Overview
Definition:
Meckel's diverticulum is a congenital outpouching of the small intestine, representing a remnant of the omphalomesenteric duct
Meckel's diverticulectomy is the surgical excision of this diverticulum when it causes symptomatic complications.
Epidemiology:
It is the most common congenital anomaly of the small intestine, found in approximately 1-2% of the general population
It is typically found within 2 feet of the ileocecal valve
Males are affected more often than females.
Clinical Significance:
While often asymptomatic, Meckel's diverticulum is a frequent cause of surgical emergencies in children, including intussusception, obstruction, bleeding, and perforation
Early diagnosis and appropriate surgical intervention are crucial to prevent severe morbidity and mortality.
Clinical Presentation
Symptoms:
Painless rectal bleeding, often intermittent and bright red or maroon-colored
Symptoms of intestinal obstruction, such as abdominal pain, vomiting, and constipation
Umbilical discharge or sinus tract
Symptoms mimicking appendicitis due to inflammation of the diverticulum (Meckel's appendicitis).
Signs:
Abdominal tenderness, particularly in the right lower quadrant if inflamed or causing obstruction
Palpable abdominal mass in cases of intussusception
Signs of hypovolemia if significant bleeding has occurred
Umbilical anomalies such as a patent omphalomesenteric duct with discharge.
Diagnostic Criteria:
No specific diagnostic criteria exist
diagnosis is often presumptive based on clinical presentation and confirmed intraoperatively
The "Rule of 2s" is a mnemonic: 2% of the population, 2 feet from the ileocecal valve, 2% symptomatic, 2:1 male to female ratio, 2 common complications (bleeding, intussusception).
Diagnostic Approach
History Taking:
Detailed history of bleeding episodes (frequency, color, amount)
Onset and progression of abdominal pain
History of vomiting or changes in bowel habits
Presence of umbilical discharge
Previous abdominal surgeries or congenital anomalies
Family history of gastrointestinal issues.
Physical Examination:
Thorough abdominal examination for tenderness, distension, masses, and bowel sounds
Careful examination of the umbilical region for any abnormalities
Rectal examination to assess for gross or occult bleeding
Assessment for signs of hemodynamic instability.
Investigations:
Complete Blood Count (CBC) to assess for anemia from chronic bleeding or leukocytosis in inflammation
Coagulation profile
Stool occult blood test
Imaging: Ultrasound can sometimes detect a thickened diverticulum or intussusception
Technetium-99m pertechnetate scan (Meckel's scan) is the most sensitive test for detecting ectopic gastric mucosa within the diverticulum, indicated by focal uptake in the right lower abdomen
CT scan can be useful for diagnosing complications like obstruction or perforation
Angiography may be considered in cases of massive bleeding.
Differential Diagnosis:
Intussusception from other causes, appendicitis, Meckel's diverticulitis, mesenteric cyst, duplication cyst, Crohn's disease, peptic ulcer disease, Meckel'sitis, inflammatory bowel disease, Meckel's knot, Meckel's abscess, Meckel's fistula, Meckel's omphaloenteric duct cyst.
Management
Initial Management:
Fluid resuscitation for bleeding or dehydration
Nasogastric tube decompression for obstruction
Pain management
Blood transfusion if anemic
Broad-spectrum antibiotics if infection or inflammation is suspected.
Medical Management:
Primarily symptomatic and supportive
Medical management is not curative for structural anomalies but addresses complications like anemia and dehydration
Consultation with pediatric surgery is paramount.
Surgical Management:
Indications include symptomatic Meckel's diverticulum (bleeding, obstruction, intussusception, perforation, or suspected malignancy)
Surgical approach can be open or laparoscopic
The procedure involves isolating the diverticulum, ligating its base, and resecting it
If the diverticulum is broad-based or associated with significant inflammation, a wedge resection of the involved bowel segment with primary anastomosis may be necessary
If ectopic gastric mucosa is present and symptomatic, diverticulectomy is indicated.
Supportive Care:
Postoperative monitoring for vital signs, pain control, fluid balance, and wound care
Early mobilization and gradual resumption of oral intake
Management of complications such as wound infection, anastomotic leak, or intra-abdominal abscess.
Complications
Early Complications:
Bleeding from the diverticulum or at the staple line
Wound infection
Intra-abdominal abscess
Suture line dehiscence or anastomotic leak
Ileus
Retained ectopic gastric mucosa leading to ulceration and bleeding post-operatively.
Late Complications:
Hernia formation (incisional or internal)
Bowel obstruction due to adhesions
Recurrence of symptoms if diverticulum is not completely excised or if other anomalies exist
Persistent omphalomesenteric duct remnants.
Prevention Strategies:
Careful surgical technique during diverticulectomy, ensuring complete excision of the diverticulum and adequate ligation of its base
Accurate identification and management of any associated anomalies of the omphalomesenteric duct
Meticulous closure of the bowel and abdominal wall
Prompt recognition and management of postoperative complications.
Prognosis
Factors Affecting Prognosis:
The presence and type of complication (bleeding vs
obstruction vs
inflammation)
The promptness of diagnosis and intervention
The child's overall health status
The skill of the surgical team.
Outcomes:
Generally excellent for uncomplicated Meckel's diverticulectomy, with low morbidity and mortality
Complications can increase the length of hospital stay and recovery time
Patients with significant bleeding or obstruction may require more extensive management.
Follow Up:
Routine follow-up is usually not required for asymptomatic patients discovered incidentally during other surgeries and left in situ
Symptomatic patients who undergo surgery require follow-up to monitor for complications and ensure complete recovery
If ectopic gastric mucosa was confirmed, vigilance for recurrent bleeding may be warranted.
Key Points
Exam Focus:
Meckel's diverticulum is the most common congenital anomaly of the small intestine
The Rule of 2s is a key mnemonic
Technetium-99m pertechnetate scan is the imaging of choice for detecting ectopic gastric mucosa
Common complications in children are bleeding and intussusception.
Clinical Pearls:
Consider Meckel's diverticulum in any child with unexplained rectal bleeding, especially if painless
Meckel's diverticulitis can mimic appendicitis, and the diagnosis is often intraoperative
Complete excision of the diverticulum is crucial to prevent recurrence of symptoms.
Common Mistakes:
Failing to consider Meckel's diverticulum in the differential diagnosis of pediatric abdominal emergencies
Inadequate resection of the diverticulum, leading to stump issues or failure to remove symptomatic ectopic mucosa
Misinterpreting findings on imaging or during laparotomy, leading to missed diagnosis or incomplete treatment.