Pediatric Meckel Diverticulum Treatment & Management

Updated: Oct 20, 2017
  • Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Carmen Cuffari, MD  more...
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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 (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.

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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. [44]

A stationary foreign body within the right lower quadrant on imaging proximal to the ileocecal valve should raise suspicion for a Meckel diverticulum and prompt early surgical intervention. In a case report, a 6-year-old boy presented after having ingested a coin 2 days prior; serial abdominal radiographs demonstrated persistence of the coin in the right lower quadrant without a change in position over a 72-hour interval. The coin led to both obstruction and perforation of a Meckel diverticulum. [45]

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. [46]  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. [47, 48, 49] 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. [6]

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.

Diagnostic laparoscopy is now being used more commonly in cases where Meckel diverticulum is the cause of intestinal perforation, which is a less common presentation in young children. A case report described the use of laparoscopy in a neonate with pneumoperitoneum to diagnose and surgically resect the perforated Meckel diverticulum. Using a multiuse single-site port in the umbilicus potentially reduces the preoperative and postoperative phases, allowing for earlier resumption of enteral nutrition, which is beneficial outcome in newborns. [50]

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 patient, 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. [51]

A study by Mizutani et al determined the specific characteristics of hemorrhagic Meckel diverticulum and incidental Meckel diverticulum at DBE. [52]  Findings during the procedure were classified into either major (ectopic gastric mucosa and/or open ulcer) or minor (ringlike scar). Hemorrhagic Meckel diverticulum correlated more with these findings. Specificity of major findings was 100%, and specificity of major and/or minor findings was 96%. This allowed identification of asymptomatic Meckel diverticulum, thus avoiding unnecessary laparotomy/laparoscopy and diverticulectomy. 

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. [53]

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. [54]

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 small series suggested that only patients younger than 50 years clearly benefitted from removal if discovered unintentionally. [55]

Another study examined whether the appearance of the Meckel diverticulum was able to predict the need for resection based on the potential for complications. The patients were evaluated according to age, sex, clinical features, laboratory data, perioperative findings (diverticulum length, diameter, depth, thickening, height-to-diameter ratio [HDR]), pathology, and postoperative follow up. [56]  The authors found a correlation between the age of the patient and the size (length, diameter, and depth) of the Meckel diverticulum. With increasing age, Meckel diverticulum reaches larger sizes. The macroscopic appearance of the Meckel diverticulum did not predict the presence of heterotopic gastric mucosa and could not be used to guide subsequent surgery. Specifically, a thickened diverticulum had the same (68%) chance of containing heterotopic gastric mucosa as one without this finding (63%). The authors concluded regardless of appearance, Meckel diverticulum should be removed, except in certain situations unrelated to complications, such as peritonitis due to appendicitis or bowel perforation. The limitations of this study were that it had a small sample size (50 children) and that macroscopic thickening is a subjective criterion, which differs among clinicians. The study also found that resection of incidental Meckel diverticulum is not associated with higher operative morbidity or mortality than resection of symptomatic Meckel diverticulum, and thus all Meckel diverticulum should be removed. [56]

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Consultations

Consultations with the following may be appropriate:

  • Radiologist

  • Surgeon

  • Gastroenterologist

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