Author:
Galeta C.Clayton
Description
- Most common congenital abnormality of the GI tract
- True diverticula (contains all layers):
- 50% contain normal ileal mucosa
- 50% contain either gastric (most common), pancreatic, duodenal, colonic, endometrial, or hepatobiliary mucosa
- Rule of 2's:
- 2% prevalence in general population
- 2% lifetime risk for complications, decreasing with age
- Symptoms commonly occur around 2 yr of age:
- 45% of symptomatic patients <2 yr old
- Average length 2 in
- Found within 2 ft of the ileocecal valve
- Male-to-female ratio approximately equal, but more often symptomatic in males
- Complications:
- Obstruction and diverticulitis in adults
- Hemorrhage and obstruction in children
- Mean age 10 yr
- Current mortality rate 0.0001%
- Occur more frequently in males
- Obstruction:
- Diverticulum attached to the umbilicus, abdominal wall, other viscera, or is free and unattached, leading to:
- Intussusception: Diverticulum is the leading edge
- Volvulus: Persistent fibrous band leads to bowel rotation
- Diverticulitis:
- Opening obstructed, leading to bacterial infection
- Presents like appendicitis (most common preoperative diagnosis with Meckel diverticulum)
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
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.
Signs and Symptoms
- 3 different types of presentation:
- Rectal bleeding due to hemorrhage. The ectopic gastric mucosa can secrete gastric enzymes, leading to erosion of the mucosal wall, resulting in bleeding
- Vomiting due to obstruction secondary to volvulus, intussusception, or intraperitoneal band s
- Abdominal pain (appendicitis-like) due to an inflamed or perforated diverticulum
- General:
- Fever
- Malaise
- Weakness
- Fatigue
- GI:
- Classically painless rectal bleeding
- Abdominal pain:
- Location depends on cause
- Appendicitis like
- Vomiting
- Distention
- Changes in bowel movements
- Hematochezia or melena (depending on briskness or location of diverticulum)
- Peritonitis and septic shock (late complications)
- Cardiovascular:
- Tachycardia (due to pain or blood loss)
- Hypotension and shock (due to bleeding)
Essential Workup
- May cause a variety of signs and symptoms:
- <10% diagnosed preoperatively
- Consider in patients with recurrent nonspecific abdominal pain, nausea and vomiting, or rectal bleeding
- History and physical exam narrow diagnosis, but will not give specific findings for Meckel diverticulum
- Rectal exam
- Nasogastric (NG) tube placement to rule out upper GI bleed
- Consider ECG in older patients to rule out cardiac cause of abdominal pain
Diagnostic Tests & Interpretation
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
- Adults:
- Adhesions
- Appendicitis
- Arteriovenous malformation
- Bowel obstruction
- Diverticulitis
- Hemorrhoids
- Inflammatory bowel disease
- Internal hernias
- Intestinal polyps
- Intussusception
- Peptic ulcer disease
- Pseudomembranous colitis
- Volvulus
- Pediatric:
- Adhesions
- Anal fissures
- Appendicitis
- Atresia
- Gastroenteritis
- Hemolytic-uremic syndrome
- Henoch-Schönlein purpura
- Intestinal polyps
- Intussusception
- Malrotation
- Milk allergy
- Strictures
- Volvulus
Prehospital
Establish IV access for patients with rectal bleeding or abdominal pain.
Initial Stabilization/Therapy
- Stabilization followed by early surgical evaluation
- Hypotension:
- Aggressive fluid resuscitation
- Packed RBC (PRBC) transfusion with brisk rectal bleeding (more common in children)
- Pressors for septic shock
ED Treatment/Procedures
- GI bleeding:
- Fluid resuscitate and transfuse PRBC as indicated
- Foley to follow urine output
- NG tube to exclude brisk upper GI bleeding
- Surgical consult for surgical intervention as indicated
- Proton pump inhibitor (PPI)
- Obstruction:
- NG tube
- Foley
- Surgical consult
- Diverticulitis/perforation:
- NPO
- Preoperative antibiotics
- Surgical consult
- Surgical intervention:
- Symptomatic Meckel diverticula should be resected
- Asymptomatic Meckel diverticula discovered incidentally at laparotomy in children should be resected
Medication
Disposition
Admission Criteria
Presumptive diagnosis of Meckel diverticulum with diverticulitis, obstruction, intussusception, hemorrhage, or volvulus requires admission and surgical evaluation.
Follow-up Recommendations
Postoperative surgical follow-up
- FrancisA, KantarovichD, KhoshnamN, et al. Pediatric Meckel's Diverticulum: Report of 208 Cases and Review of the Literature . Fetal Pediatr Pathol. 2016;35(3):199-206.
- García-BlázquezV, Vicente-BártulosA, Olavarria-DelgadoA, et al. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: Systematic review and meta-analysis . Eur Radiol. 2013;23(5):1181-1190.
- KawamotoS, RamanSP, BlackfordA, et al. CT Detection of Symptomatic and Asymptomatic Meckel Diverticulum . AJR Am J Roentgenol. 2015;205(2):281-291.
- SharmaRK, JainVK. Emergency surgery for Meckel diverticulum . World J Emerg Surg. 2008;3:27.
- ThurleyPD, HallidayKE, SomersJM, et al. Radiological features of Meckel's diverticulum and its complications . Clin Radiol. 2009;64(2):109-118.
See Also (Topic, Algorithm, Electronic Media Element)
ICD9
751.0Meckel's diverticulum
ICD10
Q43.0 Meckel's diverticulum (displaced) (hypertrophic)
SNOMED