Lower GI: Meckel's Diverticulum
Management of asymptomatic Meckel's diverticulum detected on surgery
Resect in children up to young adulthood Resect in adult (<50 years) - esp. if palpable, length > 2cm, broad base > 2cm Do not resect in patients (>50 years)
Purpose of CT angiography
detect bleed
Purpose of Meckel's scan
detect gastric mucosa
Why not CTAP?
hard to distinguish Meckel's diverticulum from small bowel loops
Most common presentation in children
hematochezia
Location of abdominal wall hernia
inguinal femoral
Symptoms of chronic peptic ulceration
pain around umbilicus
Pathogenesis of hematochezia in Meckel's diverticulum
peptic ulceration
Characteristics of hematochezia in Meckel's diverticulum
usually massive and painless
Why are Meckel's diverticulum less prone to inflammation than appendix?
wide base, little lymphoid tissue and are self-emptying
Symptomatic presentation of Meckel's diverticulum
1. Hematochezia 2. Intestinal obstruction 3. Meckel's diverticulitis 4. Chronic peptic ulceration 5. Others
Rule of 25 in Meckel's diverticulum
2 inches in length, 2m wide 2 feet (60cm) from ieleocaecal valve 2% of population 2M:1F 2-4% become symptomatic 2 types of ectopic tissue
Percentage of femoral hernias
20%
Percentage of inguinal hernias
50%
Percentage of Meckel's diverticulum containing pancreatic tissue
6%
Percentage of Meckel's diverticulum containing gastric tissue
60%
Ix: Blood
As per IO or LBGIT
Clinical Presentation of Meckel's Diverticulum
Asymptomatic Symptomatic
Management
Asymptomatic Symptomatic
Definition
Blind outpouching of the anti-mesenteric aspect of the small intestine that has all four layers of the small bowel wall, covered with serosa
Investigations
Blood Imaging
Types of surgery
Broad base: wedge ileal resection with anastomosis Narrow base: resection of diverticulum
Predisposition for Meckel's diverticulum
Children with malformation of umbilicus, alimentary tract, nervous system, CVS system
Management of asymptomatic Meckel's diverticulum
Detected on imaging Detected during surgery
Types of ectopic tissue
Gastric Pancreatic
Complications of Meckel's diverticulum containing gastric tissue
Gastric acid secretion can produce inflammation, peptic ulceration and bleeding, strictures with subsequent IO
Pathogenesis of Meckel's diverticulum
Incomplete obliteration of the vitelline duct / persistent remnant of the omphalomesenteric duct (connects mid-gut to yolk sac in the foetus)
Pathogenesis of intestinal obstruction in Meckel's diverticulum: Meckel's diverticulitis
Inflammation results in reduced luminal diameter
Most common presentation of Meckel's diverticulum
Intestinal obstruction
Abdominal wall hernia in Meckel's diverticulum also known as
Littre's hernia
Symptoms of Meckel's diverticulitis
May present exactly like acute appendicitis i.e. periumbilical pain radiating to RIF If perforate, symptoms simulate those of a perforated duodenal ulcer
Pathogenesis of intestinal obstruction in Meckel's diverticulum: Recurrent intussusception
Meckel's diverticulum acts as lead point
Ix: Imaging
Meckel's scan Barium studies CT angiography
Management of symptomatic Meckel's diverticulum
NBM , IV drip, correct electrolyte imbalnace Mx of IO Mx of PR bleed Definitive treatment
Mx of IO
NG tube on constant suction supine AXR
Familial predisposition for Meckel's diverticulum
None
Management of asymptomatic Meckel's diverticulum detected on imaging
Not for elective surgery
Risk factors for symptomatic
Presence of ectopic tissue Age < 50 Diverticulum length > 2cm Males Broad based diverticulum Presence of fibrous bands
Pathogenesis of intestinal obstruction in Meckel's diverticulum
Recurrent intussusception Volvulus Abdominal wall hernia Meckel's diverticulitis
Rule in Meckel's diverticulum
Rule of 25
Mx of PR bleed
Start PPI +- PCT Gastric lavage to r/o UBGIT OGD & colonoscopy
Definitive treatment for Meckel's diverticulum
Surgery
Meckel's scan using
Technetium-99m pertechnate scan
Other symptomatic presentations of Meckel's diverticulum
Umbilical fistula Tumour Perforation
Vitelline duct abnormalities
Vitelline fistula Vitelline cyst Vitelline cord Meckel's diverticulum Meckel's diverticulum & vitelline cord