eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Meckel Diverticulum: Treatment & Medication

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
Coauthor(s): Pauline K Mills, MD, Staff Physician, Department of Pediatrics, New York Medical College, Richmond University Medical Center; Madhavi Katturupalli, MD, Resident Physician, Department of Pediatrics, New York Medical College, Richmond University Medical Center; Hongye Li, MD, Resident Physician, Department of Pediatrics, Richmond University Medical Center, New York
Contributor Information and Disclosures

Updated: Nov 2, 2009

Treatment

Medical Care

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 decompression; also 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.

Surgical Care

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.22

  • 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.23
    • Successful resection of a Meckel diverticulum, even in children and infants, can also be accomplished through laparoscopy, using an endoscopically designed autostapling device.24,25,26
    • 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.
  • 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.27
    • 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.28

Consultations

  • Radiologist
  • Surgeon
  • Gastroenterologist

Medication

In addition to the definitive therapy, urgently administer a regimen of antibiotics (eg, ampicillin, gentamicin, and clindamycin or cefotetan) whenever acute Meckel diverticulitis, strangulation, perforation, or signs of small bowel obstruction or sepsis are present.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.


Ampicillin (Omnipen, Marcillin)

Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

Adult

2-8 g IV/IM qd divided q4-6h

Pediatric

50 mg/kg IV/IM q4-6h

Increased risk of bleeding with concomitant oral anticoagulants; increased blood concentrations with aspirin and probenecid; decreased effectiveness of PO contraceptives

Documented hypersensitivity; life-threatening reactions to other beta-lactams

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Possible need to adjust dose with renal failure; evaluate carefully to differentiate nonallergic ampicillin rash from hypersensitivity reaction


Clindamycin (Cleocin)

Useful treatment for serious skin and soft tissue infections caused by most staphylococci strains. Also effective against entericaerobic and anaerobic flora, except enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome, where it preferentially binds to the 50S ribosomal subunit, causing bacterial replication inhibition.

Adult

300-900 mg IV/IM q6-12h; not to exceed 4800 mg/d

Pediatric

<1 month: Contraindicated
>1 month: 8-25 mg/kg/d PO as palmitate divided tid/qid or 20-40 mg/kg/d IV/IM divided tid/qid

Increased duration of neuromuscular blockade induced by tubocurarine and pancuronium

Documented hypersensitivity; allergy to lincomycin; ulcerative colitis; age <1 mo

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in elderly patients, nursing mothers, and with renal, hepatic, or intestinal disease; possible need for dose adjustment with severe hepatic dysfunction; conversely, no adjustment necessary with renal insufficiency; use associated with severe and possibly fatal colitis


Gentamicin (Gentacidin, Garamycin)

If used in combination with an antianaerobic agent, such as clindamycin or metronidazole, provides broad gram-negative and anaerobic coverage. Dosing regimens are numerous and adjusted on the basis of creatinine clearance and changes in distribution volume.

Adult

2 mg/kg IV loading dose before surgery; 3-5 mg/kg/d IV divided tid/qid thereafter

Pediatric

Neonates and infants: 7.5 mg/kg/d IV divided tid
Children: 6-7.5 mg/kg/d IV divided tid

Nephrotoxic potential; possible increased toxicity with concurrent administration of other aminoglycosides, cephalosporins, penicillins, and amphotericin B; effects of neuromuscular blocking agents enhanced by aminoglycosides, thus, prolonged respiratory depression may occur; auditory toxicity of aminoglycosides appears to increase with concomitant use of loop diuretics; hearing loss of varying degrees possible and potentially irreversible; monitor patients regularly

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Not for long-term therapy because of narrow therapeutic index and toxicity with extended administration; not for patients with severe renal failure (ie, patients not undergoing hemodialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission; adjust dose with renal impairment. Obtain trough and peak levels 30 min before and after the third dose to minimize toxicity.


Cefotetan (Cefotan)

Second-generation cephalosporin used as single-drug therapy to provide broad gram-negative coverage and anaerobic coverage. Half-life is 3.5 h. Inhibits bacterial cell wall synthesis by binding to >1 of the penicillin-binding proteins; inhibits final transpeptidation step of peptidoglycan synthesis, resulting in cell wall death.
Antibiotics have proven effective in decreasing rate of postoperative wound infection and improving outcome in patients with intraperitoneal infection and septicemia.

Adult

2 g IV before surgery

Pediatric

Suggested dose:
<3 months: Not established
>3 months: 30-40 mg/kg IV once, prior to surgery

Possible acute alcohol intolerance (disulfiramlike reaction) if alcoholic beverages consumed concurrently or within 72 h of administration; possible increased hypoprothrombinemic effects of anticoagulants with coadministration of cephalosporins with the methyltetrazolethiol side chain (eg, cefotetan); monitor renal function with concomitant potent diuretics (eg, loop diuretics) because of possible increased risk of nephrotoxicity; aminoglycoside nephrotoxicity may potentiate cefotetan effects in kidney when used concurrently; closely monitor renal function

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Reduce dose by one half for patients with creatinine clearance of 10-30 mL/min and by one fourth for patients with creatinine clearance of less than 10 mL/min; use of antibiotics (especially prolonged or repeated therapy) may result in bacterial or fungal overgrowth of nonsusceptible organisms, possibly leading to secondary infection; take appropriate measures if superinfection occurs

More on Meckel Diverticulum

Overview: Meckel Diverticulum
Differential Diagnoses & Workup: Meckel Diverticulum
Treatment & Medication: Meckel Diverticulum
Follow-up: Meckel Diverticulum
Multimedia: Meckel Diverticulum
References
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References

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Further Reading

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Keywords

Meckel diverticulum, Meckel's diverticulum, omphalomesenteric duct, omphalomesenteric duct anomaly, persistent omphalomesenteric duct, vitelline duct, vitelline duct anomaly, persistent vitelline duct, yolk stalk, yolk stalk anomaly, treatment, diagnosis

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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)

Pauline K Mills, MD, Staff Physician, Department of Pediatrics, New York Medical College, Richmond University Medical Center
Disclosure: Nothing to disclose.

Madhavi Katturupalli, MD, Resident Physician, Department of Pediatrics, New York Medical College, Richmond University Medical Center
Madhavi Katturupalli, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

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.

Medical Editor

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.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing 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.

CME Editor

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: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, 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.

 
 
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