, Tripathi M, Chandrashekar N, et diverticulum a new approach: resection ature]. Schweiz med Wochenschr Suppl al. Diagnosis of ectopic gastric mucosa based on a Risk Score. Acta Chir Belg 1997;89:20S-24S. using 99Tcm-pertechnetate: spectrum of 2006;106:467-70. 31. Kovács M, Davidovics S, Gyurus P, Rácz I. scintigraphic findings. Br J Radiol 2005; 24. Varcoe RL, Wong SW, Taylor CF, Newstead [Identification of a Meckel’s diverticulum 78:714-20. GL. Diverticulectomy is inadequate treat - bleeding by urgent capsule endoscopy]. 17. Arnold JF, Pellicane JV. Meckel’s diverticu - ment for short Meckel’s diverticulum with Orv Hetil 2006;147:2003-6.

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