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Meckel's diverticulum

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Synonyms and keywords:Meckel diverticulum, persistent intestinal end of vitelline duct, persistent omphalomesenteric duct, persistent vitelline duct

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Meckel’s diverticulum is a vestigial remnant of the omphalomesenteric duct (also called the vitelline duct) and is the most frequent malformation of the gastrointestinal tract. Meckel’s diverticulum was first described by Fabricius Hildanus in the sixteenth century. In 1809, Johann Friedrich Meckel threw light on the embryological origin of Meckel’s diverticulum. The vitelline duct or the omphalomesenteric duct is the connection between the midgut and the yolk sac responsible for providing nutrition to the midgut, during fetal development. The vitelline duct subsequently undergoes involution, in the period between the fifth and the sixth weeks of gestation while the intestinal loop is rapidly pulled into the abdominal cavity. Failure of duct involution may lead to persistence of the proximal portion of omphalomesenteric duct, which may be referred to as the Meckel’s diverticulum. The “Rule of 2s” applies to patients with Meckel’s diverticulum and states that it affects approximately 2 percent of the population with a male-to-female ratio of 2:1. It is mostly located about two feet proximal to the ileocecal valve, is approximately two inches in length, and in majority of cases, affects age group <2yrs. In addition, the two most common types of ectopic mucosa found within the diverticulum are the gastric and pancreatic types. Increased prevalence of Meckel’s diverticulum is seen in children with umbilical malformations, gastrointestinal tract, neurological and cardiovascular defects. The presentation of Meckel’s diverticulum is usually asymptomatic .The hallmark feature in symptomatic patients is the occurrence of painless lower gastrointestinal bleeding. Other symptoms of Meckel’s diverticulum arise in complicated cases with features of intestinal obstruction, intussusception, volvulus and perforation. Abdominal examination of patients with Meckel’s diverticulum is usually normal, even in patients with gastrointestinal bleeding. Patient develop signs of acute abdomen due to diverticular inflammation or perforation in complicated cases. Laboratory findings are non specific and patients may show volume depletion, features of anemia (such as decreased hematocrit, decreased hemoglobin levels and positive stool guaiac test). A technetium-99m (99mTc) pertechnetate scan is the investigation of choice for the diagnosis of Meckel’s diverticulum. This scan detects gastric mucosa; since approximately 50% of symptomatic Meckel’s diverticula have ectopic gastric (stomach) cells contained within them. A Meckel’s diverticulum containing gastric mucosa manifests as a small rounded area of increased activity in the right lower quadrant, while normal activity simultaneously appears in the stomach. Initially, the medical management of a symptomatic case of Meckel’s diverticulum is directed toward management of clinical manifestations of complications. Intravenous lines for fluid and electrolyte therapy, nasogastric decompression for patients with symptoms and signs of intestinal obstruction, proton-pump inhibitors and Aluminum hydroxide for patients with gastrointestinal bleeding are preferred. Surgery is the primary treatment modality in patients with Meckel’s diverticula. Absolute indications for resection of a symptomatic Meckel’s diverticulum include complications such as hemorrhage, umbilicoileal fistulas, diverticulitis and bowel obstruction. Fibrous band division, diverticulectomy, segmental resection of the diverticulum with end-to-end intestinal anastomosis and wedge resection are the various surgical procedures performed, whenever indicated.

Historical Perspective

Meckel’s diverticulum was first described by Fabricius Hildanus in the sixteenth century. In 1809, Johann Friedrich Meckel threw light on the embryological origin of Meckel’s diverticulum.

Classification

There is no established system for the classification of Meckel’s diverticulum.

Pathophysiology

The vitelline duct or the omphalomesenteric duct is the connection between the midgut and the yolk sac responsible for providing nutrition to the midgut, during fetal development. The vitelline duct subsequently undergoes involution,in the period between the fifth and the sixth weeks of gestation while the intestinal loop is rapidly pulled into the abdominal cavity. Failure of duct involution may lead to persistence of the proximal portion of omphalomesenteric duct, which may be referred to as the Meckel’s diverticulum. The Meckel’s diverticulum is a true diverticulum (comprising of all layers of intestinal wall i.e. mucosa, submucosa and muscularis propria). It arises from the antimesenteric border of the ileum and extends into the umbilical cord. The blood supply comes from the vitelline artery, which is a branch of the superior mesenteric artery, prone to torsion, ischemia, infarction and obstruction. The diverticulum may contain ectopic tissue due to the presence of a pluripotent cell lining, faulty association between endodermal and neural crest cells and absence of inhibitory effect of the mesoderm on the local endoderm.

Causes

Persistence of the vitelline duct due to incomplete involution leads to the formation of Meckel’s diverticula, the most common congenital abnormality of the small intestine.

Differentiating Meckel’s diverticulum from Other Diseases

The common diseases responsible for lower GI bleeding that must be differentiated from Meckel’s diverticulum include diverticulosis, angiodysplasia, hemorrhoids, anal fissures, mesenteric Ischemia, and colorectal carcinoma. Meckel’s diverticulitis is a common complication of Meckel’s diverticulum in adults and must be differentiated from other causes of abdominal pain and lower gastrointestinal bleeding such as infective colitis, IBD and acute ischemic colitis.

Epidemiology and Demographics

Meckel’s diverticulum is present in approximately 2% of the population, as per the “Rule of 2s”. This rule applies to patients with Meckel’s diverticulum and states that it affects approximately 2 percent of the population with a male-to-female ratio of 2:1. It is mostly located about two feet proximal to the ileocecal valve, is approximately two inches in length, and in majority of cases, affects age group <2yrs. In addition, the two most common types of ectopic mucosa found within the diverticulum are the gastric and pancreatic types. Increased prevalence of Meckel’s diverticulum is seen in children with umbilical malformations, gastrointestinal tract, neurological and cardiovascular defects.

Risk Factors

Common risk factors in the development of Meckel’s diverticulum include histologic and anatomic features such as length of diverticulum >2cm, presence of ectopic tissue, broad based diverticulum, and attachment of fibrous bands to the diverticulum. Patient age of less than 50 years and the male gender are more susceptible to the development of Meckel’s diverticulum.

Screening

There is insufficient evidence to recommend routine screening for Meckel’s diverticulum.

Natural History, Complications and Prognosis

Meckel’s diverticulum is mostly seen in male children (mostly <2 years of age). One fourth of untreated cases of Meckel’s diverticulum may develop complications such as intestinal obstruction, hemorrhage, diverticulitis, bowel ischemia, and necrosis. Hemorrhage is the most common complication in patients with Meckel’s diverticulum. Bleeding in patients may be minimal, recurrent or massive and shock-producing. The rate of bleeding is assessed based on quantity of blood lost in the stools, appearance of the material passing through the rectum and hemodynamic state of the patient. Depending on the extent of the symptom progression at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as excellent in cases where symptomatic Meckel’s diverticulum is treated in a timely manner. Complete recovery may be expected with surgery in majority of the cases.

Diagnosis

History and Symptoms

The presentation of Meckel’s diverticulum is usually asymptomatic .The hallmark feature in symptomatic patients is the occurrence of painless lower gastrointestinal bleeding. Other symptoms of Meckel’s diverticulum arise in complicated cases with features of intestinal obstruction, intussusception, volvulus and perforation. The age of presentation for approximately half of all patients is less than 10 years of age. Patients may also develop symptoms of diverticular inflammation (ie, Meckel’s diverticulitis) which has a presentation similar to acute appendicitis.

Physical Examination

Patients with Meckel’s diverticulum usually appear normal on physical examination. Abdominal examination of patients with Meckel’s diverticulum is usually normal, even in patients with gastrointestinal bleeding. Patient develop signs of acute abdomen due to diverticular inflammation or perforation in complicated cases. These signs include Abdominal distention, abdominal tenderness, rebound tenderness and guarding.

Laboratory Findings

Laboratory findings are non specific and do not distinguish Meckel’s diverticulum from other sources of gastrointestinal bleeding. Laboratory findings in patients may show volume depletion, features of anemia (such as decreased hematocrit, decreased hemoglobin levels and positive stool guaiac test).

Other Imaging Findings

A technetium-99m (99mTc) pertechnetate scan is the investigation of choice for the diagnosis of Meckel’s diverticulum. This scan detects gastric mucosa; since approximately 50% of symptomatic Meckel’s diverticula have ectopic gastric (stomach) cells contained within them. A Meckel’s diverticulum containing gastric mucosa manifests as a small rounded area of increased activity in the right lower quadrant, while normal activity simultaneously appears in the stomach.

Other Diagnostic Studies

Diagnostic studies such as colonoscopy, double-balloon enteroscopy, laproscopy, laparotomy may help in the detection of symptomatic and asymptomatic Meckel’s diverticula. Screenings for bleeding disorders may be performed to rule out other sources of bleeding.

Treatment

Medical Therapy

Initially, the medical management of a symptomatic case of Meckel’s diverticulum is directed toward management of clinical manifestations of complications. Intravenous lines for fluid and electrolyte therapy, nasogastric decompression for patients with symptoms and signs of intestinal obstruction, proton-pump inhibitors and Aluminum hydroxide for patients with gastrointestinal bleeding are preferred. The process of initial resuscitation in patients with lower gastrointestinal bleeding due to Meckel’s diverticulum) is similar to the steps followed in any case of lower GI bleeding.

Surgery

Surgery is the primary treatment modality in patients with Meckel’s diverticula. Asymptomatic patients are treated in the presence of features such as narrow diverticular mouth, fibrous bands, ectopic gastric tissue, diverticular length >2cm, stasis, narrow neck, intramural pathology, thickening and inflammation of the diverticulum. On the other hand, absolute indications for resection of a symptomatic Meckel’s diverticulum include complications such as hemorrhage, umbilico ileal fistulas, diverticulitis and bowel obstruction. Fibrous band division, diverticulectomy, segmental resection of the diverticulum with end-to-end intestinal anastomosis and wedge resection are the various surgical procedures performed, whenever indicated.

Prevention

There are no established measures for the primary prevention of Meckel’s diverticulum. Secondary prevention involves management of post operative complications of Meckel’s diverticula include ileus, intra-abdominal abscess formation, pulmonary embolism, anastomotic leakage and intestinal obstruction due to postoperative adhesions. Treatment of complications such as intra-abdominal abscess and intestinal obstruction due to stenosis or adhesions is mainly surgical. The management of ileus is mainly supportive and the patient is kept NPO with nasogastric suction and parenteral feeds. Electrolyte levels need to be monitored and pharmacotherapy such as lactulose may also be administered to patients.

References

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Historical Perspective

Historical Perspective

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Meckel’s diverticulum was first described by Fabricius Hildanus in the sixteenth century. In 1809, Johann Friedrich Meckel threw light on the embryological origin of Meckel’s diverticulum.

Historical Perspective

  • In the 1500s, Meckel’s diverticulum was first described by Fabricius Hildanus.
  • In 1809, the embryological origin of the Meckel’s diverticulum was described by Johann Friedrich Meckel. Meckel was a famous German scientist of the nineteenth century, well known as the “restorer” of comparative anatomy due to his vast knowledge in the subject.[1][2]

References

  1. ↑ Template:WhoNamedIt
  2. ↑ J. F. Meckel. Über die Divertikel am Darmkanal. Archiv für die Physiologie, Halle, 1809, 9: 421-453.

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Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

There is no established system for the classification of Meckel’s diverticulum.

Classification

  • There is no established system for the classification of Meckel’s diverticulum.

References

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Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

The vitelline duct or the omphalomesenteric duct is the connection between the midgut and the yolk sac responsible for providing nutrition to the midgut, during fetal development. The vitelline duct subsequently undergoes involution, in the period between the fifth and the sixth weeks of gestation while the intestinal loop is rapidly pulled into the abdominal cavity. Failure of duct involution may lead to persistence of the proximal portion of omphalomesenteric duct, which may be referred to as the Meckel’s diverticulum. The Meckel’s diverticulum is a true diverticulum (comprising of all layers of intestinal wall i.e. mucosa, submucosa and muscularis propria). It arises from the antimesenteric border of the ileum and extends into the umbilical cord. The blood supply comes from the vitelline artery, which is a branch of the superior mesenteric artery, prone to torsion, ischemia, infarction, and obstruction. The diverticulum may contain ectopic tissue due to the presence of a pluripotent cell lining, faulty association between endodermal and neural crest cells and absence of inhibitory effect of the mesoderm on the local endoderm.

Pathophysiology

Meckel’s diverticulum
Source: Wikimedia commons [1]

Genetics

  • There is some evidence to suggest a familial association with the development of Meckel’s diverticulum, but this has not been adequately explored.[10]

Associated Conditions

Gross Pathology

  • On gross pathology, the features of Meckel’s diverticulum are as follows:
  • Location:
  • Appearance:
    • Small pouch or a blind segment
  • Length:
    • Variable, from less than 1cm to 8cm
  • Size:

Microscopic Pathology

Meckel’s diverticulum with gastric heterotopic cell rests
Source: Wikimedia commons [13]

References

  1. ↑ “File:Diverticule de Meckel.jpg – Wikimedia Commons”.
  2. ↑ “Fundamentals of Pediatric Surgery – Second Edition | Peter Mattei | Springer”.
  3. ↑ “The Developing Human – 9th Edition”.
  4. ↑ 4.0 4.1 “Robbins and Cotran Pathologic Basis of Disease, Professional Edition – 8th Edition”.
  5. ↑ Tiu A, Lee D (2006). “An unusual manifestation of Meckel’s diverticulum: strangulated paraumbilical hernia”. N. Z. Med. J. 119 (1236): U2034. PMID 16807577.
  6. ↑ Garg D, Singh AP, Kothari S, Kumar A (2017). “Urachal Cyst, Meckel’s Diverticulum and Band, and Urachus”. APSP J Case Rep. 8 (1): 8. doi:10.21699/ajcr.v8i1.477. PMC 5253616. PMID 28164005.
  7. ↑ Simms MH, Corkery JJ (1980). “Meckel’s diverticulum: its association with congenital malformation and the significance of atypical morphology”. Br J Surg. 67 (3): 216–9. PMID 7362966.
  8. ↑ Yahchouchy EK, Marano AF, Etienne JC, Fingerhut AL (2001). “Meckel’s diverticulum”. J. Am. Coll. Surg. 192 (5): 658–62. PMID 11333103.
  9. ↑ Elsayes KM, Menias CO, Harvin HJ, Francis IR (2007). “Imaging manifestations of Meckel’s diverticulum”. AJR Am J Roentgenol. 189 (1): 81–8. doi:10.2214/AJR.06.1257. PMID 17579156.
  10. ↑ Lajarrige C, Druon D, Gruss R, Delepierre A, Aina E, Chaqchaq A, Kremp L (1989). “[3 cases of Meckel’s diverticulum in the same family]”. Presse Med (in French). 18 (39): 1930. PMID 2531871.
  11. ↑ “Meckel’s Diverticulum”.
  12. ↑ “Meckel’s Diverticulum”.
  13. ↑ “File:Meckel’s diverticulum with ectopic gastric mucosa and perforation, HE 1.jpg – Wikimedia Commons”.

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Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Persistence of the vitelline duct due to incomplete involution leads to the formation of Meckel’s diverticula, the most common congenital abnormality of the small intestine.

Causes

Congenital: [1][2][3][4]

  • Persistence of the vitelline duct due to incomplete involution leads to its formation.

References

  1. ↑ “Robbins and Cotran Pathologic Basis of Disease, Professional Edition – 8th Edition”.
  2. ↑ Simms MH, Corkery JJ (1980). “Meckel’s diverticulum: its association with congenital malformation and the significance of atypical morphology”. Br J Surg. 67 (3): 216–9. PMID 7362966.
  3. ↑ Yahchouchy EK, Marano AF, Etienne JC, Fingerhut AL (2001). “Meckel’s diverticulum”. J. Am. Coll. Surg. 192 (5): 658–62. PMID 11333103.
  4. ↑ Elsayes KM, Menias CO, Harvin HJ, Francis IR (2007). “Imaging manifestations of Meckel’s diverticulum”. AJR Am J Roentgenol. 189 (1): 81–8. doi:10.2214/AJR.06.1257. PMID 17579156.

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Differentiating Meckel’s Diverticulum from other Diseases

Differentiating Meckel’s Diverticulum from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

The common diseases responsible for lower GI bleeding that must be differentiated from Meckel’s diverticulum inlcude diverticulosis, angiodysplasia, hemorrhoids, anal fissures, mesenteric Ischemia, and colorectal carcinoma. Meckel’s diverticulitis is a common complication of Meckel’s diverticulum in adults and must be differentiated from other causes of abdominal pain and lower gastrointestinal bleeding such as infective colitis, IBD and acute ischemic colitis.

Differentiating Meckel’s Diverticulum from other Diseases

The common diseases responsible for lower GI bleeding that must be differentiated from Meckel’s diverticulum inlcude diverticulosis, angiodysplasia, hemorrhoids, anal fissures, mesenteric Ischemia, ischemic colitis, inflammatory bowel disease, and colorectal carcinoma.[1]

Disease Symptoms Other features Diagnosis
Abdominal pain Rectal pain Weightloss Fever Type of GI bleeding Diarrhea Constipation Laboratory findings Radio-Imaging findings
Meckel’s diverticulum – – – – Frank blood – – Signs of iron deficiency anemia may be present such as:
Diverticulosis – – – – Red or maroon-colored blood – +
  • Self limiting
  • Seen in elderly
 Normal

Globular outpouchings on CT scan

Angiodysplasia – – – – Frank blood – – Normal Normal
Hemorrhoids – + – – Blood on tissues – + – Tortuous dilated vessels on anoscopy
Anal fissures – + – – Blood on tissues – + Normal except mild leucocytosis Anoscopy
Mesenteric Ischemia + – + + Frank blood + –
  • Pain alters with eating habits
  • Associated with other comorbid conditions
Ischemic colitis + – – + Frank blood + – 3 phases
  • Mild moderate diffuse bowel wall thickening
  • Marked hyperenhancement of the mucosa
Crohn’s disease + – + + Blood mixed with stools + + Extra intestinal manifestations
Ulcerative colitis + + + + Blood mixed with stools + +
Colon carcinoma + -† + + Occult bleeding + +† + FOBT (fecal occult blood test)

↑ CEA( and CA 19-9

Hypercalcemia 

The following table differentiates Meckel’s diverticulitis from other causes of abdominal pain and lower gastrointestinal bleeding:

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Acute diverticulitis LLQ or RLQ (in case of Meckel’s diverticulitis) + ± + − + ± − + Positive in perforated diverticulitis + + Hypoactive
  • CT scan
  • Ultrasound
Inflammatory bowel disease Diffuse ± − − ± − + + + − − − Normal or hyperactive

Extra intestinal findings:

Infective colitis Diffuse + − ± − − + − + Positive in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Colon carcinoma Diffuse/localized − − − − ± ± + + ± − −
  • Normal or hyperactive if obstruction present
  • CBC
  • Carcinoembryonic antigen (CEA)
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Barium enema
  • CT colonography 
  • PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction
Hemochromatosis RUQ − − − − − − − Positive in cirrhotic patients − − − N
  • >60% TS
  • >240 μg/L SF
  • Raised LFT
    Hyperglycemia
  • Ultrasound shows evidence of cirrhosis
 Extra intestinal findings:
Mesenteric ischemia Periumbilical Positive if bowel becomes gangrenous − + − − + + + Positive if bowel becomes gangrenous Positive if bowel becomes gangrenous − Hyperactive to absent CT angiography
  • SMA or SMV thrombosis
  • Also known as abdominal angina that worsens with eating
Acute ischemic colitis Diffuse + ± + − − + + + + + + Hyperactive then absent Abdominal x-ray
  • Distension and pneumatosis

CT scan

  • Double halo appearance, thumbprinting
  • Thickening of bowel
  • May lead to shock
Ruptured abdominal aortic aneurysm Diffuse ± − + − − − + + + − − N
  • Focused Assessment with Sonography in Trauma (FAST) 
  • Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse ± − ± − − − − + + − − N
  • ↓ Hb
  • ↓ Hct
  • CT scan

References

  1. ↑ “Meckel’s Diverticulum Overview”. Retrieved 2013-04-01.

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Epidemiology and Demographics

Epidemiology and Demographics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Meckel’s diverticulum is present in approximately 2% of the population, as per the “Rule of 2s”. This rule applies to patients with Meckel’s diverticulum and states that it affects approximately 2 percent of the population with a male-to-female ratio of 2:1. It is mostly located about two feet proximal to the ileocecal valve, is approximately two inches in length, and in majority of cases, affects age group <2yrs. In addition, the two most common types of ectopic mucosa found within the diverticulum are the gastric and pancreatic types. Increased prevalence of Meckel’s diverticulum is seen in children with umbilical malformations, gastrointestinal tract, neurological and cardiovascular defects.

Epidemiology and Demographics

Prevalence

Age

Race

  • The racial predilection to Meckel’s diverticulum is as follows:
    • 63.4% white
    • 16.4% Hispanic
    • 4.7% African-American
    • 3.9% Asian
    • 11.6% other

Gender

  • Males are more commonly affected by Meckel’s diverticulum than females. The male to female ratio is approximately 2 to 1.
  • The male to female ratio for development of complications in affected cases is 3:1.

References

  1. ↑ Sagar J, Kumar V, Shah DK (2006). “Meckel’s diverticulum: a systematic review”. J R Soc Med. 99 (10): 501–5. doi:10.1258/jrsm.99.10.501. PMC 1592061. PMID 17021300.
  2. ↑ Zani A, Eaton S, Rees CM, Pierro A (2008). “Incidentally detected Meckel diverticulum: to resect or not to resect?”. Ann. Surg. 247 (2): 276–81. doi:10.1097/SLA.0b013e31815aaaf8. PMID 18216533.
  3. ↑ Soltero MJ, Bill AH (1976). “The natural history of Meckel’s Diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel’s Diverticulum found in King County, Washington, over a fifteen year period”. Am. J. Surg. 132 (2): 168–73. PMID 952346.
  4. ↑ Simms MH, Corkery JJ (1980). “Meckel’s diverticulum: its association with congenital malformation and the significance of atypical morphology”. Br J Surg. 67 (3): 216–9. PMID 7362966.
  5. ↑ Francis A, Kantarovich D, Khoshnam N, Alazraki AL, Patel B, Shehata BM (2016). “Pediatric Meckel’s Diverticulum: Report of 208 Cases and Review of the Literature”. Fetal Pediatr Pathol. 35 (3): 199–206. doi:10.3109/15513815.2016.1161684. PMID 27064958.
  6. ↑ 6.0 6.1 6.2 6.3 Ruscher KA, Fisher JN, Hughes CD, Neff S, Lerer TJ, Hight DW, Bourque MD, Campbell BT (2011). “National trends in the surgical management of Meckel’s diverticulum”. J. Pediatr. Surg. 46 (5): 893–6. doi:10.1016/j.jpedsurg.2011.02.024. PMID 21616248.
  7. ↑ Yahchouchy EK, Marano AF, Etienne JC, Fingerhut AL (2001). “Meckel’s diverticulum”. J. Am. Coll. Surg. 192 (5): 658–62. PMID 11333103.
  8. ↑ Pollack ES (1996). “Pediatric abdominal surgical emergencies”. Pediatr Ann. 25 (8): 448–57. PMID 8863320.
  9. ↑ Anderson DJ (2000). “Carcinoid tumor in Meckel’s diverticulum: laparoscopic treatment and review of the literature”. J Am Osteopath Assoc. 100 (7): 432–4. PMID 10943090.
  10. ↑ Alemayehu H, Hall M, Desai AA, St Peter SD, Snyder CL (2014). “Demographic disparities of children presenting with symptomatic Meckel’s diverticulum in children’s hospitals”. Pediatr. Surg. Int. 30 (6): 649–53. doi:10.1007/s00383-014-3513-y. PMID 24811048.
  11. ↑ Ueberrueck T, Meyer L, Koch A, Hinkel M, Kube R, Gastinger I (2005). “The significance of Meckel’s diverticulum in appendicitis–a retrospective analysis of 233 cases”. World J Surg. 29 (4): 455–8. doi:10.1007/s00268-004-7615-x. PMID 15776296.

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Risk Factors

Risk Factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Common risk factors in the development of Meckel’s diverticulum include histologic and anatomic features such as length of diverticulum >2cm, presence of ectopic tissue, broad based diverticulum, and attachment of fibrous bands to the diverticulum. Patient age of less than 50 years and the male gender are more susceptible to the development of Meckel’s diverticulum.

Common Risk Factors

  • Common risk factors in the development of Meckel’s diverticulum include:[1][2][3][4]
    • Age <50 years
    • Male sex
  • Some histologic and anatomic features present in predisposed individuals include:

Less Common Risk Factors

References

  1. ↑ Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR (2005). “Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002)”. Ann. Surg. 241 (3): 529–33. PMC 1356994. PMID 15729078.
  2. ↑ Lohsiriwat V, Sirivech T, Laohapensang M, Pongpaibul A (2014). “Comparative study on the characteristics of Meckel’s diverticulum removal from asymptomatic and symptomatic patients: 18-year experience from Thailand’s largest university hospital”. J Med Assoc Thai. 97 (5): 506–12. PMID 25065089.
  3. ↑ Robijn J, Sebrechts E, Miserez M (2006). “Management of incidentally found Meckel’s diverticulum a new approach: resection based on a Risk Score”. Acta Chir. Belg. 106 (4): 467–70. PMID 17017710.
  4. ↑ Varcoe RL, Wong SW, Taylor CF, Newstead GL (2004). “Diverticulectomy is inadequate treatment for short Meckel’s diverticulum with heterotopic mucosa”. ANZ J Surg. 74 (10): 869–72. doi:10.1111/j.1445-1433.2004.03191.x. PMID 15456435.
  5. ↑ “Meckel’s Diverticulum”.
  6. ↑ “Meckel’s Diverticulum”.

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Screening

Screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

There is insufficient evidence to recommend routine screening for Meckel’s diverticulum.

Screening

  • There is insufficient evidence to recommend routine screening for Meckel’s diverticulum.

References

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Natural History, Complications and Prognosis

Natural History, Complications and Prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Meckel’s diverticulum is mostly seen in male children (mostly <2 years of age). One fourth of untreated cases of Meckel’s diverticulum may develop complications such as intestinal obstruction, hemorrhage, diverticulitis, bowel ischemia, and necrosis. Hemorrhage is the most common complication in patients with Meckel’s diverticulum. Bleeding in patients may be minimal, recurrent or massive and shock-producing. The rate of bleeding is assessed based on quantity of blood lost in the stools, appearance of the material passing through the rectum and hemodynamic state of the patient. Depending on the extent of the symptom progression at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as excellent in cases where symptomatic Meckel’s diverticulum is treated in a timely manner. Complete recovery may be expected with surgery in majority of the cases.

Natural History, Complications, and Prognosis

Natural History

Complications

Hemorrhage

  • Most common complication in patients with Meckel diverticulum
  • Accounts for one fourth of all complications
  • More commonly seen in:
    • Children younger than 2 years
    • Male sex

Intestinal obstruction

Perforation

Neoplasm

Umbilical anomalies

Diverticulitis

Meckel’s diverticulitis
Source: Wikimedia commons [32]

Other complications

Prognosis

Prognosis of patients with Meckel’s diverticulum is as follows: [38]

References

  1. ↑ “Meckel’s Diverticulum | Cleveland Clinic”.
  2. ↑ 2.0 2.1 Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, Mew D (2006). “Complications of Meckel’s diverticula in adults”. Can J Surg. 49 (5): 353–7. PMC 3207587. PMID 17152574.
  3. ↑ 3.0 3.1 Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ (1994). “Surgical management of Meckel’s diverticulum. An epidemiologic, population-based study”. Ann. Surg. 220 (4): 564–8, discussion 568–9. PMC 1234434. PMID 7944666.
  4. ↑ Hong J, Park SB (2017). “A case of retroperitoneal abscess: A rare complication of Meckel’s diverticulum”. Int J Surg Case Rep. 41: 150–153. doi:10.1016/j.ijscr.2017.10.012. PMID 29078157.
  5. ↑ Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A (2017). “Meckel’s diverticulum in the adult”. J Visc Surg. 154 (4): 253–259. doi:10.1016/j.jviscsurg.2017.06.006. PMID 28698005.
  6. ↑ Cotter TG, Buckley NS, Loftus CG (2017). “Approach to the Patient With Hematochezia”. Mayo Clin. Proc. 92 (5): 797–804. doi:10.1016/j.mayocp.2016.12.021. PMID 28473039.
  7. ↑ Rosat A, Pérez E, Oaknin HH, Mendiz J, Hernández G, Barrera M (2016). “Spontaneous hemoperitoneum caused by meckel’s diverticulum in an elder patient”. Pan Afr Med J. 24: 314. doi:10.11604/pamj.2016.24.314.10384. PMC 5267917. PMID 28154669.
  8. ↑ Rattan KN, Singh J, Dalal P, Rattan A (2016). “Meckel’s diverticulum in children: Our 12-year experience”. Afr J Paediatr Surg. 13 (4): 170–174. doi:10.4103/0189-6725.194671. PMC 5154221. PMID 28051045.
  9. ↑ Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC (2017). “The many faces of Meckel’s diverticulum and its complications”. J Med Imaging Radiat Oncol. 61 (2): 225–231. doi:10.1111/1754-9485.12505. PMID 27492813.
  10. ↑ Chabowski M, Szymanska-Chabowska A, Dorobisz T, Janczak D, Jelen M, Janczak D (2016). “A massive bleeding from a gastrointestinal stromal tumor of a Meckel’s diverticulum”. Srp Arh Celok Lek. 144 (3–4): 219–21. PMID 27483571.
  11. ↑ Srisajjakul S, Prapaisilp P, Bangchokdee S (2016). “Many faces of Meckel’s diverticulum and its complications”. Jpn J Radiol. 34 (5): 313–20. doi:10.1007/s11604-016-0530-x. PMID 26932405.
  12. ↑ Alfa-Wali M, Wardle S, Nizar S, Bloom IT (2016). “Atypical presentation of a Meckel’s diverticulum”. BMJ Case Rep. 2016. doi:10.1136/bcr-2016-214464. PMID 26884080.
  13. ↑ 13.0 13.1 Komlatsè AN, Komla G, Komla A, Azanledji BM, Abossisso SK, Hubert T (2009). “Meckel’s diverticulum strangulated in an umbilical hernia”. Afr J Paediatr Surg. 6 (2): 118–9. doi:10.4103/0189-6725.54779. PMID 19661646.
  14. ↑ Pattni V, Wright K, Marden P, Terlevich A (2016). “Meckel’s diverticulum in an adult: an obscure presentation of gastrointestinal bleeding”. BMJ Case Rep. 2016. doi:10.1136/bcr-2015-213852. PMID 27126093.
  15. ↑ Anwar MO, Ahmed HI, Al Hindi S, Al Omran Y (2014). “Meckel’s diverticulum with intussusception in a 5-year-old patient with Down’s syndrome”. BMJ Case Rep. 2014. doi:10.1136/bcr-2014-207431. PMC 4281549. PMID 25540213.
  16. ↑ Holcomb CN, Hawn MT (2014). “Occult gastrointestinal bleeding”. JAMA Surg. 149 (12): 1335–6. doi:10.1001/jamasurg.2014.109. PMID 25337720.
  17. ↑ Basani L, Aepala R, Reddy BM (2016). “Congenital diaphragmatic hernia, Meckel’s diverticulum and malrotation in a 3-month-old infant”. Afr J Paediatr Surg. 13 (1): 47–9. doi:10.4103/0189-6725.181708. PMC 4955462. PMID 27251525.
  18. ↑ Kunitsu T, Koshida S, Tanaka K, Nakahara S, Yanagi T, Maruo Y, Takeuchi Y, Kubota Y (2015). “Neonatal Meckel diverticulum: Obstruction due to a short mesodiverticular band”. Pediatr Int. 57 (5): 1007–9. doi:10.1111/ped.12694. PMID 26310428.
  19. ↑ Bălălău C, Bacalbaşa N, Motofei I, Popa F, Voiculescu S, Scăunaşu RV (2015). “Meckel’s diverticulum–a rare cause of intestinal obstruction in adults”. Rev Med Chir Soc Med Nat Iasi. 119 (1): 162–5. PMID 25970960.
  20. ↑ Kim KH, Kang KA, Lim JH, Lee KG, Kwon TJ (2016). “Inverted Meckel diverticulum as a lead point of small bowel intussusception: misinterpreting case as a lipoma”. Clin Imaging. 40 (5): 840–2. doi:10.1016/j.clinimag.2016.03.009. PMID 27179156.
  21. ↑ Luu AM, Meurer K, Herzog T, Uhl W, Tannapfel A, Braumann C (2016). “Small Bowel Obstruction due to a Giant Meckel’s Diverticulum”. Visc Med. 32 (6): 434–436. doi:10.1159/000450589. PMC 5290431. PMID 28229080.
  22. ↑ Fiegel H, Gfroerer S, Rolle U (2016). “Systematic review shows that pathological lead points are important and frequent in intussusception and are not limited to infants”. Acta Paediatr. 105 (11): 1275–1279. doi:10.1111/apa.13567. PMID 27588829.
  23. ↑ Clasen K, Kalinski T, Meissner C, Bruns CJ, Meyer F (2016). “[77-year-old man with rare Littré’s hernia]”. Dtsch. Med. Wochenschr. (in German). 141 (15): 1099–101. doi:10.1055/s-0041-109109. PMID 27464282.
  24. ↑ Qin D, Liu G, Wang Z (2014). “Littre’s hernia in a paediatric patient”. Afr J Paediatr Surg. 11 (4): 351–3. doi:10.4103/0189-6725.143168. PMID 25323188.
  25. ↑ Ahmed Z, Chhabra S, Kankaria J, Jenaw RK (2016). “Meckel’s diverticular perforation presenting as acute abdomen in the second trimester of pregnancy”. BMJ Case Rep. 2016. doi:10.1136/bcr-2016-216643. PMID 27507693.
  26. ↑ Farah RH, Avala P, Khaiz D, Bensardi F, Elhattabi K, Lefriyekh R, Berrada S, Fadil A, Zerouali NO (2015). “Spontaneous perforation of Meckel’s diverticulum: a case report and review of literature”. Pan Afr Med J. 20: 319. doi:10.11604/pamj.2015.20.319.5980. PMC 4491457. PMID 26175810.
  27. ↑ Karadeniz Cakmak G, Emre AU, Tascilar O, Bektaş S, Uçan BH, Irkorucu O, Karakaya K, Ustundag Y, Comert M (2007). “Lipoma within inverted Meckel’s diverticulum as a cause of recurrent partial intestinal obstruction and hemorrhage: a case report and review of literature”. World J. Gastroenterol. 13 (7): 1141–3. PMC 4146883. PMID 17373755.
  28. ↑ Thirunavukarasu P, Sathaiah M, Sukumar S, Bartels CJ, Zeh H, Lee KK, Bartlett DL (2011). “Meckel’s diverticulum–a high-risk region for malignancy in the ileum. Insights from a population-based epidemiological study and implications in surgical management”. Ann. Surg. 253 (2): 223–30. doi:10.1097/SLA.0b013e3181ef488d. PMC 4129548. PMID 21135700.
  29. ↑ Zhou B, Lai H, Lin Y, Mo X (2016). “Omphalomesenteric duct remnant adenocarcinoma in adults: a case study”. Springerplus. 5 (1): 2027. doi:10.1186/s40064-016-3713-0. PMC 5126029. PMID 27995004.
  30. ↑ Metwally IH, Elalfy AF, Awny S, Megahed N (2016). “Meckel’s diverticulum complicated with gastro-intestinal stromal tumor: Case report”. J Egypt Natl Canc Inst. 28 (2): 123–7. doi:10.1016/j.jnci.2016.02.002. PMID 26936384.
  31. ↑ Yıldız İ, Koca YS, Barut İ (2016). “An unusual case of intraabdominal abscess and acute abdomen caused by axial torsion of a Meckel’s diverticulum”. Ann Med Surg (Lond). 6: 74–6. doi:10.1016/j.amsu.2016.01.082. PMC 4761698. PMID 26955478.
  32. ↑ “File:Meckel’s Diverticulum AFIP.jpg – Wikimedia Commons”.
  33. ↑ Marwah S, Singla P, Marwah N, Gupta S, Singh VP (2016). “Ileal stricture following Meckel’s diverticulitis: a rare cause of intestinal obstruction”. Clin J Gastroenterol. 9 (3): 118–23. doi:10.1007/s12328-016-0647-6. PMID 27146826.
  34. ↑ Hamilton CM, Arnason T (2015). “Ileitis associated with Meckel’s diverticulum”. Histopathology. 67 (6): 783–91. doi:10.1111/his.12717. PMID 25892011.
  35. ↑ Gasparella M, Marzaro M, Ferro M, Benetton C, Ghirardo V, Zanatta C, Zoppellaro F (2016). “Meckel’s diverticulum and bowel obstruction due to phytobezoar: a case report”. Pediatr Med Chir. 38 (2): 117. doi:10.4081/pmc.2016.117. PMID 27345602.
  36. ↑ Lo T, Sagar J, Trickett J (2015). “A rare presentation of complication arising from Meckel’s diverticulum in the form of diverticulotransverse colonic fistula in an adult”. BMJ Case Rep. 2015. doi:10.1136/bcr-2013-203330. PMC 4460404. PMID 26040824.
  37. ↑ Wu SY, Ho MH, Hsu SD (2014). “Meckel’s diverticulum incarcerated in a transmesocolic internal hernia”. World J. Gastroenterol. 20 (37): 13615–9. doi:10.3748/wjg.v20.i37.13615. PMC 4188914. PMID 25309093.
  38. ↑ “Meckel diverticulum Prognosis – Epocrates Online”.
  39. ↑ Yagnik VD, Yagnik BD (2010). “Asymptomatic Meckel’s diverticulum in adults: is diverticulectomy indicated?”. Saudi J Gastroenterol. 16 (4): 306. doi:10.4103/1319-3767.70626. PMC 2995107. PMID 20871204.
  40. ↑ Zani A, Eaton S, Rees CM, Pierro A (2008). “Incidentally detected Meckel diverticulum: to resect or not to resect?”. Ann. Surg. 247 (2): 276–81. doi:10.1097/SLA.0b013e31815aaaf8. PMID 18216533.

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