meckels diverticulum

2. Contents
• Intro
• Embryology
• Epidemiology
• Clinical presentation
• Differential diagnosis
• Diagnosis
• Treatment
• References

3. Introduction
• Meckel's diverticulum is the most common congenital
anomaly of the gastrointestinal tract.
• It results from incomplete obliteration of the vitelline duct
leading to the formation of a true diverticulum of the small
intestine

5. Embryology
• It arises from the antimesenteric
surface of the middle-to-distal
ileum.
• The diverticulum represents a
persistent remnant of the
omphalomesenteric duct, which
connects the midgut to the yolk
sac in the fetus.
• The omphalomesenteric duct
normally involutes between the
fifth and sixth weeks of human
gestation as the bowel settles
into its permanent position
within the abdominal cavity.
• The persistence of the
omphalomesenteric duct beyond
fetal development may result in a
variety of anatomic patterns
• The rich blood supply to the
diverticulum is provided by the
vitelline artery, which is a branch
of the superior mesenteric artery

7. Epidemiology
• United States data
• The prevalence of Meckel diverticulum is usually
noted to be approximately 2% of the population
• International data
• Europe and Asia have reported prevalence figures
similar to those found in the United States.
• In a large series of cases from 2007 to 2008, Meckel
diverticulectomy was 2.3 times more common in
boys, and boys accounted for 74% of the primary
cases.

8. Clinical Presentation
• The three most common symptomatic
presentations are
– gastrointestinal (GI) bleeding,
– intestinal obstruction, and
– acute inflammation of the diverticulum +
intussusception.

9. Bleeding
• When a severe bleeding episode occurs, the
patient can present in hemorrhagic shock.
Tachycardia is an early clinical sign of
hemorrhagic shock, but pale conjunctivae
and orthostatic hypotension may actually
precede this.

10. Obstruction
• Most patients with intestinal obstruction
present with abdominal pain, bilious vomiting,
generalized abdominal tenderness, distention,
hypoactive or hyperactive bowel sounds,
peritoneal signs, and rebound tenderness upon
examination. Patients may develop a palpable
abdominal mass. Occasionally, when patients do
not present early or if the diagnosis is missed,
the obstruction can progress to intestinal
ischemia or infarction; the latter manifests with
acute peritoneal signs and lower GI bleeding.

11. Inflammation
• Patients with diverticulitis present with either
focal or diffuse abdominal tenderness. Usually,
abdominal tenderness is more marked in the
periumbilical region than that from the pain of
appendicitis. Children may present with
abdominal guarding and rebound tenderness, in
addition to abdominal tenderness. Abdominal
distention and hypoactive bowel sounds are late
findings. Suppurative Meckel diverticulum can
present in a child with abdominal pain and
periumbilical cellulitis.

12. Ddx
Colitis
Colonic Vascular Malformations
Emergent Treatment of Gastroenteritis
Gastrointestinal Duplications
IgA Vasculitis (Henoch-Schonlein Purpura)
Intestinal Polyposis Syndromes
Intussusception
Juvenile Polyps
Necrotizing Enterocolitis Imaging
Pediatric Appendicitis
Pediatric Constipation
Pediatric Crohn Disease
Pediatric Hirschsprung Disease
Pediatric Urolithiasis
Peptic Ulcer Disease
Peutz-Jeghers Syndrome
Postoperative Adhesions
Ulcerative Colitis in Children
Volvulus

13. Diagnosis
Key diagnostic factors
• age <2 years
• passage of bright red blood per rectum (haematochezia)
• intractable constipation (obstipation)
Other diagnostic factors
• male sex
• nausea and vomiting
• abdominal cramps
• lower abdominal pain
• Rectal bleeding (painless)
• Bloody, mucus-y stools
• Co-morbid with intussusception

14. 1st investigations to order
• FBC
• technetium-99m pertechnetate scan ('Meckel's scan')- A radio-nucleotide
scan called a Meckel’s scan is the most effective diagnostic test, it
looks for the presence of ectopic gastric mucosa and enlarged bowel
using a gamma camera for the best picture
• CT scan of the abdomen and pelvis
• ultrasound of the abdomen
Investigations to consider
• contrast enema
• mesenteric angiography
• endoscopic exploration of the small intestine
• surgical exploration of the abdomen

16. Treatment
• Meckel diverticulectomy
If you have open surgery:
• Your surgeon will make a large surgical cut in your belly to open up the area.
• Your surgeon will look at the small intestine in the area where the pouch or
diverticulum is located.
• Your surgeon will remove the diverticulum from the wall of your intestine.
• Sometimes, the surgeon may need to remove a small part of your intestine along with
the diverticulum. If this is done, the open ends of your intestine will be sewn or
stapled back together. This procedure is called an anastomosis.
In surgery using a laparoscope:
• Three to five small cuts are made in your belly. The camera and other small tools will
be inserted through these cuts.
• Your surgeon may also make a cut that is 2 to 3 inches (5 to 7.6 cm) long to put a
hand through, if needed.
• Your belly will be filled with gas to allow the surgeon to see the area and perform the
surgery with more room to work.
• The diverticulum is operated on as described above

18. Indications for surgery
• Painless bleeding
• Because initial bleeding from a Meckel diverticulum can be massive, it is essential that the patient be
adequately resuscitated. This may require the transfusion of packed red blood cells (RBCs) to return
the hematocrit level to approximately 30%. Two large-bore intravenous (IV) lines must be in place in
case bleeding recurs, and crossmatched blood should be available.
• Bowel obstruction
• Patients present with bowel obstruction due to volvulus, intussusception, a mesodiverticular band, or
incarceration of the Meckel diverticulum in a hernia (though the presence of a Meckel diverticulum in
a hernia does not actually increase the risk of incarceration).
• Meckel diverticulitis
• The presentation of Meckel diverticulitis may be indistinguishable from that of appendicitis. As with
appendicitis, the course is progressive and may result in perforation, diffuse peritoneal
contamination, and septic shock. Exploration is usually performed for suspected appendicitis; an
inflamed Meckel diverticulum must be sought if a normal-appearing appendix is discovered.
• Umbilical drainage
• Drainage of succus entericus or feculent material indicates a persistent connection between the
intestine and the umbilicus. Ultrasonography (US) or contrast studies may be used to confirm the
diagnosis. An exploration can then be performed to resect the fistula.

19. Contraindications for surgery
• Because many of the operations for
omphalomesenteric remnants are used in emergency
situations, surgery has relatively few
contraindications.
• However, patients must be adequately prepared for
surgery, even given short notice.
• In patients who are bleeding, the blood volume must
be returned to acceptable levels, and adequate IV
access must be obtained.
• In patients with bowel obstruction and repeated
emesis, electrolyte abnormalities must be corrected
while hydration is restored.

20. WHAT DO YOU DO BEFORE
SURGERY?
Provide blood transfusions to
correct hypovolemia.
Administer IV fluid and
electrolyte replacement
Provide oxygen as prescribed.
Administer IV antibiotics.
NPO after midnight.
Maintain bed rest.
Closely monitor blood loss in
stools.
HOW ABOUT AFTER SURGERY?
Assess respiratory status and maintain
airway.
Provide supplemental oxygen as
prescribed.
Obtain vital signs.
Administer analgesics for pain as
prescribed.
Assess surgical site for bleeding or any
other abnormalities.
Assess bowel sounds and bowel function.
Administer IV fluids and antibiotics as
prescribed.
Maintain NPO status.
Maintain NG tube to low
continuous suction.

22. References
• https://www.uptodate.com/contents/meckels-
diverticulum
• https://emedicine.medscape.com/article/931229-
overview?icd=login_success_email_match_norm
• https://bestpractice.bmj.com/topics/en-gb/804
• https://www.studocu.com/en-us/document/regis-
college/maternal-newborn/meckels-
diverticulum-fact-sheet/20409336