Pediatric Meckel Diverticulum Clinical Presentation

  • Author: Simon S Rabinowitz, MD, PhD; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Mar 18, 2010
 

History

Most patients are asymptomatic. Meckel diverticulum is most frequently diagnosed as an incidental finding when a barium study or laparotomy is performed for other abdominal conditions.

  • Symptomatic Meckel diverticulum is virtually synonymous with a complication. This is estimated to occur in as many as 4-16% of patients.[2] Complications are the result of obstruction, ectopic tissue, or inflammation. In one study of 830 patients of all ages, complications included bowel obstruction (35%), hemorrhage (32%), diverticulitis (22%), umbilical fistula (10%), and other umbilical lesions (1%).
  • In children, hematochezia is the most common presenting sign.[6] Bleeding in adults is much less common.[7, 8]
    • Acute lower GI bleeding is secondary to hemorrhage from peptic ulceration. Such ulceration occurs when acid secreted by heterotopic gastric mucosa damages contiguous vulnerable tissue, often times resulting in direct erosion of a vessel. Clinically, hemorrhage is usually noted to be substantial painless rectal bleeding. However, some patients may present only with pain preceding the onset of hematochezia. The pain can be quite significant and often delays the correct diagnosis.
    • Not all patients have abdominal pain; however, when present, it can be significant. A rare cause of abdominal pain from the Meckel diverticulum is inversion without intussusception.[9]
  • Although intestinal obstruction in pediatrics is not considered very prevalent, some series report it in 25-40% of pediatric complications. It is the most common complication in adults. Obstruction can be the result of various mechanisms.[2]
    • Omphalomesenteric band (most frequent cause)
    • Internal hernia through vitelline duct remnants
    • Volvulus occurring around vitelline duct remnants
    • T-shaped prolapse of both efferent and afferent loops of intestine through a persistent vitelline duct fistula at the umbilicus in a neonate
    • Intussusception (when Meckel diverticulum itself acts as a lead point for an ileocolic or ileoileal intussusception)
  • None of these mechanisms have clinical features that are pathognomonic, and the precise etiology is rarely known preoperatively.
  • Like other diverticula in the body, Meckel diverticulum can become inflamed. Diverticulitis is usually seen in older patients. Meckel diverticulum is less prone to inflammation than the appendix because most diverticula have a wide mouth, have very little lymphoid tissue, and are self-emptying.
    • The clinical presentation includes abdominal pain in the periumbilical area that radiates to the right lower quadrant.
    • Persistence of periumbilical pain or a history of bleeding per rectum may be helpful in distinguishing this entity from appendicitis.
    • Subacute or chronic inflammation of Meckel diverticulum is rare, but a few cases of tuberculosis and Crohn disease within the diverticulum have been reported.
  • Less frequently, the Meckel diverticulum may develop benign tumors (eg, leiomyomas, angiomas, neuromas, lipomas) or malignant neoplasms (eg, sarcoma,[10]carcinoid tumor,[11] adenocarcinomas[12] , and Burkitt lymphoma.[13] Rarely, it may perforate from a swallowed fish bone or sewing needle.
Next

Physical

Although most patients are asymptomatic, patients can present with various clinical signs, including peritonitis or hypovolemic shock. The 3 most common symptomatic presentations are GI bleeding, intestinal obstruction, and acute inflammation of the diverticulum.

  • Most often, painless rectal bleeding (hematochezia) occurs suddenly and tends to be massive in younger patients.[14] Bleeding occurs without prior warning and usually spontaneously subsides.
    • When a severe bleeding episode occurs, the patient can present in hemorrhagic shock. Tachycardia is an early clinical sign of hemorrhagic shock, but orthostatic hypotension may actually precede this.
    • The color of the stool often provides physicians with a clue to determine the site of bleeding. This has been well addressed in a classic description of the types of rectal bleeding associated with Meckel diverticulum.[15]
    • Prevalence of different types of bleeding has been described as follows:
      • Dark red (maroon) - 40%
      • Bright red - 35%
      • Bright red or dark red - 12%
      • Dark red or tarry - 6%
      • Tarry - 7%
    • When bleeding is rapid, stools are bright red or have an appearance like currant jelly. When slow bleeding occurs, the stools are black and tarry.
    • Most patients with intestinal obstruction present with abdominal pain, bilious vomiting, abdominal tenderness, distension, and hyperactive bowel sounds upon examination.
    • Patients may develop a palpable abdominal mass.
    • Occasionally, when patients do not present early or if the diagnosis is missed, the obstruction can progress to intestinal ischemia or infarction. The latter manifests with acute peritoneal signs and lower GI bleeding.
  • Patients with diverticulitis present with either focal or diffuse abdominal tenderness. Usually, abdominal tenderness is more marked in the periumbilical region than the pain of appendicitis.
    • Children may present with abdominal guarding and rebound tenderness, in addition to abdominal tenderness.
    • Abdominal distention and hypoactive bowel sounds are late findings.
  • Rarely, Meckel diverticulum has been reported to become incarcerated in the inguinal (Littre hernia),[16] femoral, or obturator hernial sacs.
Previous
Next

Causes

Meckel diverticulum is caused by the failure of the omphalomesenteric duct to completely obliterate at 5-7 weeks' gestation, followed by one of the various complications listed above.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Simon S Rabinowitz, MD, PhD  Professor of Clinical Pediatrics, New York Medical College; Chairman, Chief and Medical Administrator, Department of Pediatrics, Chief, Pediatric Gastroenterology and Nutrition, Richmond University Medical Center

Simon S Rabinowitz, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Gastroenterology, American Gastroenterological Association, American Medical Association, New York Academy of Sciences, North American Society for Pediatric Gastroenterology and Nutrition, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

Coauthor(s)

Hongye Li, MD  Resident Physician, Department of Pediatrics, Richmond University Medical Center, New York

Hongye Li, MD is a member of the following medical societies: American Academy of Pediatrics and American Society of Nephrology

Disclosure: Nothing to disclose.

Specialty Editor Board

Alan D Schmetzer, MD  Professor and Vice-Chair for Education, Director of Residency Training, Department of Psychiatry, Indiana University School of Medicine

Alan D Schmetzer, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, American Society of Transplant Surgeons, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Steven M Schwarz, MD, FAAP, FACN, AGAF  Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center

Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research

Disclosure: Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor; Johnson & Johnson, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References

  1. Opitz JM, Schultka R, Gobbel L. Meckel on developmental pathology. Am J Med Genet A. Jan 15 2006;140(2):115-28. [Medline].

  2. Elsayes KM, Menias CO, Harvin HJ, Francis IR. Imaging manifestations of Meckel's diverticulum. AJR Am J Roentgenol. Jul 2007;189(1):81-8. [Medline].

  3. Anderson DJ. Carcinoid tumor in Meckel's diverticulum: laparoscopic treatment and review of the literature. J Am Osteopath Assoc. Jul 2000;100(7):432-4. [Medline].

  4. Ghahremani GG. Radiology of Meckel's diverticulum. Crit Rev Diagn Imaging. 1986;26(1):1-43. [Medline].

  5. Sinha CK, Fishman J, Clarke SA. Neonatal Meckel's diverticulum: spectrum of presentation. Pediatr Emerg Care. May 2009;25(5):348-9. [Medline].

  6. St-Vil D, Brandt ML, Panic S, Bensoussan AL, Blanchard H. Meckel's diverticulum in children: a 20-year review. J Pediatr Surg. Nov 1991;26(11):1289-92. [Medline].

  7. Cserni G. Gastric pathology in Meckel's diverticulum. Review of cases resected between 1965 and 1995. Am J Clin Pathol. Dec 1996;106(6):782-5. [Medline].

  8. Stone PA, Hofeldt MJ, Campbell JE. Meckel diverticulum: ten-year experience in adults. South Med J. Nov 2004;97(11):1038-41. [Medline].

  9. Yigiter M, Kiyici H, Yucesan S, Hicsonmez A. An unusual cause of acute abdominal pain in a child: An inverted meckel diverticulum: Report of a case. J Clin Ultrasound. Feb 19 2010;[Medline].

  10. Calderale SM, Marchioni L, Malizia A, et al. Malignant stromal tumor consistent with fibrosarcoma arising from Meckel's diverticulum. Clinicopathological study of an incidentally discovered tumor and review of the literature. Tumori. May-Jun 1997;83(3):703-8. [Medline].

  11. Nies C, Zielke A, Hasse C, et al. Carcinoid tumors of Meckel's diverticula. Report of two cases and review of the literature. Dis Colon Rectum. Jun 1992;35(6):589-96. [Medline].

  12. Kusumoto H, Yoshitake H, Mochida K, et al. Adenocarcinoma in Meckel's diverticulum: report of a case and review of 30 cases in the English and Japanese literature. Am J Gastroenterol. Jul 1992;87(7):910-3. [Medline].

  13. Beyrouti MI, Ben Amar M, Beyrouti R, et al. [Complications of Meckel's diverticulum. Report of 42 cases]. Tunis Med. Apr 2009;87(4):253-6. [Medline].

  14. DeBartolo HM Jr, van Heerden JA. Meckel's diverticulum. Ann Surg. Jan 1976;183(1):30-3. [Medline].

  15. Kusumoto H, Yoshida M, Takahashi I, Anai H, Maehara Y, Sugimachi K. Complications and diagnosis of Meckel's diverticulum in 776 patients. Am J Surg. Oct 1992;164(4):382-3. [Medline].

  16. Muakkassa FF, Abouchedid C. Littre's hernia. N J Med. Sep 1987;84(9):653-5. [Medline].

  17. Park JJ, Wolff BG, Tollefson MK. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg. Mar 2005;241(3):529-33. [Medline].

  18. Connolly SA, Drubach LA, Connolly LP. Meckel's diverticulitis: diagnosis with computed tomography and Tc-99m pertechnetate scintigraphy. Clin Nucl Med. Dec 2004;29(12):823-4. [Medline].

  19. Rerksuppaphol S, Hutson JM, Oliver MR. Ranitidine-enhanced 99mtechnetium pertechnetate imaging in children improves the sensitivity of identifying heterotopic gastric mucosa in Meckel's diverticulum. Pediatr Surg Int. May 2004;20(5):323-5. [Medline].

  20. Wilton G, Froelich JW. The "false-negative" Meckel's scan. Clin Nucl Med. Oct 1982;7(10):441-3. [Medline].

  21. Petrokubi RJ, Baum S, Rohrer GV. Cimetidine administration resulting in improved pertechnetate imaging of Meckel's diverticulum. Clin Nucl Med. Oct 1978;3(10):385-8. [Medline].

  22. Rossi P, Gourtsoyiannis N, Bezzi M, et al. Meckel's diverticulum: imaging diagnosis. AJR Am J Roentgenol. Mar 1996;166(3):567-73. [Medline].

  23. Sagar J, Kumar V, Shah DK. Meckel's diverticulum: a systematic review. J R Soc Med. Oct 2006;99(10):501-5. [Medline].

  24. Fritscher-Ravens A, Scherbakov P, Bufler P, et al. The feasibility of wireless capsule endoscopy in detecting small intestinal pathology in children under the age of 8 years: a multicentre European study. Gut. Nov 2009;58(11):1467-72. [Medline].

  25. Steinwald PM, Trachiotis GD, Tannebaum IR. Intussusception in an adult secondary to an inverted Meckel's diverticulum. Am Surg. Nov 1996;62(11):889-94. [Medline].

  26. DiGiacomo JC, Cottone FJ. Surgical treatment of Meckel's diverticulum. South Med J. Jun 1993;86(6):671-5. [Medline].

  27. Sanders LE. Laparoscopic treatment of Meckel's diverticulum. Obstruction and bleeding managed with minimal morbidity. Surg Endosc. Jun 1995;9(6):724-7. [Medline].

  28. Shalaby RY, Soliman SM, Fawy M, Samaha A. Laparoscopic management of Meckel's diverticulum in children. J Pediatr Surg. March/2005;40:562-7. [Medline].

  29. Palanivelu C, Jategaonkar PA, Rangarajan M. Complicated Meckel's diverticulum in pediatrics: role of laparoscopy-two rare cases. J Laparoendosc Adv Surg Tech A. Apr 2009;19(2):245-8. [Medline].

  30. Soltero MJ, Bill AH. The natural history of Meckel's Diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel's Diverticulum found in King County, Washington, over a fifteen year period. Am J Surg. Aug 1976;132(2):168-73. [Medline].

  31. McKay R. High incidence of symptomatic Meckel's diverticulum in patients less than fifty years of age: an indication for resection. Am Surg. March/2007;73:271-5. [Medline].

  32. Cullen JJ, Kelly KA, Moir CR, et al. Surgical management of Meckel's diverticulum. An epidemiologic, population-based study. Ann Surg. Oct 1994;220(4):564-8; discussion 568-9. [Medline].

  33. Farrar MJ. Meckel's diverticulum: should it be excised prophylactically in service personnel?. J R Army Med Corps. Feb 1994;140(1):42-4. [Medline].

  34. Garretson DC, Frederich ME. Meckel's diverticulum. Am Fam Physician. Jul 1990;42(1):115-9. [Medline].

  35. [Guideline] Gomes AS, Yucel EK, Bettmann MA, Casciani T, Grollman JH, Holtzman SR, Polak JF, Sacks D, Schoepf UJ, Stanford W, Jaff M, Moneta GL, Expert Panel on Cardiovascular Imaging. Hematemesis. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. [Full Text].

  36. Imaeda T, Kanematsu M, Sone Y, et al. A case of intermittent bleeding Meckel's diverticulum. Ann Nucl Med. Nov 1990;4(3):107-10. [Medline].

  37. Levy AD, Hobbs CM. From the archives of the AFIP. Meckel diverticulum: radiologic features with pathologic Correlation. Radiographics. Mar-Apr 2004;24(2):565-87. [Medline].

  38. Malhotra S, Roth DA, Gouge TH, et al. Gangrene of Meckel's diverticulum secondary to axial torsion: a rare complication. Am J Gastroenterol. Aug 1998;93(8):1373-5. [Medline].

  39. Matsukuma Y, Matsuo Y, Sakaguchi M, et al. A case of siblings with Meckel's diverticulum diagnosed before operation. Acta Paediatr Jpn. Jun 1994;36(3):291-3. [Medline].

  40. Mitchell AW, Spencer J, Allison DJ, Jackson JE. Meckel's diverticulum: angiographic findings in 16 patients. AJR Am J Roentgenol. May 1998;170(5):1329-33. [Medline].

  41. Mostbeck GH, Liskutin J, Dorffner R, Bittmann B, Resinger M. Ultrasonographic diagnosis of a bleeding Meckel's diverticulum. Pediatr Radiol. Jun 2000;30(6):382. [Medline].

  42. Parler DW, Cathcart RS 3d. Crohn's disease of a Meckel's diverticulum causing diverticulitis and small bowel obstruction. South Med J. Sep 1989;82(9):1190-1. [Medline].

  43. Paulsen SR, Huprich JE, Fletcher JG, et al. CT enterography as a diagnostic tool in evaluating small bowel disorders: review of clinical experience with over 700 cases. Radiographics. May-Jun 2006;26(3):641-57; discussion 657-62. [Medline].

  44. Sai Prasad TR, Chui CH, Singaporewalla FR, Ong CP, Low Y, Yap TL. Meckel's diverticular complications in children: is laparoscopy the order of the day?. Pediatr Surg Int. Feb 2007;23(2):141-7. [Medline].

  45. Shimizu N, Kuramoto S, Mimura T, et al. Leiomyosarcoma originating in Meckel's diverticulum: report of a case and a review of 59 cases in the English literature. Surg Today. 1997;27(6):546-9. [Medline].

  46. Simms M, Malatjalian DA, Fried L, al-Jawad H. Inverted Meckel's diverticulum simulating a pedunculated small bowel polyp. Abdom Imaging. May-Jun 1995;20(3):236-7. [Medline].

  47. Van Hee R, Brewaeys P, Buyssens N. Ileal intussusception due to invagination of Meckel's diverticulum. Acta Chir Belg. Jan-Feb 1992;92(1):55-9. [Medline].

  48. Vane, DW, West KW, Grosfeld JL. Vitelline duct anomalies. Experience with 217 childhood cases. Arch Surg. May 1987;122:542-7. [Medline].

  49. Yao JL, Zhou H, Roche K, et al. Adenomyoma arising in a meckel diverticulum: case report and review of the literature. Pediatr Dev Pathol. Sep-Oct 2000;3(5):497-500. [Medline].

 
Previous
Next
 
Anteroposterior view of abdominal radiograph showing multiple dilated loops of a small bowel with air-fluid levels.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.