Diagnosis

Meckels diverticulum

Etiology

Etiology [n3p]

• Persistence of the omphalomesenteric (vitelline) duct (should disappear by seventh week of gestation).

Pathophysiology [n3p]

1. The vitelline duct connects the yolk sac to the gut in the developing embryo

2. It provides nutrition until the placenta forms

3. At 7 weeks of gestation, the duct separates from the intestine and disappear

4. Incomplete or failed separation --> omphalomesenteric cyst/fistula

5. Clinical presentation:

   • GI bleeding/ulcer: ectopic gastric mucosa secretes an acid that is not neutralized

   • Obstruction: volvulus, intussusception, stricture, tumor

   • Diverticulitis/perforation: periumbilical pain that radiates to the RLQ

   • Rare: hernia torsion, umbilical sinus/fistula and neoplasm

6. Rule of 2s:

   • 2% of the population

   • 2 feet proximal to the ileocecal valve

   • 2 inches long

   • 2 times more common in males than females

   • Symptomatic mostly before 2 years of age

   • 2% are symptomatic in adult patients

Complications [n3p]

• Rectal bleeding --> anemia

• Small bowel obstruction: Internal hernia, volvulus and intussusception

• Meckel diverticulitis with perforation and peritonitis

Epidemiology

Incidence per 100.000 [evp][ee5]

Approach

• Meckels scan (technetium-99m scintigraphy)

• CT abdomen

• Diagnostic laparoscopy

Treatment

1. Asymptomatic Meckel diverticulum: treatment is controversial [n3p]

   • Surgery versus observation

   • Incidentally discovered during abdominal surgery --> removal?

2. Painless bleeding: [oqc]

   • Complete removal of the ectopic mucosa by resection of the Meckel diverticulum and any ulcerated intestine

3. Bowel obstruction:

   • Volvulus around a fibrous Meckel band

   • Intussuscepted Meckel diverticulum

   • Incarcerated hernia that contains a Meckel diverticulum (Littre hernia)

4. Meckel diverticulitis: Laparoscopic resection (treated like acute appendicitis)

5. Umbilical sinus/fistula:

   • Periumbilical incision --> Division and removal of the fistulous tract --> Enterotomy is closed

Differential diagnoses

Anal fissure, Appendicitis, Arteriovenous malformation, Colorectal cancer, Colorectal polyp, Crohn disease, Diverticulitis, Gastroenteritis, Gastrointestinal hemorrhage, Hemolytic uremic syndrome, Infectious colitis, Intussusception, Necrotizing enterocolitis, Obstipasjon, Perforated ulcer, Ulcerative colitis, Ulcer disease, Volvulus