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Meckel diverticulum, the commonest congenital abnormality of the gastrointestinal tract, may be difficult to diagnose. Appearances on CT are often non-specific unless there is connection to the umbilicus or a complication has occurred. We report a case of an inflamed Meckel diverticulum seen on CT.
Meckel's diverticulum is a persistent embryonic remnant occurring in 2% of the general population. As an "ileal appendix", it is usually clinically silent and only discovered at the time of complications: inflammation, hemorrhage, obstruction, tumor. The preoperative diagnosis is rarely made because of the non specific nature of the symptomatology and only about 10% of complicated cases are diagnosed at imaging. Complications from Meckel's diverticulum should always be considered in patients presenting with an acute abdomen, especially in young adults.
AIM: Meckel s diverticulum is the most common congenital abnormality of the small bowel. It may be silent or symptomatic when complicated by hemorrage, intestinal occlusion, diverticulitis and umbilical fistulas. Radiologic diagnosis is often difficult because abdominal plain radiography and ultrasound are not sufficiently specific; CT is most accurate in differential diagnosis. MATERIAL AND METHODS. 11 patients (age 5-69 ys) were studied. Clinical symptoms included acute abdomen (4 pts), intestinal occlusion (3 pts), abdominal pain (4 pts), fever (5 pts). Radiological studies were abdominal plain radiography (8 pts), ultrasound (5 pts), CT (9 pts). RESULTS: Abdominal plain radiography depicted signs of intestinal occlusion (4 pts) and perforation (1 pts); in 4 pts the signs were non diagnostic. Ultrasound showed an abscess in the pelvis (2 pts), dilatation and wall-thickening of an intestinal loop (2 pts), intestinal invagination (1 pts); it was not diagnostic in 3 pts. CT was not diagnostic in 3 pts; in 2 pts it showed an abscessual fluid collection in the pelvis, adherent to intestinal loops, with flogosis of the perivisceral fat; in 1 pt it revealed perforation; in 4 cases it was specific showing inversion of the diverticulum in an intestinal loop (2 pts) or a tubular fluid-filled structure, with thickened walls and contrast enhancement, which was interpreted as a inflammatory diverticulum (2 pts). DISCUSSION: Our series confirms the difficulty of diagnosing Meckel s diverticulum in an acute setting. Abdominal plain radiography only allowed to diagnose intestinal occlusion or perforation. Ultrasound revealed abscessual collections in the pelvis, fluid distention of the diverticulum, segmental thickening of the intestinal walls and invagination. CT proved to be more specific showing signs suggestive of correct diagnosis in 6 pts. In particular, evidence of an intraluminal prolonged mass with central area of fat density and peripherral collar was considered suggestive of intraluminal invagination of Meckel s diverticulum. Another diagnostic sign is the evidence of a tubular fluid-filled structure, with thickened, enhanced walls. In 2 cases CT showed an abscessual collection with gas-fluid level (complication of perforation) confirming the need for surgery. CONCLUSION: Meckel s diverticulum is a not uncommon condition that in some cases is complicated, resulting in acute abdomen. Preoperative radiological diagnosis can be suspected in the presence of suggestive signs, more often depicted by CT.
Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract, occurring in 2%-3% of the population. It results from improper closure and absorption of the omphalomesenteric duct. Meckel diverticulum is the most common end result of the spectrum of omphalomesenteric duct anomalies, which also include umbilicoileal fistula, umbilical sinus, umbilical cyst, and a fibrous cord connecting the ileum to the umbilicus. The formation of Meckel diverticulum occurs with equal frequency in both sexes, but symptoms from complications are more common in male patients. Sixty percent of patients come to medical attention before 10 years of age, with the remainder of cases manifesting in adolescence and adulthood. Heterotopic gastric and pancreatic mucosa are frequently found histologically within the diverticula of symptomatic patients. The most common complications are hemorrhage from peptic ulceration, small intestinal obstruction, and diverticulitis. Although the clinical, pathologic, and radiologic features of the complications of Meckel diverticulum are well known, the diagnosis of Meckel diverticulum is difficult to establish preoperatively.
Neoplasia is an unusual complication of Meckel diverticulum. Most tumors of Meckel diverticulum are neuroendocrine or mesenchymal in origin. Adenocarcinomas represent a minority of the tumors that arise in Meckel diverticulum and are generally thought to develop from either endogenous small intestinal epithelium or heterotopic gastric epithelium. Despite the presence of ectopic pancreas in a small fraction of Meckel diverticula, convincing evidence of tumors that arise from heterotopic pancreatic exocrine tissue has not been described in this setting. Intraductal papillary mucinous neoplasms are relatively uncommon tumors of pancreatic ductal epithelial cells that line the main pancreatic duct or its major side branches. We present an unusual case of an intraductal papillary mucinous neoplasm that arose in a heterotopic pancreas within a Meckel diverticulum.
Nine cases of Meckel diverticulum presenting with intussusception were reviewed and correlated clinically, radiologically and pathologically. The appearance of intussuscepted Meckel diverticulum by small bowel series is not specific. However, by CT, a central fat density surrounded by a thick collar of soft tissue was noted in one case correlating well with the gross pathologic appearance. The pathologic material in all our cases suggests that this CT appearance is characteristic of an inverted Meckel diverticulum.
Meckel diverticulum and residual urachus have a common embryological origin: the yolk sac at the eight day of life. Their course is independent but the underlying mechanisms are identical. Meckel diverticulum occurs in 2 to 4% of the population. Clinical signs are often absent and complications occur in 4% of the cases (haemorrhage, occlusion, inflammation, and rarely tumoural formation). Residual urachus occurs as a cystic formation, a sinus or a fistulization and may degenerate into adenocarcinoma of severe prognosis. The reported association has not apparently been reported previously in the literature. Due to the risk of cancerization, it is suggested that residual urachus should be searched in cases of Meckel diverticulum.
This paper presents the appearances of inverted Meckel diverticulum with an irreducible intussusception on air enema in four children. The inverted Meckel diverticulum appeared as a bulbous (3) or triangular (1) filling defect in the air column projecting off the distal end of the soft tissue mass of the irreducible intussusceptum. The bulbous defect appears to be highly suggestive, and may be specific, for inverted Meckel diverticulum. Earlier recognition of the presence of the Meckel diverticulum as the lead point of the intussusception could have changed the management in two of the children.
Meckel diverticulum was diagnosed preoperatively as the cause of recurrent rectal bleeding in a 2-year-old child by means of a sodium pertechnetate Tc 99m scan. Although false-negative scans have been reported to occur in approximately 50% of all cases of Meckel diverticulum, the procedure should be considered in any case of unexplained, painless rectal bleeding, especially in pediatric patients.
OBJECTIVE: Through a comprehensive review of the Mayo Clinic experience with patients who had Meckel diverticulum, we sought to determine which diverticula should be removed when discovered incidentally during abdominal surgery. SUMMARY BACKGROUND DATA: Meckel diverticula occur so infrequently that most articles have reported either small series or isolated cases. From these limited series, various conclusions have been reported without clearly indicating which incidental diverticula should be removed. METHODS: Medical records were reviewed of 1476 patients found to have a Meckel diverticulum during surgery from 1950 to 2002. Preoperative diagnosis; age; sex; date of surgery; and intraoperative, macroscopic, and microscopic findings from operative and pathology reports were recorded. Logistic regression analysis was used to determine which clinical or histologic features were associated with symptomatic Meckel diverticulum. The features analyzed were age; sex; length, base width, and ratio of length to base width of the diverticulum; and the presence of ectopic tissue or abnormal tissue (inflammation or enteroliths). RESULTS: Among the 1476 patients, 16% of the Meckel diverticula were symptomatic. The most common clinical presentation in adults was bleeding; in children, obstruction. Among patients with a symptomatic Meckel diverticulum, the male-female ratio was approximately 3:1. Clinical or histologic features most commonly associated with symptomatic Meckel diverticula were patient age younger than 50 years (odds ratio [OR], 3.5; 95% confidence interval [CI], 2.6-4.8; P < 0.001), male sex (OR, 1.8; 95% CI, 1.3-2.4; P < 0.001); diverticulum length greater than 2 cm (OR, 2.2; 95% CI, 1.1-4.4; P = 0.02), and the presence of histologically abnormal tissue (OR, 13.9; 95% CI, 9.9-19.6; P < 0.001). CONCLUSIONS: After analyzing our data, we neither support nor reject the recommendation that all Meckel diverticula found incidentally should be removed, although the procedure today has little risk. If a selective approach is taken, we recommend removing all incidental Meckel diverticula that have any of the 4 features most commonly associated with symptomatic Meckel diverticulum.
OBJECTIVE: To describe color Doppler sonographic findings in 2 cases of inflamed and perforated Meckel diverticulum. METHODS: Two patients with inflamed and perforated Meckel diverticulum underwent color Doppler sonographic studies. RESULTS: Gray scale sonographic examination identified a fixed cystlike structure with a gut signature surrounded by a hyperechoic layer. Color Doppler sonography revealed hyperemia in the diverticular wall and hyperechoic layer, which was more intense in 1 patient. CONCLUSIONS: Identification of a fixed cystlike structure with a gut signature and wall hyperemia suggests the diagnosis of inflamed Meckel diverticulum; when a hyperechoic layer surrounds this structure, perforation of the diverticulum should be suspected.
Although the association of Crohn disease and Meckel diverticulum has been widely reported, the direct involvement of a Meckel diverticulum by Crohn disease is less common and is usually the result of contiguous spread. The presence of heterotopic tissues in an affected diverticulum is rare and most often consists of gastric mucosa. We report herein the presence of Crohn disease within a Meckel diverticulum, with a normal small bowel immediately adjacent to the diverticulum, associated with pancreatic heterotopia.
We report a case of adenomyoma of the small intestine arising in a Meckel diverticulum. The patient was a 22-month-old boy who presented with signs and symptoms of intussusception. At surgery, a Meckel diverticulum was found and removed. On histologic examination, a tumor consisting of dilated cystic glands and smooth muscle bundles was identified. A diagnosis of adenomyoma arising in a Meckel diverticulum was made. A review of the literature showed that only six other pediatric cases of adenomyoma of the small intestine have been reported. The presence of an adenomyoma in a young patient within a Meckel diverticulum favors the view that adenomyomas are a variant of pancreatic heterotopia.
Intestinal obstruction caused by internal hernia due to Meckel diverticulum is a rare disease. The condition is seldom diagnosed preoperatively. In this paper, we present a 10-month-old boy who suffered from abdominal pain, persistent vomiting, and mild fever for 2 days. Abdominal sonography, plain abdomen X-ray, and computed tomography merely showed mechanical ileus and partial malrotation. However, exploratory laparotomy revealed a Meckel diverticulum through which the small bowel had herniated. We introduce the Meckel diverticulum and internal hernia and discuss intestinal obstructions.
PURPOSE: To determine the clinical, radiologic, and pathologic findings of inverted Meckel diverticulum by retrospectively reviewing a large series of cases. MATERIALS AND METHODS: Among 84 cases of Meckel diverticulum, 18 (21%) were found at surgery to be inverted into the lumen of the bowel. Thirteen of these 18 (72%) cases were associated with small bowel intussusception and five (28%) were not. RESULTS: All 18 patients (median age at time of diagnosis, 32 years) were symptomatic, but the symptoms were subacute or chronic in 14 (78%). At barium examination in 15 cases, inverted diverticulum was depicted in 10 (67%) as a solitary, elongated, smoothly marginated, often club-shaped intraluminal mass in the distal ileum. At computed tomography (CT) in three cases, a central area of fat attenuation was surrounded by a thick collar of soft-tissue attenuation. At ultrasound (US) in two cases, a target-like mass contained a central area of increased echogenicity. At pathologic examination in all cases, the inverted sac contained mesenteric fat. CONCLUSION: Inverted Meckel diverticulum occurs more commonly than previously recognized and is associated with characteristic findings at barium examination, CT, and US.
Thirteen patients with surgically confirmed Meckel diverticula encountered in a 30 month period are reported. Of 11 symptomatic patients, all had lower gastrointestinal bleeding, except one who had recurrent abdominal pain only. Two diverticula were incidental, coexisting with Crohn disease of the distal ileum. One of these had occasional diarrhea and hematochezia. The diagnosis was established preoperatively by enteroclysis in 11 of these cases. The enterographic demonstration of the mucosal triangular plateau or the triradiate fold pattern indicating the site of exit of the omphalomesenteric duct should lead to a diagnosis of Meckel diverticulum. Pitfalls in interpretation due to the pseudotriangular plateau appearance formed by superimposition of two intestinal loops and the pseudosaccule produced by the axial projection of a fixed loop of bowel and the differential diagnosis are discussed. Enteroclysis seems to be the most dependable method currently available for preoperative demonstration of Meckel diverticulum.
BACKGROUND: Meckel diverticulum (MD) is traditionally considered a pediatric disease that is associated with intestinal hemorrhage or perforation. Symptomatic MD is rarely a consideration in the geriatric population. OBJECTIVE: To notify clinicians of the clinical variety and diagnostic uncertainty of MD in the elderly, we report 7 cases of complicated MD that presented as common disorders of the gastrointestinal (GI) tract in patients older than 65 years. METHODS: A retrospective record review at 2 university-affiliated hospitals revealed 7 patients older than 65 years with MD and abdominal complaints necessitating laparotomy. The patients represented a subset of 27 adults (age range, 21-89 years; mean age, 39 years) with symptomatic MD who required surgery during a 7-year period. RESULTS: The presenting complaints represented a variety of common GI presentations, including nausea, vomiting, and acute abdominal pain (n = 3); acute abdominal pain with peritonitis (n = 2); crampy abdominal pain lasting several weeks (n = 1); and rectal bleeding (n = 1). Meckel diverticulum was a preoperative consideration in only 2 of 7 cases. The preoperative diagnoses were consistent with common disorders of the GI tract in the elderly, including small-bowel obstruction (n = 2), ischemic colitis (n = 1), unrelenting bleeding in the GI tract (n = 1), perforated viscus (n = 1), diverticulitis (n = 1), and appendicitis (n = 1). In contradistinction to the pediatric age group, only 1 of 7 patients had an MD with ectopic mucosa. CONCLUSIONS: Many different mechanisms can be responsible for complications due to MD in the geriatric population. Misdiagnosis occurs frequently in the elderly because of the poor sensitivity of diagnostic tests, nonspecificity of complaints, and lack of recognition that this anomaly can present in this age group. Clinicians must be cognizant of this common pediatric disease and its varied guises when they are evaluating unexplained acute or intermittent abdominal pain, nausea and vomiting, rectal bleeding, peritonitis, or obstruction in geriatric patients.
OBJECTIVES: Meckel diverticulum, a congenital gastrointestinal anomaly, is well studied in pediatrics, but less so in the adult population. At the Charleston Area Medical Center (CAMC), in addition to the removal of Meckel diverticula in symptomatic patients, diverticula are commonly removed when found incidentally during other procedures. We present our experience over the past ten years with this condition, unusual in the adult population. METHODS: From 1992 to 2002 at the Charleston Area Medical Center, Meckel diverticula were removed from 47 patients older than 18 years of age. We reviewed the age, sex, indication for removal, pathologic findings, and perioperative complications of these cases. RESULTS: Diverticula were removed most often from female patients (31 female, 66%; 16 male, 34%). The removal of the diverticulum was incidental in 35 patients (74.5%) and symptomatic in 12 (25.5% percent). Symptomatic patients presented with: obstruction (n = 4), acute bleeding (n = 1) and diverticulitis (n = 7). Female patients were significantly less likely than male patients to be symptomatic (4 of 31, 13% among females, and 8 of 16, 50% among males; P < 0.05). Heterotopic mucosa was identified in six patients, two of whom were symptomatic at the time of removal. Gastric mucosa was found in all six of the diverticula with ectopic mucosa, although one of the six had a mixed gastric and pancreatic cell population. One asymptomatic patient had a malignancy identified as a 1.5 cm carcinoid with no evidence of metastatic disease. An adenomyoma was found incidentally in one patient upon pathologic evaluation. Hospital complications that could possibly be attributed to removal of diverticula included two wound infections and two anastomotic leaks requiring exploration (8.5% morbidity). Complications were experienced by two asymptomatic females, one asymptomatic male, and a symptomatic male. There were no mortalities. CONCLUSIONS: Meckel diverticulum is found infrequently in the adult population. Adults rarely become symptomatic, but symptoms that do arise are associated with significant morbidity. Complications directly attributable to diverticulum removal are uncommon; however, those that do occur are often life threatening. Therefore, incidental removal of asymptomatic diverticula, particularly in women, is not recommended.