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Basics

[Section Outline]

Author:

Galeta C.Clayton


Description!!navigator!!

Pediatric Considerations
  • Most common cause of significant lower GI bleeding in children
  • Presents at age <5 yr with episodic painless, brisk, and bright-red rectal bleeding

Etiology!!navigator!!

Remnant of the omphalomesenteric duct that typically regresses by week 7 of gestation. The ectopic gastric mucosa can secrete gastric enzymes, leading to erosion of the mucosal wall, resulting in bleeding.

Diagnosis

[Section Outline]

Signs and Symptoms!!navigator!!

Essential Workup!!navigator!!

Diagnostic Tests & Interpretation!!navigator!!

Lab

  • CBC:
    • Decreased hematocrit due to bleeding
    • Rarely a cause of chronic anemia
    • Leukocytosis with diverticulitis, perforation, or gangrene
  • Electrolytes, BUN, creatinine, coagulation studies
  • Type and screen/cross-match when significant GI bleeding

Imaging

  • CT abdomen/pelvis:
  • Abdominal radiographs:
    • Screening for bowel obstruction
    • Cannot diagnose Meckel diverticulum
  • Tc-99m pertechnetate radioisotope scan (Meckel scan):
    • Noninvasive scan that identifies Meckel diverticulum containing heterotopic gastric mucosa
    • Useful in hemodynamically stable patients with high clinical suspicion for Meckel
    • Sensitivity: Approximately 90% in children, 60% in adults
    • Specificity: 95% in children and adults
  • Small bowel enteroclysis:
    • 75% accuracy
    • Barium/methyl cellulose introduced through NG tube into distal duodenum or proximal jejunum
    • Increases the ability to detect Meckel diverticulum in adults
    • Diverticulum may be short and wide-mouthed, making diagnosis difficult
  • Mesenteric arteriography may be useful in cases of brisk bleeding, showing active contrast extravasation
  • CT angiogram for further evaluation of Meckel diverticulum if radioisotope scan and enteroclysis normal
  • Ultrasound may be useful in nonbleeding presentations
  • Capsule endoscopy or double-balloon enteroscopy may be useful for diagnosis
  • Laparoscopic evaluation may provide both diagnosis and definitive treatment

Differential Diagnosis!!navigator!!

Treatment

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Prehospital!!navigator!!

Establish IV access for patients with rectal bleeding or abdominal pain.

Initial Stabilization/Therapy!!navigator!!

ED Treatment/Procedures!!navigator!!

Medication!!navigator!!

Follow-Up

[Section Outline]

Disposition!!navigator!!

Admission Criteria

Presumptive diagnosis of Meckel diverticulum with diverticulitis, obstruction, intussusception, hemorrhage, or volvulus requires admission and surgical evaluation.

Discharge Criteria

None

Follow-up Recommendations!!navigator!!

Postoperative surgical follow-up

Pearls and Pitfalls

  • Painless, brisk, bright-red blood per rectum in an infant is often caused by Meckel diverticulum
  • Presents with a wide range of complications, including obstruction, intussusception, and hemorrhage
  • Often diagnosed in the OR for patients undergoing surgery for a presumptive appendicitis
  • Rule of 2's:
    • 2% of the population
    • 2% risk of complications
    • Mostly <2 yr old
    • 2 in long
    • 2 ft from the ileocecal valve

Additional Reading

See Also (Topic, Algorithm, Electronic Media Element)

Codes

ICD9

751.0Meckel's diverticulum

ICD10

Q43.0 Meckel's diverticulum (displaced) (hypertrophic)

SNOMED