Meckel’s diverticulum

Question 1

A 15-month-old child is brought into the emergency department after feeling generally unwell and being off food. The child’s mother informs you that he has also been bleeding from his back passage. There are no reports of nausea or vomiting. On examination, you note that the patient is tender in the right lower quadrant and appears in evident distress. There were no masses felt in the abdomen on palpation. His heart rate is 170 beats per minute, respiratory rate is 32 breaths per minute, blood pressure is 68/37 mmHg and temperature is 36.2 ºC. His medical records show no known medical conditions and regular medications.

What is the most likely diagnosis?

• Appendicitis
• Caecal volvulus
• Intussuscception
• Meckel’s diverticulum
• Peutz-Jeghers polyposis

Answer 1

Meckel’s diverticulum - most common cause of painless GI bleeding requiring transfusion in 1-2 year olds. Patients are haemodynamically unstable, can be asymptomatic.

Not intussusception as this occurs in 3-12 month olds and usually causes colic type pains with inconsolable crying.

Not Peutz-Jeghers as this is autosomal dominant and causes hamartomatous polyps which cause symptoms around 10 years of age.

Not caecal volvulus - causes sudden abdominal pain with abdominal distension and no flatur or stool passage.

Question 2

What is the pathophysiology of Meckel’s diverticulum?

Answer 2

A congenital diverticulum of the small intestine.

Results from the failure of the vitelline/omphalomesenteric duct to the yolk sac to obliterate during the 5th week of fetal development.

Can contain ectopic ileal, gastric or pancreatic mucosa

Question 3

What is the rule of 2s for meckel’s diverticulum?

Answer 3

• affects 2% of the population
• 2 feet away from the ileocaecal valve
• 2 inches long

Question 4

What is the management of meckel’s diverticulum?

Answer 4

Surgical

• Removed if narrow/symptomatic
• Wedge excision or formal bowel resection and anastomosis

Question 5

Why is there an increased risk of peptic ulceration with the presence of meckel’s diverticulum?

Answer 5

It can consist of ectopic gastric mucosa

Question 6

What is the typical presentation of Meckel’s diverticulum?

Answer 6

Asymptomatic (MOST)

Or

1. asymptomatic rectal bleeding (requiring transfusion),
2. intestinal obstruction (due to the presence of an omphalomesenteric band),
3. abdominal pain mimicking appendicitis.