Pediatric Meckel Diverticulum
- Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Carmen Cuffari, MD more...
Meckel diverticulum (also referred to as Meckel's diverticulum) is the most common congenital abnormality of the small intestine; it is caused by an incomplete obliteration of the vitelline duct (ie, omphalomesenteric duct). Although originally described by Fabricius Hildanus in 1598, it is named after Johann Friedrich Meckel, who established its embryonic origin in 1809.
Despite the availability of modern imaging techniques, diagnosis is challenging. Although Meckel diverticulum is usually of no medical significance, two types of complications can require clinical attention. One type involves ectopic mucosal tissue and most often leads to GI bleeding in younger children. In the second type, the sequelae lead to an obstruction, inflammation, or rarely perforation of the bowel.
Early in embryonic life, the fetal midgut receives its nutrition from the yolk sac via the vitelline duct. The duct then undergoes progressive narrowing and usually disappears by 7 weeks' gestation. When the duct fails to fully obliterate, different types of vitelline duct anomalies appear. Examples of such anomalies include (1) a persistent vitelline duct (appearing as a draining fistula at the umbilicus); (2) a fibrous band that connects the ileum to the inner surface of the umbilicus; (3) a patent vitelline sinus beneath the umbilicus; (4) an obliterated bowel portion; (5) a vitelline duct cyst; and, most commonly (97%) Meckel diverticulum, which is a blind-ending true diverticulum that contains all of the layers normally found in the ileum. The tip of the diverticulum is free in 75% of cases and is attached to the anterior abdominal wall or another structure in the remainder of cases.
Enterocystomas, umbilical sinuses, and omphaloileal fistulas are among the other congenital anomalies associated with Meckel diverticulum.
The diverticulum is usually supplied by the omphalomesenteric artery (a remnant of the vitelline artery), which arises from the ileal branch of the superior mesenteric artery. Usually, the artery terminates in the diverticulum; however, it has been reported to continue up to the abdominal wall in some cases. Rarely, these blood vessels persist in the form of fibrous remnants that run between the Meckel diverticulum and the abdominal wall or small bowel mesentery.
The Meckel diverticulum is almost always found on the antimesenteric border of the ileum, usually 40-60 cm proximal to the ileocecal valve. On average, the diverticulum is 3 cm long and 2 cm wide. Slightly more than one half contain ectopic mucosa. Meckel diverticulum is typically lined by ileal mucosa, but other tissue types are also found with varying frequency.
Although Meckel diverticulum almost always occurs on the antimesenteric border of the ileum, case reports have described a mesenteric location. As per the rule of 2s, it is usually 2 feet (40-60 cm) proximal to the ileocecal valve, 2 cm wide (and is 3 cm long), found in 2% of the population, often presents before age 2 years, is twice as likely to be symptomatic in boys, and contains ectopic mucosa about half the time. Meckel diverticulum is typically lined by ileal mucosa, but other tissue types are also found with varying frequency.
The heterotopic mucosa is most commonly gastric. This is important because peptic ulceration of this or adjacent mucosa can lead to painless bleeding, perforation, or both. In one study, heterotropic gastric mucosa was found in 62% of cases, pancreatic tissue was found in 6%, both pancreatic tissue and gastric mucosa were found in 5%, jejunal mucosa was found in 2%, Brunner tissue was found in 2% and both gastric and duodenal mucosa were found in 2%. Rarely, colonic, rectal, endometrial, and hepatobiliary tissues have been noted.
The prevalence of Meckel diverticulum is usually noted to be approximately 2% of the population, but published series range from 0.2-4%. Complications are only seen in about 5% of those with the anomaly. In a comprehensive survey of 43 children's hospitals in the United States, 815 children had a Meckel diverticulectomy during a 2-year span. Slightly more than half (60%) were symptomatic and the remainder were incidental in children who had laparotomy for a different reason.
Prevalence figures similar to those found in the United States have been reported in Europe and Asia.
One study investigated the Pediatric Hospital Information System (PHIS) database to identify demographics of patients with ICD-9 diagnoses of Meckel diverticulum and a procedure code for Meckel diverticulectomy. Data from a 9-year period (2004-2012) was analyzed for age, payor, ethnicity and symptoms. The database included patients admitted to 44 children’s hospitals in the United States. The ethnic distribution of symptomatic Meckel diverticulum was 63.4% white, 4.7% African-American, 16.4% Hispanic, 3.9% Asian, and 11.6% other.
Although no sex-based difference was reported in studies that evaluated this condition as an incidental finding during operations or autopsies, males are as much as 3-4 times more prone to complications than females. In a large series of cases from 2007-2008, Meckel diverticulectomy was 2.3 times more common in boys and boys accounted for 74% of the primary cases.
The classic presentation in children is considered to be painless rectal bleeding in a toddler younger than 2 years. One large series found that 53% had surgery before their fourth birthday. However, the largest group (slightly more than 30%) were younger than one year. Although most other pediatric cases occur in patients aged 2-8 years, many continue to present with hematochezia.
Although children usually present with hematochezia and adults usually present with obstruction, the same recent series of 815 children found that a primary diverticulectomy was performed in 30% of the children (< 18 y) for obstruction while 27% presented with bleeding and 19% had intussusception. About one quarter did not have a clear cut diagnosis. Although neonatal presentation of Meckel is rare, case reports have described perforation, intussusception, segmental ileal dilation, ileal volvulus, and massive hematochezia.
A recent literature review of Meckel Diverticulum in the neonatal period found that the most common manifestations in this age were bowel obstruction (58.3%) and pneumoperitoneum (33.3%). In addition, in both term and preterm neonates, males were even more frequently affected than females, with a male-to-female ratio of 6.5:1.
In adults, obstruction and inflammation are more common presentations than lower GI bleeding. Several population-based studies have reported a decreased incidence of complications with increasing age, although other studies have not. Therefore, the issue of incidental diverticulectomy in older patients remains controversial.
Opitz JM, Schultka R, Gobbel L. Meckel on developmental pathology. Am J Med Genet A. 2006 Jan 15. 140(2):115-28. [Medline].
Elsayes KM, Menias CO, Harvin HJ, Francis IR. Imaging manifestations of Meckel's diverticulum. AJR Am J Roentgenol. 2007 Jul. 189(1):81-8. [Medline].
Anderson DJ. Carcinoid tumor in Meckel's diverticulum: laparoscopic treatment and review of the literature. J Am Osteopath Assoc. 2000 Jul. 100(7):432-4. [Medline].
Ghahremani GG. Radiology of Meckel's diverticulum. Crit Rev Diagn Imaging. 1986. 26(1):1-43. [Medline].
Ruscher KA, Fisher JN, Hughes CD, Neff S, Lerer TJ, Hight DW. National trends in the surgical management of Meckel's diverticulum. J Pediatr Surg. 2011 May. 46(5):893-6. [Medline].
Alemayehu H, Hall M, Desai AA, St Peter SD, Snyder CL. Demographic disparities of children presenting with symptomatic Meckel's diverticulum in children's hospitals. Pediatric Surgery International. 2014 Jun 30. 6:649-653. [Medline].
St-Vil D, Brandt ML, Panic S, Bensoussan AL, Blanchard H. Meckel's diverticulum in children: a 20-year review. J Pediatr Surg. 1991 Nov. 26(11):1289-92. [Medline].
Cserni G. Gastric pathology in Meckel's diverticulum. Review of cases resected between 1965 and 1995. Am J Clin Pathol. 1996 Dec. 106(6):782-5. [Medline].
Stone PA, Hofeldt MJ, Campbell JE. Meckel diverticulum: ten-year experience in adults. South Med J. 2004 Nov. 97(11):1038-41. [Medline].
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. 2010 Feb 19. [Medline].
Thirunavukarasu P, Sathaiah M, Sukumar S, et al. Meckel's diverticulum--a high-risk region for malignancy in the ileum. Insights from a population-based epidemiological study and implications in surgical management. Ann Surg. 2011 Feb. 253(2):223-30. [Medline].
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. 1997 May-Jun. 83(3):703-8. [Medline].
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. 1992 Jun. 35(6):589-96. [Medline].
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. 1992 Jul. 87(7):910-3. [Medline].
Beyrouti MI, Ben Amar M, Beyrouti R, et al. [Complications of Meckel's diverticulum. Report of 42 cases]. Tunis Med. 2009 Apr. 87(4):253-6. [Medline].
Halverson JM, Butterman MK, Legier JF, Mann WJ Jr, Hoefer RA Jr. Perforation of Meckel’s diverticulum caused by ingestion of coin. South Med J. 1994 Aug. 87:823-4. [Medline].
Redmond P, Sawaya D, Nowicki M. Bowel obstruction due to multiple retained foreign bodies in a Meckel diverticulum. The Journal of Pediatrics. 2014 Sep. 165:639. [Medline].
DeBartolo HM Jr, van Heerden JA. Meckel's diverticulum. Ann Surg. 1976 Jan. 183(1):30-3. [Medline].
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. 1992 Oct. 164(4):382-3. [Medline].
Park JS, Lim CW, Park T, Cho JM, Seo JS, Youn HS. Meckel diverticulum in a 3- year old girl presenting with periumbilical cellulitis. Pediatric Gastroenterology, Hepatology and Nutriton. 2015 Mar 18. 1:66-70. [Medline]. [Full Text].
Muakkassa FF, Abouchedid C. Littre's hernia. N J Med. 1987 Sep. 84(9):653-5. [Medline].
Al Janabi M, Samuel M, Kahlenberg A, Kumar S. Symptomatic paediatric Meckel's diverticulum: stratified diagnostic indicators and accuracy of Meckel's scan. Nucl Med Commun. 2014 Nov. 35(11):1162-6. [Medline].
Park JJ, Wolff BG, Tollefson MK. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg. 2005 Mar. 241(3):529-33. [Medline].
Connolly SA, Drubach LA, Connolly LP. Meckel's diverticulitis: diagnosis with computed tomography and Tc-99m pertechnetate scintigraphy. Clin Nucl Med. 2004 Dec. 29(12):823-4. [Medline].
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. 2004 May. 20(5):323-5. [Medline].
Wilton G, Froelich JW. The "false-negative" Meckel's scan. Clin Nucl Med. 1982 Oct. 7(10):441-3. [Medline].
Petrokubi RJ, Baum S, Rohrer GV. Cimetidine administration resulting in improved pertechnetate imaging of Meckel's diverticulum. Clin Nucl Med. 1978 Oct. 3(10):385-8. [Medline].
Rossi P, Gourtsoyiannis N, Bezzi M, et al. Meckel's diverticulum: imaging diagnosis. AJR Am J Roentgenol. 1996 Mar. 166(3):567-73. [Medline].
Sagar J, Kumar V, Shah DK. Meckel's diverticulum: a systematic review. J R Soc Med. 2006 Oct. 99(10):501-5. [Medline].
Vali R, Daneman A, McQuattie S, Shammas A. The value of repeat scintigraphy in patients with a high clinical suspicion for Meckel diverticulum after a negative or equivocal first Meckel scan. Pediatr Radiol. 2015 Sep. 45(10):1506-14. [Medline].
Kawamoto S, Raman SP, Blackford A, Hruban RH, Fishman EK. CT Detection of symptomatic and asymptomatic Meckel diverticulum. AJR Am J Roentgenol. 2015 Aug. 205(2):281-291. [Medline].
Zhang M, Zhuang H, Luo Y. Retrospective analysis of ultrasound imaging characteristics of 58 patients with Meckel's diverticulum disease. Sheng Wu Yi Xue Gong Cheng Xue Za Zhi. 2014 Aug. 31(4):875-80. [Medline].
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. 2009 Nov. 58(11):1467-72. [Medline].
Yoshikawa T, Suzuki N, Kikuyama M, Watanabe M. Virtual enteroscopic images of inverted Meckel's diverticulum. Dig Liver Dis. 2011 Oct. 43(10):834. [Medline].
Tuzun A, Polat Z, Kilciler G, Turan I, Kilic A, Ozcan A. Evaluation for Helicobacter pylori in Meckel's diverticulum by using real-time PCR. Dig Dis Sci. 2010 Jul. 55(7):1969-74. [Medline].
Steinwald PM, Trachiotis GD, Tannebaum IR. Intussusception in an adult secondary to an inverted Meckel's diverticulum. Am Surg. 1996 Nov. 62(11):889-94. [Medline].
DiGiacomo JC, Cottone FJ. Surgical treatment of Meckel's diverticulum. South Med J. 1993 Jun. 86(6):671-5. [Medline].
Sanders LE. Laparoscopic treatment of Meckel's diverticulum. Obstruction and bleeding managed with minimal morbidity. Surg Endosc. 1995 Jun. 9(6):724-7. [Medline].
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].
Palanivelu C, Jategaonkar PA, Rangarajan M. Complicated Meckel's diverticulum in pediatrics: role of laparoscopy-two rare cases. J Laparoendosc Adv Surg Tech A. 2009 Apr. 19(2):245-8. [Medline].
Qi S, Huang H, Wei D, Lv C, Yang Y. Diagnosis and minimally invasive surgical treatment of bleeding Meckel's diverticulum in children using double-balloon enteroscopy. J Pediatr Surg. 2015 Sep. 50(9):1610-2. [Medline].
Papparella A, Nino F, Noviello C, Marte A, Parmeggiani P, Martino A, et al. Laparoscopic approach to Meckel's diverticulum. World J Gastroenterol. 2014 Jul 07. 20(25):8173-8. [Medline].
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. 1976 Aug. 132(2):168-73. [Medline].
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].
Cullen JJ, Kelly KA, Moir CR, et al. Surgical management of Meckel's diverticulum. An epidemiologic, population-based study. Ann Surg. 1994 Oct. 220(4):564-8; discussion 568-9. [Medline].
Farrar MJ. Meckel's diverticulum: should it be excised prophylactically in service personnel?. J R Army Med Corps. 1994 Feb. 140(1):42-4. [Medline].
Garretson DC, Frederich ME. Meckel's diverticulum. Am Fam Physician. 1990 Jul. 42(1):115-9. [Medline].
[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].
Imaeda T, Kanematsu M, Sone Y, et al. A case of intermittent bleeding Meckel's diverticulum. Ann Nucl Med. 1990 Nov. 4(3):107-10. [Medline].
Levy AD, Hobbs CM. From the archives of the AFIP. Meckel diverticulum: radiologic features with pathologic Correlation. Radiographics. 2004 Mar-Apr. 24(2):565-87. [Medline].
Malhotra S, Roth DA, Gouge TH, et al. Gangrene of Meckel's diverticulum secondary to axial torsion: a rare complication. Am J Gastroenterol. 1998 Aug. 93(8):1373-5. [Medline].
Matsukuma Y, Matsuo Y, Sakaguchi M, et al. A case of siblings with Meckel's diverticulum diagnosed before operation. Acta Paediatr Jpn. 1994 Jun. 36(3):291-3. [Medline].
Mitchell AW, Spencer J, Allison DJ, Jackson JE. Meckel's diverticulum: angiographic findings in 16 patients. AJR Am J Roentgenol. 1998 May. 170(5):1329-33. [Medline].
Mostbeck GH, Liskutin J, Dorffner R, Bittmann B, Resinger M. Ultrasonographic diagnosis of a bleeding Meckel's diverticulum. Pediatr Radiol. 2000 Jun. 30(6):382. [Medline].
Parler DW, Cathcart RS 3d. Crohn's disease of a Meckel's diverticulum causing diverticulitis and small bowel obstruction. South Med J. 1989 Sep. 82(9):1190-1. [Medline].
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. 2006 May-Jun. 26(3):641-57; discussion 657-62. [Medline].
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. 2007 Feb. 23(2):141-7. [Medline].
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].
Simms M, Malatjalian DA, Fried L, al-Jawad H. Inverted Meckel's diverticulum simulating a pedunculated small bowel polyp. Abdom Imaging. 1995 May-Jun. 20(3):236-7. [Medline].
Sinha CK, Fishman J, Clarke SA. Neonatal Meckel's diverticulum: spectrum of presentation. Pediatr Emerg Care. 2009 May. 25(5):348-9. [Medline].
Van Hee R, Brewaeys P, Buyssens N. Ileal intussusception due to invagination of Meckel's diverticulum. Acta Chir Belg. 1992 Jan-Feb. 92(1):55-9. [Medline].
Vane, DW, West KW, Grosfeld JL. Vitelline duct anomalies. Experience with 217 childhood cases. Arch Surg. May 1987. 122:542-7. [Medline].
Yao JL, Zhou H, Roche K, et al. Adenomyoma arising in a meckel diverticulum: case report and review of the literature. Pediatr Dev Pathol. 2000 Sep-Oct. 3(5):497-500. [Medline].