Pediatric Meckel Diverticulum Workup

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

Laboratory Studies

  • Routine laboratory findings, including CBC count, electrolyte levels, glucose test results, BUN levels, creatinine levels, and coagulation screen results, are not helpful in establishing the diagnosis of Meckel diverticulum but are necessary to manage a patient with GI bleeding along with a type and cross.
    • Hemoglobin and hematocrit levels are low in the setting of anemia or bleeding.
    • Patients with significant bleeding develop anemia. In one series, 58% of children had average hemoglobin levels of less than 8.8 g/dL.
  • Ongoing bleeding from a Meckel diverticulum can cause iron deficiency anemia. However, megaloblastic anemia can also be seen due to vitamin B12 or folate deficiency. These can occur secondary to small bowel overgrowth if dilation and/or stasis related to the diverticulum is present. Low albumin and low ferritin levels may lead to a diagnosis of inflammatory bowel disease.
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Imaging Studies

  • According to Mayo, "Meckel's Diverticulum is frequently suspected, often looked for, and seldom found." Preoperative diagnosis is difficult, especially if the presenting symptom is not GI bleeding. In one series, patients often had a correct preoperative diagnosis if the presenting symptom was GI bleeding, but only 11% of preoperative diagnoses were correct if other symptoms predominated.[17]
  • History and physical examination are of paramount importance for establishing a clinical diagnosis. Imaging studies are performed to confirm a clinical suspicion of Meckel diverticulum.
  • Plain radiography of the abdomen is of limited value. It may reveal evidence of nonbleeding complications, including enteroliths and signs of intestinal obstruction or perforation, such as air or air-fluid levels (see the image below). Anteroposterior view of abdominal radiograph showiAnteroposterior view of abdominal radiograph showing multiple dilated loops of a small bowel with air-fluid levels.
  • When a patient has GI bleeding suggestive of Meckel diverticulum, the diagnostic evaluation should focus on Meckel scanning, a technetium-99m pertechnetate scintiscan (0.2mCi/kg in children and 10-20mCi in adults). The pertechnetate is taken up by gastric mucosa. Because bleeding from the Meckel diverticulum is related to acid induced damage of mucosa adjacent to the parietal cell containing tissue, it is always included early in the work-up.[18]
    • After intravenous injection of the isotope, the gamma camera is used to scan the abdomen. This procedure usually lasts approximately 30 minutes. Gastric mucosa secretes the radioactive isotope; thus, if the diverticulum contains this ectopic tissue, it is recognized as a hot spot.
    • The Meckel scan is the preferred procedure because it is noninvasive, involves less radiation exposure, and is more accurate than an upper GI and small-bowel follow-through study.
    • In children the Meckel scan has a reported sensitivity of 80-90%, a specificity of 95% and an accuracy of 90%. However, in adults where GI bleeding is a much less common presentation, the scan has a lower sensitivity (62.5%), a much lower specificity (9%), and a lower accuracy (46%).[19]
    • Because the Meckel scan is specific for gastric mucosa (ie, in the stomach or ectopic) and not specifically diagnostic of Meckel diverticulum, false positive results occur whenever ectopic gastric mucosa is present. Duodenal ulcer, small intestinal obstruction, some intestinal duplications, ureteric obstruction, aneurysm, and angiomas of the small intestine have yielded positive results. False negative results can occur when gastric mucosa is very slight or absent in the diverticulum, if necrosis of the diverticulum has occurred, or if the Meckel is superimposed on the bladder.[20]
    • Accuracy of the scan may be enhanced with administration of cimetidine, glucagon, and pentagastrin. Cimetidine enhances the uptake and blocks the secretion of technetium-99m pertechnetate from ectopic gastric mucosa.[21] This helps to improve the lesion to background ratio in enhancing a Meckel scan. Pentagastrin also enhances uptake of the isotope but also increases peristalsis, attenuating its value. Glucagon is used to decrease peristalsis, thus allowing the signal to be taken up during a longer exposure time. One strategy uses both pentagastrin and glucagon. With newer imaging technology, false-positive and false-negative rates have declined.
    • Barium studies have largely been replaced by other imaging techniques; however, if a barium study is indicated, it should never precede the technetium-99m scan because barium may obscure the hot spot.
    • A bleeding scan can be performed to identify the source if the patient is bleeding at 0.1ml/min or more. This scan involves removing and labeling some of the patient's own RBCs with technetium-99m, reinjecting them into the patient, and then scanning the abdomen for hot spots.[22, 23]
  • Selective arteriography may be helpful in patients in whom the results from scintigraphy and barium studies are negative. Usually, this occurs if the bleeding is either intermittent or has completely resolved.
    • When the rate of bleeding is greater than 1 mL/min, a superior mesenteric arteriogram can be helpful, but interpretation may be difficult due to overlying blood vessels. In these cases, selective catheterization of the distal ileal arteries may be needed.
    • Demonstration of abnormal arterial branches, dense capillary staining, or extravasation of the contrast medium confirms the presence of a Meckel diverticulum. However, a well-developed arterial supply may not always be present in the Meckel diverticulum; thus, these arteriographic signs are not very reliable.
  • Traditional small-bowel series using barium have been unreliable in the detection of Meckel diverticulum. However, in patients who require barium study to primarily look for other conditions, enteroclysis is more sensitive in detecting Meckel diverticulum.
    • Enteroclysis involves using a continuous infusion of barium with adequate compression of the ileal loops and intermittent fluoroscopy to detect Meckel diverticulum.
    • If the barium mixture is too dense and the fold pattern cannot be visualized, carboxymethylcellulose sodium can be used as the contrast medium.
    • On barium studies, Meckel diverticulum may appear as a blind-ending pouch on the antimesenteric side of the distal ileum. If filling defects are visualized, the diverticulum may contain a tumor.
    • Characteristic radiologic signs for Meckel diverticulum include demonstration of a triradiate fold pattern or a mucosal triangular plateau. Occasionally, a gastric rugal pattern may also be found within the Meckel diverticulum.
  • A barium enema can be performed if intussusception is suspected. Some people have tried hydrostatic therapy to reduce intussusception, but this has not been found to be useful.
  • Abdominal CT scanning is usually not helpful because differentiating Meckel diverticulum from the small-bowel loops is difficult; however, a blind-ending fluid-filled and/or gas-filled structure in continuity with small bowel may be visualized. CT scanning may also reveal an enterolith, intussusception, or diverticulitis. CT enterography advancements have increased the sensitivity in the diagnosis of Meckel diverticulum.[18]
  • Ultrasonography has been used in some cases of Meckel diverticulum. Ultrasonography tends to be helpful if the patient presents with anatomic rather than mucosal complications.
  • Wireless capsule endoscopy has been successfully used to identify Meckel diverticulum in young children.[24]
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Histologic Findings

  • 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%.[2]
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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)

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.

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Anteroposterior view of abdominal radiograph showing multiple dilated loops of a small bowel with air-fluid levels.
 
 
 
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