Meckel's diverticulum differential diagnosis

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
Disease	Abdominal pain	Rectal pain	Weightloss	Fever	Type of GI bleeding	Diarrhea	Constipation	Other features	Laboratory findings	Radio-Imaging findings
Meckel’s diverticulum	–	–	–	–	Frank blood	–	–	Painless bleeding May present with complications such as: Bowel obstruction Intussusception Diverticulitis Perforation	Signs of iron deficiency anemia may be present such as: Decreased Hematocrit Decreased Hemoglobin Positive stool guaiac test	Technetium-99m pertechnetate scanning helps in the detection of a symptomatic bleeding Meckel’s diverticulum. Upper GI series with small-bowel follow-through may help in the detection of a diverticulum. Appearance of Meckel’s diverticulum on upper GI series: Smooth Globular White Location: Arising from the antimesenteric border of the ileum 50cm proximal to the ileocecal valve
Diverticulosis	–	–	–	–	Red or maroon-colored blood	–	+	Self limiting Seen in elderly	Normal	Globular outpouchings on CT scan
Angiodysplasia	–	–	–	–	Frank blood	–	–	Painless bleeding Iron deficiency anemia	Normal	Normal
Hemorrhoids	–	+	–	–	Blood on tissues	–	+	Pain during defecation Anemia	–	Tortuous dilated vessels on anoscopy
Anal fissures	–	+	–	–	Blood on tissues	–	+	Pain during defecation Pain recurs with every bowel movement	Normal except mild leucocytosis	Anoscopy
Mesenteric Ischemia	+	–	+	+	Frank blood	+	–	Pain alters with eating habits Associated with other comorbid conditions	Leukocytosis Increased hematocrit High anion gap metabolic acidosis Lactic acidosis High phosphate levels	Mesenteric edema Bowel dilatation Bowel wall thickening Intramural gas Mesenteric stranding
Ischemic colitis	+	–	–	+	Frank blood	+	–	3 phases Hyperactive phase Paralytic phase (absent bowel sounds) Shock phase	Elevated white blood cell count more than 15,000/mm³ in 20 patients (27%) The serum bicarbonate level was less than 24 mmol/L in 26 patients (36%)	Mild moderate diffuse bowel wall thickening Marked hyperenhancement of the mucosa
Crohn’s disease	+	–	+	+	Blood mixed with stools	+	+	Extra intestinal manifestations Uveitis Sacroiliitis Anemia Peripheral neuropathy	Anemia Leukocytosis Thrombocytosis Anti-Saccharomyces cerevisiae antibodies	Skip lesions Bowel wall thickening Surrounding inflammation, abscess, and fistulae
Ulcerative colitis	+	+	+	+	Blood mixed with stools	+	+	Joint swelling Joint pain Inflammation of the eye Skin involvement Fatty liver Thromboembolism Parenchymal lung disease	Anemia Thrombocytosis A high platelet count	Loss of the vascular appearance of the colon Erythema (or redness of the mucosa) and friability of the mucosa Superficial ulceration, which may be confluent Pseudopolyps
Colon carcinoma	+	-†	+	+	Occult bleeding	+	+†		+ FOBT (fecal occult blood test) ↑ CEA( and CA 19-9 Hypercalcemia	Biopsy

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

	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
Disease	Clinical manifestations													Diagnosis		Comments
	Symptoms									Signs				Diagnosis
Acute diverticulitis	LLQ or RLQ (in case of Meckel’s diverticulitis)	+	±	+	−	+	±	−	+	Positive in perforated diverticulitis	+	+	Hypoactive	Leukocytosis	CT scan Ultrasound	History of constipation History of painless lower GI bleed (in case of Meckel’s diverticulitis)
Inflammatory bowel disease	Diffuse	±	−	−	±	−	+	+	+	−	−	−	Normal or hyperactive	Anti-neutrophil cytoplasmic antibody (P-ANCA) in Ulcerative colitis Anti saccharomyces cerevisiae antibodies (ASCA) in Crohn’s disease	String sign on abdominal x-ray in Crohn’s disease	Extra intestinal findings: Uveitis Arthritis
Infective colitis	Diffuse	+	−	±	−	−	+	−	+	Positive in fulminant colitis	±	±	Hyperactive	Stool culture and studies Shiga toxin in bloody diarrhea PCR	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: Hyperpigmentation Diabetes mellitus Arthralgia Impotence in males Cardiomyopathy Atherosclerosis Hypopituitarism Hypothyroidism Extrahepatic cancer Prone to specific infections
Mesenteric ischemia	Periumbilical	Positive if bowel becomes gangrenous	−	+	−	−	+	+	+	Positive if bowel becomes gangrenous	Positive if bowel becomes gangrenous	−	Hyperactive to absent	Leukocytosis and lactic acidosis Amylase levels D-dimer	CT angiography SMA or SMV thrombosis	Also known as abdominal angina that worsens with eating
Acute ischemic colitis	Diffuse	+	±	+	−	−	+	+	+	+	+	+	Hyperactive then absent	Leukocytosis	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	Fibrinogen D-dimer	Focused Assessment with Sonography in Trauma (FAST)	Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage	Diffuse	±	−	±	−	−	−	−	+	+	−	−	N	↓ Hb ↓ Hct	CT scan	History of trauma

References

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

Template:WS Template:WH

[urlMeckels_Diverticulum_Overview-1] “Meckel’s Diverticulum Overview”. Retrieved 2013-04-01.

[1]

Meckel's diverticulum differential diagnosis

Overview

Differentiating Meckel’s Diverticulum from other Diseases

References

Looking for the patient version?