Lecture Notes For Medical Students

1. Tips on using my ppt.
1. You can freely download, edit, modify and put your
name etc.
2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Aetiology ) > Ask
students what they already know about aetiology of
today's topic. > Then show next slide which enumerates
aetiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also.
7. See notes for bibliography.

2. Learning Objectives
• At the end of this session the learner will
be able to describe the –
– Anatomy and applied anatomy of Meckel's
Diverticulum.

3. Introduction & History.
•

4. Introduction & History
Meckel's Diverticulum:
• The most common congenital anomaly of the
gastrointestinal tract.
• Remains of vitelline duct of embryo.
• Usually found incidentally during abdominal
operations.
•

5. Meckel's Diverticulum

6. Rule of twos
•

7. Rule of twos
• Present in 2% of people
• 2 feet from ileocecal junction
• 2 inch long
• Contains ectopic mucosa about half the time
• Contains gastric or pancreatic tissue.
• Often presents before age 2 years (or within
the first 2 decades of life),
• Is twice as likely to be symptomatic in boys
than girls.

8. Embryology
•

9. Embryology
• A Meckel’s diverticulum results from incomplete
obliteration of the Vitelline duct aka.
Omphalomesenteric duct which connects the
midgut to the yolk sac in the fetus.
• Early in embryonic life, the fetal midgut receives
its nutrition from the yolk sac via the
Omphalomesenteric/Vitelline duct.
• 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.

10. Embryology
• The persistence of the omphalomesenteric
duct beyond fetal development may result
in a variety of anatomic patterns-
– The most common form is a diverticulum without
additional attachment, commonly referred to as
Meckel's diverticulum
– Omphalomesenteric cysts
– Omphalomesenteric fistulas that drain through the
umbilicus
– Fibrous bands from the diverticulum to the umbilicus
that predispose to bowel obstruction.
– Umbilical sinus.

11. Anatomy
• Meckel's diverticulum is a true
diverticulum, containing all layers of the
small bowel wall .

12. Microscopic Anatomy
• The mucosal lining of the diverticulum may
contain heterotopic mucosa (most
commonly gastric).
•

13. Heterotopic mucosa
• Heterotopic gastric mucosa was found in 62% of
cases,
• Pancreatic tissue was found in 6%,
• Both pancreatic tissue and gastric mucosa were
found in 5%,
• Jejunal mucosa was found in 2%,
• Brunner tissue was found in 2%
• Both gastric and duodenal mucosa were found in
2%.
• Rarely, colonic, rectal, endometrial, and
hepatobiliary tissues have been noted.

14. Applied Anatomy

15. Applied Anatomy
• Usually found incidentally during
abdominal operations.
• Less commonly, they are found incidentally
on diagnostic imaging.
• Inflammation may mimic Acute
appendicitis.
• Clue is shifting tenderness.
•

16. Applied Anatomy: Symptoms
• Usually asymptomatic.
• Can cause -
– Peptic Ulceration and present with lower
gastrointestinal (GI) bleeding
– Diverticulitis- Abd. pain
– Small bowel obstruction (SBO).
– Intussusception
– Perforation.
– As many as 5% of complicated Meckel diverticulum
contain malignant tissue.
– Neuroendocrine tumors arising from Meckel
diverticulum are very rare.

17. Applied Anatomy: Symptoms
• In children bleeding PR is more common.
• In adults diverticulitis and intestinal
obstruction are more common.
• Complications become less common with
increasing age.

18. Applied Anatomy: Investigations
– Computed tomography (CT) has become an invaluable
tool for the evaluation of abdominal pain. CT scanning
is useful in demonstrating acutely inflamed diverticula,
typically identified as a blind pouch off the distal small
intestine and associated with bowel wall thickening
– A Meckel’s scan (technetium-99m scan) can detect the
diverticulum in hemodynamically stable patients.
– Bleed scan -Technetium-99m lebelled RBC scan.
– For those with active bleeding, arteriography is the
diagnostic option.
– Capsule endoscopy
– Magnetic resonance imaging (MRI)
– Single-photon emission tomography
/CT (SPECT/CT) scanning.

19. Applied Anatomy: Treatment
• The treatment for a symptomatic Meckel’s
diverticulum is surgery.

20. Applied Anatomy: Treatment
• Resection of incidental Meckel's found during
laparotomy is controversial in children and
adults.
• It is generally recommended that asymptomatic
Meckel's to be resected in children during
laparotomy
• Incidentally found normal-appearing Meckel's
diverticulum should not be resected in adults.
• Elective prophylactic resection of asymptomatic
Meckel's diverticulum identified on imaging is
not recommended for both children and adult.

21. Applied Anatomy: Treatment
Indications for incidental resection –
• If there is a palpable abnormality
(suggestive of the presence of ectopic
mucosa)
• A long diverticulum (>4 cm)
• A narrow neck or base of diverticulum (<2
cm wide)

22. Applied Anatomy: Treatment
• The standard surgical approach is to perform a
segmental (wedge or v-shaped diverticulectomy)
resection of the narrow-based diverticulum or to
perform a limited small bowel resection followed
by primary end-to-end anastomosis if an
inflamed or ulcerated diverticulum is
encountered.
• For bleeding -segmental small bowel resection
followed by end-to-end ileoileostomy rather than
simple diverticulectomy is preferred.

23. Minimally invasive Therapy
• The long-term outcomes with laparoscopy
approaches (including laparoscopic
diverticulectomy and laparoscopic-assisted
trans umbilical Meckel's diverticulectomy)
are still lacking.

24. MCQ
True about Meckel's diverticulum is-
• A. Congenital anomaly of the intestine
• B. Always heterotopic mucosa
• C. Pseudodiverticulum
• D. Located on mesenteric border

25. MCQ
True about Meckel's diverticulum is-
• A. Congenital anomaly of the intestine
• B. Always heterotopic mucosa
• C. Pseudodiverticulum
• D. Located on mesenteric border

26. MCQ
Least common complication of Meckel's
diverticulum (NEET 2018)
a) Bleeding
b) Obstruction
c) Neoplasm
d) Obstruction

27. MCQ
Least common complication of Meckel's
diverticulum (NEET 2018)
a) Bleeding
b) Obstruction
c) Neoplasm
d) Obstruction

28. MCQ
• Meckel's diverticulum most commonly
presents as:
A. Gastrointestinal bleeding.
B. Obstruction.
C. Diverticulitis.
D. Intermittent abdominal pain

29. MCQ
• Meckel's diverticulum most commonly
presents as:
A. Gastrointestinal bleeding.
B. Obstruction.
A. Diverticulitis.
B. Intermittent abdominal pain

30. MCQ
• How proximal to the caecum is a Meckel's
diverticulum usually found?
• A 20 cm
• B 30 cm
• C 40 cm
• D 50 cm
• E 60 cm

31. MCQ
• How proximal to the caecum is a Meckel's
diverticulum usually found?
• A 20 cm
• B 30 cm
• C 40 cm
• D 50 cm
• E 60 cm

32. MCQ
• What percentage of the general population
have a Meckel's diverticulum?
• A 2%
• B 5%
• C 10%
• D 15%
• E 20%

33. MCQ
• What percentage of the general population
have a Meckel's diverticulum?
• A 2%
• B 5%
• C 10%
• D 15%
• E 20%

34. MCQ
• What is the most common cause of
intussusception in adults?
A. Colorectal carcinoma
B. Gastrointestinal stromal tumor
C. Lymphoid hyperplasia
D. Meckel diverticulum
E. Small bowel lymphoma

35. MCQ
• What is the most common cause of
intussusception in adults?
A. Colorectal carcinoma
B. Gastrointestinal stromal tumor
C. Lymphoid hyperplasia
D. Meckel diverticulum
E. Small bowel lymphoma

36. Teaching Point
In adults, a lead point is frequently identified up to 90% of the
time, usually malignant in the large bowel and benign in the
small bowel. Lead points are numerous and include:
• Gastrointestinal malignancy
(most common cause in adults,
accounting for 65% of cases)
• Colorectal carcinoma (most
common)
• Metastases, e.g. Malignant
melanoma, breast cancer, lung
cancer
• Small bowel
lymphoma/Burkitt lymphoma
• Benign neoplasms
• Gastrointestinal stromal tumor
(GIST)
• Intestinal polyps
• Intestinal lipoma
• Polypoid hemangioma
• Congenital
• Meckel diverticulum
• Duplication cyst
• Ectopic pancreas
• Inflammatory
• Peri appendicitis
• Trauma
• Mural hematoma

37. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

38. • Lectures one drive

40. Get my ppt collection
• https://1drv.ms/u/s!AvOWIE3I3JkugQ7qQv9vsY
8pGHLf?e=CSNFK2
• https://t.me/surgerypresentation
• https://www.slideshare.net/drpradeeppande/edit_m
y_uploads
• https://www.dropbox.com/sh/x600md3cvj85woy/
AACVMHuQtvHvl_K8ehc3ltkEa?dl=0
• https://www.facebook.com/doctorpradeeppande/?r
ef=pages_you_manage
• https://t.me/+eqNYT21gmWZjMjI9