Pediatric Meckel Diverticulum Clinical Presentation

Updated: Sep 08, 2016
  • Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Carmen Cuffari, MD  more...
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Presentation

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, most series have historically noted that hematochezia is the most common presenting sign. [7] Bleeding in adults is much less common. [8, 9]

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.

A rare cause of abdominal pain from the Meckel diverticulum is inversion without intussusception. [10]

A case report described a rare presentation of Meckel diverticulum perforation as a result of blunt abdominal trauma. This report emphasized the importance of including perforation of Meckel diverticulum in the differential diagnosis of abdominal trauma. [11]

Another case report described a rare presentation of pyogenic liver abscess due to an infected Meckel diverticulum. Perforated Meckel diverticulum can rarely present as an abdominal abscess or as a pyogenic liver abscess. The authors conclude that that elective resection of a Meckel diverticulum should be considered in the presence of a pyogenic liver abscess if no other etiologies are identified. [12]

Recent reports have brought into question the belief that intestinal obstruction in pediatrics secondary to Meckel's diverticulum is not very prevalent, with some series reporting a prevalence of 25-40% of pediatric complications. Obstruction is the most common complication in adults.  In children or adults, obstruction can be secondary to various mechanisms. [2]  Complications include the following:

  • 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 (eg, leiomyomas, angiomas, neuromas, lipomas) or malignant tumors. About three quarters of the malignant tumors are carcinoids [13] but others include sarcoma, [14] carcinoid tumor, [15] adenocarcinomas14 and Burkitt lymphoma15, as well as additional rare lesions.11

Foreign bodies can become confined in Meckel diverticulum and lead to obstruction or perforation. The most common foreign body that causes perforation in Meckel diverticulum is ingested bone fragments (58%), followed by wood splinters (14%), food (12%), pin/needles (9%), and miscellaneous (7%). [16]

Ingestion of multiple foreign bodies is more commonly seen in individuals with psychiatric illness or intellectual disabilities. One case study described a child with autism spectrum disorder who presented to the ED with complaints of acute onset of abdominal pain and bilious vomiting. Abdominal radiographs revealed evidence for obstruction with dilated small bowel with air fluid levels. A CT scan revealed foreign objects in the distal small bowel, with dilation of the proximal intestine and decompressed bowel distally. Exploratory laparotomy was performed, and a Meckel diverticulum was found containing multiple foreign objects. [17]

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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. [18] 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. [19]

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. Suppurative Meckel diverticulum can present in a child with abdominal pain and periumbilical cellulitis. [20]  Rarely, Meckel diverticulum has been reported to become incarcerated (Littre hernia) in the inguinal, [21] femoral, or obturator hernial sacs or even incisional defects.

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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.

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