This document describes a case of a 12-year-old female who presented with abdominal pain and signs of peritonitis. She underwent an exploratory laparotomy which revealed a Meckel's diverticulum with gastric mucosa and a jejunal perforation. She had a complicated postoperative course requiring a second surgery. Meckel's diverticulum is a common congenital abnormality caused by incomplete vitelline duct obliteration. It can contain heterotopic gastric or pancreatic mucosa and commonly presents in children with GI bleeding. Surgical resection is often required for complications like perforation or obstruction.

1. DR SYED FAHAD ALI ZAIDI
RESIDENT SU II BBH

3.  Asma, D/O tanveer ,
 12 years
 female
 CR No 7995
 Resident of rawalpindi
 Presented to ER
 On 09-04-2012

4.  Presented to ER with C/O
 Pain abdomen 3 days
 Constipation; 2 days
 Vomiting 2 days
Pain was initially mild and peri-umblical; later became
generalized and severe. It was associated with nausea,
anorexia and multiple episodes of vomiting.
No associated history of fever, no h/O bleeding PR

5.  On examination patient had tachycardia, mild fever
and she had generalized abdominal tenderness, and
guarding, suggestive of peritonitis.
 AXR erect showed free gas under diaphragm
 Hb was 14, and TLC was 15900/mm3

6.  Patient was resuscitated with wide bore IV lines, using
crytalloids.
 NG tube and foley’s catheter was passed.
 After resuscitation she was shifted to COT for
exploration

7.  SINGLE 2x2 cm perforation in jejunum, in proximity
of a diverticulum at anti-mesenteric border of the
bowel.
 Omentum was sealing the perforation
 150-200 ml free fluid in the abdomen
 Appendix secondarily inflammed.

8.  Resection of perforated gut, and Primary closure,
followed by appendectomy and abdominal lavage was
done.
 Diverticulum was left in situ as it was broad based
 Abdomen was closed en mass with vicryl 1.

9.  Patient did not have a smooth post op course, and pain
abdomen , along with signs of toximea were present.
 Wound had sero-sanguinous discharge, with early
features of dehiscence
 On 2nd post op day, an USG abdomen was done to rule
out free fluid. No free fluid was reported.
 On 4th post op day, a decision was made to re-explore
the patient.

10.  OP FINDINGS showed
 A diverticulum in proximity of the anastomosis
 A new perforation in the jejunum, 6 “ distal to previous
anastomosis.
 The diverticulum was excised, and perforation
exteriorized as tube jejunostomy.
 Post operatively patient remained stable

11.  A segment of gut was resected in both laparotomies;
histopathology specimen were sent to two different
labs.
 Both specimen reported presence of MECKEL’S
DIVERTICULUM with gastric mucosa, and perforation

12.  Meckel diverticulum (also referred to as Meckel's
Diverticulum) is the most common congenital
abnormality of the small intestine; it is caused by an
incomplete obliteration of the vitelline duct (ie,
omphalomesenteric duct).
 Although originally described by Fabricius Hildanus
in 1598, it is named after Johann Friedrich Meckel, who
established its embryonic origin in 1809.[1]

13.  Early in embryonic life, the fetal midgut receives its
nutrition from the yolk sac via the vitelline duct. The
duct then undergoes progressive narrowing and
usually disappears by 7 weeks' gestation.
 When the duct fails to fully obliterate, different types
of vitelline duct anomalies appear.

14.  Examples of such anomalies include
1) A persistent vitelline duct (appearing as a draining fistula at
2)
3)
4)
5)
the umbilicus);
A fibrous band that connects the ileum to the inner surface of
the umbilicus;
A patent vitelline sinus beneath the umbilicus
A an obliterated bowel portion;
A vitelline duct cyst; and, most commonly (97%)
 Meckel diverticulum, which is a blind-ending true diverticulum
that contains all of the layers normally found in the ileum.
 The tip of the diverticulum is free in 75% of cases and is attached
to the anterior abdominal wall or another structure in the
remainder of cases.

15.  Meckel diverticulum occurs on the antimesenteric
border of the ileum, usually 40-60 cm proximal to the
ileocecal valve.
 On average, the diverticulum is 3 cm long and 2 cm
wide. Slightly more than one half contain ectopic
mucosa.
 Meckel diverticulum is typically lined by ileal mucosa,
but other tissue types are also found with varying
frequency.

16.  The heterotopic mucosa is most commonly gastric.
This is important because peptic ulceration of this or
adjacent mucosa can lead to painless bleeding,
perforation, or both.
 Second most common heterotopic mucosa in meckel
diverticulum is pancreatic
 Rarely, colonic, rectal, endometrial, and hepatobiliary
tissues have been noted.

17.  Found in 2 % of population
 Found at 2 feet proximal to ICJ in most cases
 It is 2 inches long
 Has two types of heterotopic mucosa
 In pediatric group; presentation is common around 2
years of age

18.  Most patients are asymptomatic. Meckel diverticulum
is most frequently diagnosed as an incidental finding
when a barium study or laparotomy is performed for
other abdominal conditions.
 Symptomatic Meckel diverticulum is virtually
synonymous with a complication.
 Patients can present with various clinical signs,
including peritonitis or hypovolemic shock
 The 3 most common symptomatic presentations are GI
bleeding, intestinal obstruction, and acute
inflammation of the diverticulum.

19.  In children, hematochezia is the most common
presenting sign. Bleeding in adults is much less
common.
 Acute lower GI bleeding is secondary to hemorrhage
from peptic ulceration. Such ulceration occurs when
acid secreted by heterotopic gastric mucosa damages
contiguous vulnerable tissue, often times resulting in
direct erosion of a vessel.

20.  Intestinal obstruction is the most common
complication in adults. Obstruction can be the
result of various mechanisms.
Omphalomesenteric band (most frequent cause)
Internal hernia through vitelline duct remnants
Volvulus occurring around vitelline duct remnants
T-shaped prolapse of both efferent and afferent loops of
intestine through a persistent vitelline duct fistula at the
umbilicus in a neonate
 Intussusception (when Meckel diverticulum itself acts
as a lead point for an ileocolic or ileoileal
intussusception)





21.  Most patients with intestinal obstruction present with
abdominal pain, bilious vomiting, abdominal
tenderness, distension, and hyperactive bowel sounds
upon examination.
 Patients may develop a palpable abdominal mass.
 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.

22.  Like other diverticula in the body, Meckel
diverticulum can become inflamed. Diverticulitis
is usually seen in older patients.
 The clinical presentation includes abdominal pain in
the peri-umbilical area that radiates to the right lower
quadrant. Usually, abdominal tenderness is more
marked in the periumbilical region than the pain of
appendicitis.
 Persistence of peri-umbilical pain or a history of
bleeding per rectum may be helpful in distinguishing
this entity from appendicitis.

23.  Clinical history resembles that of perforated appendix.
 Patient may present with peritonitis or shock
 History of persistant abdominal pain and bleeding PR
may help differentiate it from perf appendix.

24.  Appendicitis
 Colitis
 Colonic Vascular








Malformations
Constipation
Crohn Disease
Gastroenteritis
Gastrointestinal Duplications
Henoch-Schoenlein Purpura
Hirschsprung Disease
Intestinal duplication
Intestinal
PolyposisSyndromes









Intussusception
Juvenile Polyps
Necrotizing Enterocolitis
Peptic Ulcer Disease
Peutz-Jeghers Syndrome
Postoperative Adhesions
Ulcerative Colitis
Urolithiasis
Volvulus

25.  Routine laboratory findings, including CBC count,
electrolyte levels, glucose test results, BUN levels,
creatinine levels, and coagulation screen results,
are not helpful in establishing the diagnosis of
Meckel diverticulum but are necessary to manage a
patient with GI bleeding along with a type and
cross.
 Hemoglobin and hematocrit levels are low in the
setting of anemia or bleeding.

26.  On BARIUM STUDIES, Meckel diverticulum may appear
as a blind-ending pouch on the antimesenteric side of the
distal ileum. If filling defects are visualized, the
diverticulum may contain a tumor.
 MECKEL SCAN is a more useful and specific
investigation.
 SMA angiogram may help in some patients
 Capsule Endoscopy may be useful in some cases.

27.  When a patient has GI bleeding suggestive of Meckel
diverticulum, the diagnostic evaluation should focus on
Meckel scanning, a technetium-99m pertechnetate
scintiscan
 The pertechnetate is taken up by gastric mucosa. Because
bleeding from the Meckel diverticulum is related to acid
induced damage of mucosa adjacent to the parietal cell
containing tissue, it is always included early in the workup.

28.  After intravenous injection of the isotope, the
gamma camera is used to scan the abdomen. This
procedure usually lasts approximately 30 minutes.
 Gastric mucosa secretes the radioactive isotope;
thus, if the diverticulum contains this ectopic
tissue, it is recognized as a hot spot.
 In children the Meckel scan has a reported
sensitivity of 80-90%, a specificity of 95% and an
accuracy of 90%.

29.  The emergency department evaluation and treatment of
patients depends on the clinical presentation of Meckel
diverticulum.
 Because most symptomatic patients are acutely ill,
establish an intravenous line immediately, start crystalloid
fluids, and keep the patient on nothing by mouth (NPO)
status. Obtain the blood investigations suggested above
with a type and cross match.If significant bleeding occurs,
perform a transfusion of packed red cells.
 Broad spectrum antibiotics should be started
 A patient who presents with intestinal obstruction usually
requires nasogastric decompression; also perform plain
radiography of the abdomen.

30.  Decision of further management depends on the
patient’s condition and clinical findings.
 If the patient is bleeding but is hemodynamically
stable, a Meckel scan is warranted.
 On the other hand, the presence of peritoneal signs or
hemodynamic instability demands urgent surgical
intervention. Signs of small bowel obstruction also
require surgical intervention.

31.  Four possible surgical procedures are as follows:
 Diverticulectomy with suture closure of the base
 Wedge resection of the intestinal wall containing the diverticulum
with suture closure
 Segmental resection of the intestine, including the diverticulum,
and end-to-end anastomosis
 Division of the fibrous band with or without diverticulectomy
 Adjacent ileum should be included in the resection because
ulcers frequently develop in the adjacent part of the ileum.
 Successful resection of a Meckel diverticulum, even in children
and infants, can also be accomplished through laparoscopy,
using an endoscopically designed autostapling device.

32.  Most surgeons prefer to leave a broad based and
asymptomtaic meckel diverticulum in situ as such,
assuming a 6% mortality rate from Meckel
diverticulum complications, 400 asymptomatic
diverticula would have to be excised to save one
patient
 Another faction favors prophylactic removal of a
diverticulum, which is a simple operation. This view is
supported by data that demonstrate that managing a
complication of Meckel diverticulum is associated
with high morbidity and mortality rates.

33.  Complicated Meckel diverticulum can lead to significant




morbidity and mortality, most often because of a delay in
diagnosis.
Causes of mortality include strangulation, perforation, and
exsanguination because of delay in resuscitation.
Once a complication arises and surgery is required, the
operative mortality and morbidity rates have both been
estimated at 12%.
If the Meckel diverticulum is removed as an incidental
finding, the risk of mortality and morbidity and long-term
complications are much less (1%, 2%, and 2%,
respectively).
As many as 5% of complicated Meckel diverticulum
contain malignant tissue.