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Meckel's Diverticulum

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Written by Neville Dastur   
Wednesday, 02 September 2009 17:44

Meckel's diverticulum

A Meckel's diverticulum is a true congenital diverticulum in that it consists of al three layers of the intestine. It is a remnant of the primitive yolk sac (the viteline duct) which occurs on the ante-mesenteric border of the ileum.

Meckle's Diverticulum

Historical background

  • 1st described by Littre in a hernial sac in 1700, 81 years before Meckel was born.
  • Diverticulum described by Johann Meckel, Prof. of Anatomy, Germany.

Embryology and Anatomy

  • Remnant of the viteline duct which connects the yolk sac to the digestive tube of an embryo. It appears towards the fourth embryonic week and should obliterate by seven weeks after birth. Persistance results in a Meckle's diverticulum.
  • May be connected by a fibrous band to the umbilicus which is remnant of the vitello-intestinal duct. The bowel can tort around this point leading to obstruction.
  • The Vitello-intestinal duct may persist completely or incompletely which leads to formation of:
  1. Meckel's diverticulum (commonest)
  2. Complete - umbilical fistula.
  3. Incomplete - vitello-intestinal fistula.
  4. Enterocystoma (encysted fluid collection in the band)

Rule of twos

Although not strictly acurate the rule of two provides a useful aide menior. A Meckel's occurs in 2% of the population; 2 feet from the ileo-ceacal valve; is 2 inches in lenght; is symtomatic in 2%; and 2 times as many male are affected than females.

Actually the incidence is equal amongst males and females it is just that males are more commonly symptomatic.

It is important to note that a Meckel's diverticulum has it's own artery and 20% will contain ectopic mucosa. This can be gastric, pancreatic or colonic which is often hyperplastic & extends into the surrounding ileum.

Presentation

  • Acute peptic ulceration - with vomiting, and bleeding P/R with melena. Vomitus does not have blood.
  • Chronic peptic ulcer - Pain onset after meals. Pain is in umbilical region rather than epigastric. Not relieved by local antacids, but relief with H2 blockers or Omeprazole.
  • Meckel's diverticulitis - Leads to oedema, inflammation, gangrene, perforation. Presents exactly like appendicitis, or salpingitis.
  • Intussusception - Apex of the intussusception formed by hyperplastic epithelium of the Meckel's presents as acute intestinal obstruction.
  • Intestinal obstruction - Either as an internal hernia caused by the fibrous band or volvulus with the fibrous band as the axis.
  • "Hernia of Littre" cf Litter's hernia - Meckel's in the hernial sac may present as inflamed hernia, usually on the right
  • May present as carcinoid tumor in the Meckel's diverticulum.

Diagnosis

  • Often completely incidental at laparotomy
  • Technetium scan (99mTc) is performed. 50% have ectopic gastric/pancreatic mucosa and it is this that is highlighted by the scan distant from the stomach.
  • Most sensitive radiological investigation is small enema

Differential Diagnosis

Treatment

  • If Symptomatic then a resection is required as well treating what ever other pathology exists along side the Meckel's (i.e. hernia reapir / release of small bowel obstruction). The base is often broad and so a resection and end to end anastomosis is advocated, otherwise there is a risk of stricture.
  • The treatment of an asymptomatic Meckel's diverticulum is contraversal. Resection involves an anastomosis and so a risk of leak and other complications. There are those that advocate resection in young (under 40) or those with a thickened wall.
  • An interesting 2008 Annals of Surgery Paper reviewed a total of 244 papers. They concluded that there was a significantly higher post-op complication rate of Meckel's resection vs those left in-situ and that the long term outcome for patients find to have a Meckel's was of no complications. A NNT analysis revealed that 758 resections would need to be performed to prevent one death from Meckel's diverticulum.
  • The important thing to remember is that if you are going to leave an asymtomatic Meckel's in-situ make it clear and in bold in the operative note and ensure you inform the patient plus their GP on discharge.

 

 

Comments  

 
+1 # hossam shoaib 2009-11-10 19:30
Thank you
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+1 # Guest 2009-11-14 04:07
My father became symptomatic with Meckel's diverticulum in 2004 diagnosed during emergency surgery following an x-ray and scan which showed he had a bowel obstruction. The interesting thing was that he was aged 84 at the time! The section was removed but probably due to his age, the bowel took 10 days to restart following surgery. Coincidentally he had further bowel surgery at age 86, but this time sadly palliatively to prevent an obstruction occurring due to a tumour in the descending colon. He passed away in 2006 six months following the second surgery with terminal cancer. He certainly had an eventful final two years of life - his medical records prior to this were very thin indeed!
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+4 # Guest 2009-12-23 21:10
I HAVE BEEN RACKING MY BRAIN FOR 11 YEARS MY 15 YEARS OLD SON STARTED BLEEDING FROM HIS RECTUM AT THE AGE OF 4 YEARS OLD AND FOR YEARS HIS DOCTOR, SPECIALIST, ETC COULD NOT FIND OUT WHY TODAY 12-23-09 HE WAS DIAGNOSIS WITH MECKEL'S DIVERTICULUM HE IS SCHEDULED FOR SURGERY AND I PRAY THINGS GET ON TRACK
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+2 # Administrator 2009-12-23 21:41
Patrica, I am glad a cause was found. I have to say I haven't heard of this presentation before. It is incredible how strange medicine can be.
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0 # Judy 2010-05-03 02:36
In 2006, I was thought to have a ruptured appendix but during surgery they found a Mckel diverticula and bowel obstruction. It is my understanding this disorder is usually found in men so I have not been able to find any long term affects following removal in women. I had 4 1/2 inches of my small intestine removed- should I worry about more surgeries in the future?
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0 # Fran Eden 2010-03-31 20:40
I am looking for advice - My son is 2 years of age had 4 episodes of rectal bleeding over last 2 months (2 severe and 2 were less) the blood is dark red and contains ‘shreds’.
He does not appear to be in any pain and as this followed a prolonged viral infection, the GP originally put it down to a possibly inflamed bowel due to antibiotics.
His history includes Downs Syndrome, Complex AVSD - closed at 4 months, Hypothyroidism -thyroxine for 1 year and an Ectopic - lingual thyroid - untreated.
He was referred after the second episode of bleeding for a meckel scan and as a precaution was placed on a completely dairy free diet (after which the 2 lesser bleeds occurred)
The meckel scan was clear, however, this took place 10 days after the last rectal bleed which I was informed can affect the result?????
Obviously I am reluctant for him to undergo any unnecessary surgical procedure but at the same time concerned about the effects of prolonged blood loss…..??????
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0 # Jarryd C. 2010-06-30 05:22
I had Meckel's Diverticulum but it turned in to a giant cyst and connected itself to different parts of my bowel. The surgeon had to cut a lengthy piece of my bowel out. Funny thing was it wasn't in the usual spot, it was 5 feet up from the ileo-ceacal valve so I'm in quite a small percentile :P. I'm starting to get melena again 6 months after the operation so I'm going to have to get it checked out again. Hopefully nothing has gone wrong with the resection! *worried*
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