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. The embryology, clinical features, diagnosis, and treatment of Meckel's diverticulum are reviewed here. The clinical evaluation of various gastrointestinal symptoms (abdominal pain, gastrointestinal bleeding, bowel obstruction) in children and adults is found in separate topic reviews. General considerations for the management of other congenital anomalies of the gastrointestinal tract are reviewed elsewhere. Meckel's diverticulum is a true diverticulum, containing all layers of the small bowel wall. 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. Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract [1]. There is probably no familial predisposition for Meckel's diverticulum, although a few cases of occurrence within the same family have been reported . The prevalence of Meckel's diverticulum is increased in children born with major malfo

1. MECKEL’S DIVERTICULUM
Dr.Sabin Shrestha
1st Year Surgery Resident

2. INTRODUCTION
• Meckel diverticulum is a common congenital abnormality of the small intestine caused by
incomplete obliteration of the vitelline (omphalomesenteric) duct leading to formation of true
diverticulum.
• Occurs as Single diverticulum.
• Antimesenteric border.

6. EMBRYOLOGY
• 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.
• A persistent vitelline duct (appearing as a draining fistula at the umbilicus).
• A fibrous band that connects the ileum to the inner surface of the umbilicus.
• A patent vitelline sinus beneath the umbilicus.
• A vitelline duct cyst most commonly (97%).

8. MUCOSAL LINING
• 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.
• 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.

9. Rule of 2
• 2% population
• 2%symptomatic
• Child less than 2 year
• Male:female(2:1)
• 2 feet proximal to ileocecalvalve
• 2 inch long
• Mostly 2 type of mucosa

10. CLINICAL PRESENTATION
• Clinically silent.
• Presents as acute appendicitis
• only 4 to 6 % present with GÍ bleed or acute abdominal symptoms cause by complication such as
obstruction, inflammation or perforation.
• In pediatric group; presentation is common around 2 years of age.
• Meckel diverticulum is most frequently diagnosed as an incidental finding during appendectomy

11. PER RECTAL BLEEDING
• In children, dark red or maroon stool while adult typically present with melena
• 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.

12. OBSTRUCTION
• Intestinal obstruction is the most common complication in adults. Obstruction can be the
result of various mechanisms.
• Omphalomesenteric band (most frequent cause)
• Volvulus occurring around vitelline duct remnants.
• Intussusception(when Meckel diverticulum itself acts as a lead point for an ileocolic or
ileoileal intussusception)

13. • Most patients with intestinal obstruction present with sign like abdominal pain,
vomiting, Distension and symptoms like abdominal tenderness, 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 signs
of peritonitis and lower GI bleeding.

14. DIVERTICULITIS
• Meckel diverticulum can become inflamed. Diverticulitis is usually seen in elder patients.
• The clinical symptoms resemble with that of acute appendicitis .

15. Meckel`s Diverticulum should be suspected in:
• Children , particularly those less than 10 years of age who present with painless lower GI bleed without
symptoms or signs of gastroenteritis(diarrhea) or inflammatory bowel disease(abdominal pain diarrhea)
• Children and adults with intussusception ,particularly recurrent.
• Patients with features of acute appendicitis, particularly when the appendix has already been removed.

16. DIFFERENTIAL DIAGNOSIS
-Acute appendicitis
-Acute non-specific mesenteric lymphadenitis

17. INVESTIGATION
• Transabdominal ultrasound
• CBC
• On Barium study, Meckel diverticulum may appear as a blind-ending pouch on the antimesenteric
side of the distal ileum.

18. SPECIFIC INVESTIGATION
MECKEL SCAN is a more useful and specific investigation.
The most sensitive test is a Meckel radionuclide scan (commonly known as a Meckel
scan). It is a nuclear study done by injecting technetium-99m, which is absorbed by the
ectopic gastric mucosa allowing for visualization of the Meckel diverticulum. The uptake
of the dye can be enhanced using cimetidine.

19. Nuclear imaging of Meckel diverticulum.

20. MANAGEMENT
• Most symptomatic patients are acutely ill, establish an intravenous line immediately, give IV fluids,
and keep the patient on nothing by mouth (NPO) status. Broad spectrum antibiotics should be started
• A patient who presents with intestinal obstruction usually requires nasogastric decompression; also
perform plain radiography of the abdomen.

22. SURGICAL TECHNIQUE
• Simple diverticulectomy – Diverticulectomy is performed.
• Segmental resection of ileum containing the diverticulum – This involves resection of the small
bowel segment containing the diverticulum followed by primary small bowel anastomosis.

24. Risk Factor for development of complication
• Younger than 50 yrs
• Male sex
• Diverticulum length more than 2 cm
• Ectopic tissue

25. COMPLICATION

26. COMPLICATION
• Complicated Meckel diverticulum can lead to significant morbidity and mortality, most often
because of a delay in diagnosis.
• Causes of mortality include strangulation and perforation 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.

27. REFERENCE
• Bailey and love short practice of surgery 28th edition.
• Sabiston Textbook of Surgery 21st edition.
• Schwartz principle of surgery 11th edition.
• Shackel ford’s
• Uptodate.

28. THANK YOU