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Meckel Diverticulum, Emergency Medicine

Basics

Description

- 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

- Diverticulitis: - Opening obstructed - Bacterial infection follows. - Presents like appendicitis (most common preoperative diagnosis with Meckel diverticulum)

- 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

- Vomiting - Distention - Changes in bowel movements - Hematochezia or melena (depending on briskness or location of diverticulum) - Peritonitis and septic shock (late complications)

- 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.

- CBC: - Decreased hematocrit due to bleeding - Rarely a cause of chronic anemia - Leukocytosis with diverticulitis, perforation, or gangrene

- 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.

- 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

- 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

- 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

  • Most common congenital abnormality of the GI tractResults 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 population2% lifetime risk for complications, decreasing with ageSymptoms commonly occur around 2 yr of age:45% of symptomatic patients <2 yr oldAverage length 2 inFound within 2 ft of the ileocecal valve
  • Male-to-female ratio approximately equal, but more often symptomatic in males
  • Complications:Obstruction and diverticulitis in adultsHemorrhage and obstruction in childrenMean age 10 yrCurrent 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 obstructedBacterial 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 tissueVomiting due to obstruction secondary to volvulus, intussusceptions, or intraperitoneal bandsAbdominal pain (appendicitis like) due to an inflamed or perforated diverticulum
  • General:FeverMalaiseWeaknessFatigue
  • GI:Classically painless rectal bleedingAbdominal pain:Location depends on causeAppendicitis likeVomitingDistentionChanges in bowel movementsHematochezia 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 preoperativelyConsider 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 bleedingRarely a cause of chronic anemiaLeukocytosis 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 obstructionCannot diagnose Meckel diverticulum
  • Tc-99m pertechnetate radioisotope scan (Meckel scan):Noninvasive scan that identifies Meckel diverticulum containing heterotopic gastric mucosa90% accurate in children45% accurate in adults
  • Small bowel enteroclysis:75% accuracyBarium/methyl cellulose introduced through NG tube into distal duodenum or proximal jejunumIncreases the ability to detect Meckel diverticulum in adultsDiverticulum may be short and wide-mouthed, making diagnosis difficult.
  • Barium enema:Introduces fluid into distal small bowelLook 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:AdhesionsAppendicitisArteriovenous malformationBowel obstructionDiverticulitisHemorrhoidsInflammatory bowel diseaseInternal herniasIntestinal polypsIntussusceptionPeptic ulcer diseasePseudomembranous colitisVolvulus
  • Pediatric:AdhesionsAnal fissuresAppendicitisAtresiaGastroenteritisHemolytic-uremic syndromeHenoch " Sch Άnlein purpuraIntestinal polypsIntussusceptionMalrotationMilk allergyStricturesVolvulus

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 resuscitationPacked 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 indicatedFoley to follow urine outputNG tube to exclude brisk upper GI bleedingSurgical consult for surgical intervention as indicated
  • Obstruction:NG tubeFoleySurgical consult
  • Diverticulitis/perforation:NPOPreoperative antibioticsSurgical consult
  • Surgical intervention:Symptomatic Meckel diverticula should be resectedAsymptomatic 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 population2% risk of complicationsMostly <2 yr old2 in long2 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Abdominal Pain
  • Appendicitis
  • Bowel Obstruction
  • Diverticulitis
  • Intussusceptions

Codes

ICD9

751.0 Meckels diverticulum

ICD10

Q43.0 Meckels diverticulum (displaced) (hypertrophic)

SNOMED

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