Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition (Strange, Pediatric Emergency Medicine), 4th Ed.

CHAPTER 49. Meckel’s Diverticulum

Jay Pershad

Eunice Y. Huang

HIGH-YIELD FACTS

• The classical presentation of Meckel’s diverticulum is painless bright-red bleeding per rectum.

• The nuclear medicine technetium-99m pertechnetate scan (Meckel’s scan) is the imaging procedure of choice for the diagnosis of Meckel’s diverticulum.

Bleeding per rectum is a common complaint among children seeking care at an emergency department (ED). In general, the differential diagnosis of hematochezia can be divided into conditions causing painful or painless rectal bleeding. Large volume, painless rectal bleeding suggests a specific, localizable lesion. The most common causes of such painless rectal bleeding in children are Meckel’s diverticulum and colonic juvenile polyps.

Meckel’s diverticulum is a persistent remnant of the omphalomesenteric duct that is seen in 2% of the population.1 A typical Meckel’s diverticulum is approximately 2 in (5 cm) long and is located on the antimesenteric border of the ileum, most commonly within 2 ft (approximately 60 cm) of the ileocecal valve, and, thus, is usually located in the right lower quadrant. More than 60% of patients who develop symptoms are younger than 2 years of age, and there are two types of mucosa, gastric and pancreatic, seen in the diverticulum. These findings of Meckel’s diverticulum are commonly referred to as the “rule of twos.”

Approximately 4% to 35% of affected individuals experience symptoms associated with a Meckel’s diverticulum.2 The most common presentation in children younger than age 4 is painless rectal bleeding secondary to the acid secretion of functional ectopic gastric mucosa. This results in ulceration of the adjacent ileal mucosa and bleeding, which may present as hematochezia or less commonly as melena. Less-frequent presentations include Meckel’s diverticulitis (which can mimic appendicitis), intestinal obstruction from intussusception, herniation of bowel through a patent omphalomesenteric fistula, or volvulus of bowel around a fibrous omphalomesenteric remnant attachment to the abdominal wall, and (rarely) perforation from an ingested foreign body trapped in the diverticulum.36

PRESENTATION AND MANAGEMENT

Management of the Meckel’s diverticulum consists of hemodynamic stabilization followed by surgical resection. A child who experiences gastrointestinal bleeding from a Meckel’s diverticulum typically presents acutely, with large volume (>30 mL) rectal bleeding that may require transfusion. The diagnostic imaging modality of choice is the nuclear medicine Technetium-99m pertechnetate scan (Meckel’s scan).7 It localizes ectopic gastric mucosa that is found within the Meckel’s diverticulum (Fig. 49-1) and elsewhere such as in enteric duplication cysts.2,8 A technetium-99m pertechnetate scan identifies the lesion in approximately 80% to 90% of cases.

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FIGURE 49-1. Technetium-99m pertechnetate scan of Meckel’s diverticulum. Solid arrow shows diverticulum seen in the coronal view. Open arrow shows diverticulum seen in the sagittal view.

False-positive results can occur with ureteral obstruction, inflammatory masses such as those seen in Crohn’s disease, abscess, arteriovenous malformation, or intussusception. A negative scan should not delay surgical intervention if bleeding from a Meckel’s diverticulum is strongly suspected. Technetium 99m-labeled red cell scan, also called a “bleeding scan,” can also help to localize a lesion that bleeds intermittently or at a low rate (0.1–0.3 mL/min or 500 mL/day) and eludes endoscopic detection. Labeled red cells remain in circulation for up to 5 days, which allows detection of intermittent bleeding. In rare cases in which Meckel’s diverticulum is strongly suspected and the Meckel’s scan yields negative results, abdominal computed tomography scan, angiography, and exploratory laparoscopy can be considered.9Once confirmed, the definitive treatment is excision of the lesion.

Other possibilities for painless rectal bleeding include juvenile colonic polyps, and, less commonly, hemangiomas, venous malformations, or a brisk upper gastrointestinal bleed. The investigations for these conditions are beyond the scope of ED management.

REFERENCES

1. Pepper VK, Stanfill AB, Pearl RH. Diagnosis and management of pediatric appendicitis, intussusception, and Meckel’s diverticulum. Surg Clin North Am. 2012;92:505.

2. Sawin RS. Appendix and Meckel’s diverticulum. In: Oldham KT, Colombani PM, Foglia RP, Skinner MA, eds. Principles and Practice of Pediatric Surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2005:1269.

3. Jelenc F, Strlic M, Gvardijancic D. Meckel’s diverticulum perforation with intraabdominal hemorrhage. J Pediatr Surg. 2002;37:E18.

4. Ko SF, Tiao MM, Huang FC, et al. Internal hernia associated with Meckel’s diverticulum in 2 pediatric patients. Am J Emerg Med. 2008;26:86.

5. Menezes M, Tareen F, Saeed A, Khan N, Puri P. Symptomatic Meckel’s diverticulum in children: a 16-year review. Pediatr Surg Int. 2008;24:575.

6. Tseng YY, Yang YJ. Clinical and diagnostic relevance of Meckel’s diverticulum in children. Eur J Pediatr. 2009;168:1519.

7. Thurley PD, Halliday KE, Somers JM, et al. Radiological features of Meckel’s diverticulum and its complications. Clin Radiol. 2009;64:109.

8. Lunia S, Lunia C, Chandramouly B, Chodos RB. Radionuclide Meckel’sogram with particular reference to false-positive results. Clin Nucl Med. 1979;4:285.

9. Brenes RA, Abbas HM, Palesty JA, Tripodi G. Difficulty in identifying a bleeding Meckel’s diverticulum: case report and review of the literature. Conn Med. 2010;74:333.