Meckel Diverticulum, Emergency Medicine

Basics

Description

Most common congenital abnormality of the GI tract
- Results from incomplete obliteration of the omphalomesenteric duct
True diverticula (contains all layers):
- 50% contain normal ileal mucosa.
- 50% contain either gastric (most common), pancreatic, duodenal, colonic, endometrial, or hepatobiliary mucosa.
Rule of 2 's:
- 2% prevalence in general population
- 2% lifetime risk for complications, decreasing with age
- Symptoms commonly occur around 2 yr of age:
  - 45% of symptomatic patients <2 yr old
- Average length 2 in
- Found within 2 ft of the ileocecal valve
Male-to-female ratio approximately equal, but more often symptomatic in males
Complications:
- Obstruction and diverticulitis in adults
- Hemorrhage and obstruction in children
- Mean age 10 yr
- Current mortality rate 0.0001%
- Occurs more frequently in males
Obstruction:
- Diverticulum attached to the umbilicus, abdominal wall, other viscera, or is free and unattached, leading to:
  - Intussusception: Diverticulum is the leading edge.
  - Volvulus: Persistent fibrous band leads to bowel rotation.
Diverticulitis:
- Opening obstructed
- Bacterial infection follows.
- Presents like appendicitis (most common preoperative diagnosis with Meckel diverticulum)

Most common cause of significant lower GI bleeding in children.
Presents at age <5 yr with episodic painless, brisk, and bright-red rectal bleeding.

Etiology

Remnant of the omphalomesenteric duct that typically regresses by week 7 of gestation.

Diagnosis

Signs and Symptoms

3 different types of presentation:
- Rectal bleeding due to hemorrhage, which results from mucosal ulcerations within the ectopic gastric tissue
- Vomiting due to obstruction secondary to volvulus, intussusceptions, or intraperitoneal bands
- Abdominal pain (appendicitis like) due to an inflamed or perforated diverticulum
General:
- Fever
- Malaise
- Weakness
- Fatigue
GI:
- Classically painless rectal bleeding
- Abdominal pain:
  - Location depends on cause
  - Appendicitis like
- Vomiting
- Distention
- Changes in bowel movements
- Hematochezia or melena (depending on briskness or location of diverticulum)
- Peritonitis and septic shock (late complications)
Cardiovascular:
- Tachycardia (due to pain or blood loss)
- Hypotension and shock (due to bleeding)

Essential Workup

May cause a variety of signs and symptoms:
- <10% diagnosed preoperatively
- Consider in patients with recurrent nonspecific abdominal pain, nausea and vomiting, or rectal bleeding.
History and physical exam narrow diagnosis, but will not give specific findings for Meckel diverticulum.
Rectal exam mandatory
Nasogastric (NG) tube placement to rule out upper GI bleed

Diagnosis Tests & Interpretation

Lab

CBC:
- Decreased hematocrit due to bleeding
- Rarely a cause of chronic anemia
- Leukocytosis with diverticulitis, perforation, or gangrene
Electrolytes, BUN, creatinine, coagulation studies
Type and screen/cross-match when significant GI bleeding.

Imaging

CT abdomen/pelvis:
- For suspected infection (appendicitis/diverticulitis) or bowel obstruction
Abdominal radiographs:
- Screening for bowel obstruction
- Cannot diagnose Meckel diverticulum
Tc-99m pertechnetate radioisotope scan (Meckel scan):
- Noninvasive scan that identifies Meckel diverticulum containing heterotopic gastric mucosa
- 90% accurate in children
- 45% accurate in adults
Small bowel enteroclysis:
- 75% accuracy
- Barium/methyl cellulose introduced through NG tube into distal duodenum or proximal jejunum
- Increases the ability to detect Meckel diverticulum in adults
- Diverticulum may be short and wide-mouthed, making diagnosis difficult.
Barium enema:
- Introduces fluid into distal small bowel
- Look for diverticulum
Angiogram for further evaluation of Meckel diverticulum if radioisotope scan and enteroclysis normal:
- Blood supply is not always abnormal (vitelline artery).
Ultrasound may be useful in nonbleeding presentations.
Laparoscopic evaluation may provide both diagnosis and definitive treatment.
ECG:
- Eliminate myocardial ischemia as cause of abdominal pain.
Colonoscopy:
- Not useful in diagnosing Meckel diverticulum

Differential Diagnosis

Adults:
- Adhesions
- Appendicitis
- Arteriovenous malformation
- Bowel obstruction
- Diverticulitis
- Hemorrhoids
- Inflammatory bowel disease
- Internal hernias
- Intestinal polyps
- Intussusception
- Peptic ulcer disease
- Pseudomembranous colitis
- Volvulus
Pediatric:
- Adhesions
- Anal fissures
- Appendicitis
- Atresia
- Gastroenteritis
- Hemolytic-uremic syndrome
- Henoch " Sch Άnlein purpura
- Intestinal polyps
- Intussusception
- Malrotation
- Milk allergy
- Strictures
- Volvulus

Treatment

Pre-Hospital

Establish IV access for patients with rectal bleeding or abdominal pain.

Initial Stabilization/Therapy

Stabilization followed by early surgical evaluation
Hypotension:
- Aggressive fluid resuscitation
- Packed RBC (PRBC) transfusion with brisk rectal bleeding (more common in children)
- Pressors for septic shock

Ed Treatment/Procedures

GI bleeding:
- Fluid resuscitate and transfuse PRBC as indicated
- Foley to follow urine output
- NG tube to exclude brisk upper GI bleeding
- Surgical consult for surgical intervention as indicated
Obstruction:
- NG tube
- Foley
- Surgical consult
Diverticulitis/perforation:
- NPO
- Preoperative antibiotics
- Surgical consult
Surgical intervention:
- Symptomatic Meckel diverticula should be resected
- Asymptomatic Meckel diverticula discovered incidentally at laparotomy in children should be resected

Medication

Ampicillin/sulbactam (Unasyn): 3 g (peds: 100 " 200 mg ampicillin/kg/24h) q8h IV
Cefoxitin (Mefoxin): 1 " 2 g (peds: 100 " 160 mg/kg/24h) IV q6h
Dopamine: 2 " 20 Ό/kg/min IV

Follow-Up

Disposition

Admission Criteria
Presumptive diagnosis of Meckel diverticulum with diverticulitis, obstruction, intussusception, hemorrhage, or volvulus requires admission and surgical evaluation.
Discharge Criteria
None

Followup Recommendations

Postoperative surgical follow-up

Pearls and Pitfalls

Painless, brisk, bright-red blood per rectum in an infant is often caused by Meckel diverticulum.
Presents with a wide range of complications, including obstruction, intussusception, and hemorrhage.
Often diagnosed in the OR for patients undergoing surgery for a presumptive appendicitis.
Rule of 2 's:
- 2% of the population
- 2% risk of complications
- Mostly <2 yr old
- 2 in long
- 2 ft from the ileocecal valve

Additional Reading

McCollough M, Sharieff GQ. Abdominal pain in children. Pediatr Clin North Am. 2006;53(1):107 " 137.
Park JJ, Wolff BG, Tollefson MK, et al. Meckel diverticulum: The Mayo Clinic experience with 1476 patients (1950 " 2002). Ann Surg. 2005;241:529 " 533.
Sagar J, Kumar V, Shah DK. Meckels diverticulum: A systematic review. J R Soc Med. 2006;99(10):501 " 505.
Sharma RK, Jain VK. Emergency surgery for Meckel diverticulum. World J Emerg Surg. 2008;3:27.
Zani A, Eaton S, Rees CM, et al. Incidentally detected Meckel diverticulum: To resect or not to resect? Ann Surg. 2008;247(2):276 " 281.

Codes

ICD9

751.0 Meckels diverticulum

ICD10

Q43.0 Meckels diverticulum (displaced) (hypertrophic)

SNOMED

37373007 Meckels diverticulum (disorder)
204687007 Displaced Meckel's diverticulum (disorder)

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