Meckel's diverticulum

Question 1

Define

Answer 1

One of the commonest congenital malformations of the small bowel

No.1 cause of painless massive GI bleeding in children between 1-2 years

Question 2

Causes

Answer 2

2% of people have an ileal remnant of the vitello-intestinal duct (also known as omphalomesenteric duct)- a long narrow tube that joins the yolk sac to the midgut lumen of the developing foetus

• It contains either gastric mucosa or pancreatic tissue
• i.e. can form gastric ulcers caused by acidity that bleed
• The acid produced within the pouch can be released/ spilled causing ulcers or peritonitis

Rule of 2’s
* (1 to) 2-years-old
* 2% population
* 2x more common in boys
* 2 feet from ileocecal valve
* 2 inches long
* 2 different mucosae (gastric and pancreatic)

Question 3

Presentation

Answer 3

Most are ASYMPTOMATIC

Some may present with severe rectal bleeding (classically neither bright red or true melaena)
* May cause haemodynamic instability

Sometimes, patients may have intractable constipation

Other presentations of Meckel’s diverticulum:
* Intussusception
* Volvulus
* Meckel’s diverticulitis (mimics appendicitis)

Bowel obstruction- abdominal cramps, lower abdominal pain, diffuse abdominal tenderness

Nausea and vomiting (may be bilious)

DDx
1. Appendicitis - unlikely to have rectal bleeding, pt will be febrile & N+V
2. Intusception - peak age around 9m, will have colic pain and inconsolable crying
3. Anal fissure
4. Polyp
5. Clotting disorder
6. Peutz-Jeghers syndrome is a rare autosomal dominant disorder that is characterised by hamartomatous polyposis. Gastrointestinal symptoms first start becoming apparent at around 10 years of age. 

Question 4

Investigations

Answer 4

Abdominal examination

Basic observations

Bloods- FBC (will often have an acute reduction in haemoglobin)

USS or X-ray (if obstructed)

Stool sample

A Technetium scan (Meckel’s Scan) will demonstrate increased uptake by ectopic gastric mucosa in 70% of cases

• Used if the child is haemodynamically stable with less severe or intermittent bleeding 

Question 5

Management

Answer 5

Asymptomatic

• Incidental imaging finding- NO treatment required
• Detected during surgery for other reasons- prophylactic excision

Symptomatic

• Bleeding- excision of diverticulum with blood transfusion (if haemodynamically unstable)
• Obstruction- excision of diverticulum and lysis of adhesions
• Perforation/ peritonitis- excision of diverticulum or small bowel segmental resection with perioperative antibiotics
• Surgery usually performed laparoscopically

Question 6

Complications

Answer 6

Complications

• Haemorrhage
• Intestinal obstruction
• Umbilico-ileal fistulas
• Perforation

Prognosis

• Excellent if treated in a timely fashion
• Most common complication is post-operative bowel obstruction (due to adhesions)

SIDE NOTE: If it is joined to the abdo wall then it is known as a VI fitsula, otherwise unjoined is known as the meckel’s diverticulum