Pediatric Meckel Diverticulum Treatment & Management
- Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Carmen Cuffari, MD more...
The emergency department evaluation and treatment of patients depends on the clinical presentation of Meckel diverticulum.
- Because most symptomatic patients are acutely ill, establish an intravenous line immediately, start crystalloid fluids, and keep the patient on nothing by mouth (NPO) status. Obtain the blood investigations suggested above with a type and cross match.
- If significant bleeding occurs, perform a transfusion of packed red cells.
- A patient who presents with intestinal obstruction usually requires nasogastric (NG) decompression. After passing the NG tube, perform plain radiography of the abdomen.
- When a child presents with bleeding, specifically a dark tarry stool, perform a gastric lavage to rule out upper GI bleeding. If the gastric lavage is negative for bleeding, consider an upper endoscopy and flexible sigmoidoscopy.
- Meckel scan results may be negative despite a high clinical suspicion of Meckel diverticulum. The surgery team should be consulted to discuss the possible need for laparoscopy and/or laparotomy, even without a nuclear medicine diagnosis.
If the patient is bleeding but is hemodynamically stable, a Meckel scan is warranted. On the other hand, the presence of peritoneal signs or hemodynamic instability demands urgent surgical intervention. Signs of small bowel obstruction also require surgical intervention.
- Definitive treatment of a complication, such as a bleeding Meckel diverticulum, is the excision of the diverticulum along with the adjacent ileal segment.
- Excision is carried out by performing a wedge resection of adjacent ileum and anastomosis, with the use of a stapling device. Adjacent ileum is included in the resection because ulcers frequently develop in the adjacent part of the ileum.
- In those rare instances when the diverticulum is located on the mesenteric border, resection and anastomosis is preferred instead of a wedge resection.
- Successful resection of a Meckel diverticulum, even in children and infants, can also be accomplished through laparoscopy, using an endoscopically designed autostapling device.[38, 39, 40] A large series of national trends in the surgical management of Meckel diverticulum found that one fourth of cases are now treated laparoscopically. This group was older (6.4 y ± 5.1 y vs 5.1 y ± 5.3 y) and had shorter length of stay and trended toward lower total hospital charges.
- In some cases of Meckel diverticulum, a primitive persistent right vitelline artery originating from the mesentery has been found during operation. When present, the artery is found to supply the Meckel diverticulum; therefore, it must be identified and ligated during the operation.
- A new technique using double-balloon enteroscopy (DBE) to diagnose a bleeding Meckel diverticulum and to assist in a minimally invasive standard surgical resection has been described. Previously, DBE has been used as a diagnostic tool followed by laparoscopic treatment of Meckel diverticulum.
- Twenty-one patients with melena and or/maroon-colored stools had retrograde transanal DBE as the initial diagnostic method once they were stabilized. The enteroscope was passed from the cecum into the terminal ileum and then advanced until a lesion was identified. The light source was then manipulated to bring the lesion close to the umbilicus. An incision was made at the umbilicus. The diverticulum was then removed, resected, and after an intestinal anastomosis. The bowel was placed back in abdominal cavity. This approach revealed Meckel diverticulum in 14 patients, who were all successfully treated. Five had a negative DBE study, and 2 had a lesion that prevented insertion of the enteroscope.
- A clear advantage of this technique is direct visualization of the distal small bowel lumen permits easy identification of the bleeding source. Noninvasive diagnostic methods such as ultrasonography, scintigraphy, and CT scanning often yield false positive or false negative results which may delay laparoscopy and treatment in pediatric patients. One potential significant limitation of this technique is that the upper small bowel is not examined. Thus DBE should not be routinely used as the first investigation to diagnose gastrointestinal bleeding presenting with a large quantity of melena and/or maroon-colored stools.
- The most common postoperative complication after Meckel’s diverticulectomy is adhesive intestinal obstruction. This usually presents with gastrointestinal bleeding, and most commonly been reported in patients with an ischemic and congested intestine.
- Management of Meckel diverticulum in asymptomatic patients is controversial.
- In the past, if a Meckel diverticulum was encountered in a patient undergoing abdominal surgery for some other intra-abdominal condition, many surgeons recommended its removal.
- This practice was questioned when a large series described an overall 4.2% likelihood of complications in Meckel diverticulum and a decreasing risk with increasing age. These authors concluded that assuming a 6% mortality rate from Meckel diverticulum complications, 400 asymptomatic diverticula would have to be excised to save one patient.
- Another faction favors prophylactic removal of a diverticulum, which is a simple operation. This view is supported by data that demonstrate that managing a complication of Meckel diverticulum is associated with high morbidity and mortality rates. Others feel the only exception to universal excision is if the diverticulum is so broad based or so short that stapled excision cannot be performed technically. Fortunately, patients are less likely to develop complications in both of these situations.
- One recent small series suggested that only patients younger than 50 years clearly benefitted from removal if discovered unintentionally.
See the list below:
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].