The case
A 20-month-old boy presents with a four-day history of vomiting, abdominal distension and constipation. He is pale and tachycardic with a capillary refill of three seconds. He is revived with two boluses of 10ml per kg of 0.9% saline. Abdominal X-ray shows small bowel obstruction. A closed loop obstruction by a band associated with a Meckel's diverticulum is identified on laparotomy.
The problem
Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract.
It occurs because of failure of regression of the vitelline duct.
The most common complications are inflammatory (bleeding and inflammation because of ectopic gastric or pancreatic tissue) and mechanical (as a lead point in intussusception or volvulus around a Meckel's band).
Remnants of the vitelline duct can cause less common problems such as fibrous cord, umbilical fistula, vitelline cyst and umbilical sinus or polyp.
Features
The ‘rule of twos' broadly applies. Meckel's diverticulum:
- occurs in 2% of the population
- is located two feet from the ileocecal valve
- becomes symptomatic before two years
- is 2cm in diameter and 2in long
- is twice as common in boys as in girls.
Most cases are asymptomatic, but in those with symptoms, abdominal pain, rectal bleeding, vomiting and abdominal distension are features. In neonates, bowel obstruction is a typical presentation. Older infants often present with painless bleeding, and older children usually have inflammatory symptoms similar to appendicitis.
Diagnosis
Examination reveals lethargy, pallor, dehydration, abdominal distension and tenderness. A mass may be felt in intussusception. In a bleeding Meckel's diverticulum, the test of choice is technetium-99m isotope scan (sensitivity 85%). The isotope concentrates in the ectopic gastric mucosa lining the diverticulum. If intussusception is suspected, an ultrasound may be diagnostic.
Management
Urgent hospital referral is needed in cases of bleeding or obstruction. Some patients need resuscitation, analgesia and nasogastric decompression. Haemoglobin, plasma electrolytes and inflammatory markers may be helpful.
Resection and end-to-end anastomosis is generally the preferred treatment, but diverticulectomy is also used.
Whether to treat an incidentally discovered Meckel's diverticulum is debateable because the reported incidence of complications is only around 5%. Generally, resection of the Meckel's diverticulum is recommended in children under the age of eight, or at any age if there is ectopic tissue, since this makes complications more likely.
Ms Joanne Minford is a consultant paediatric surgeon and Dr Osama Abusanad is a core surgical trainee at Alder Hey Children's Hospital, Liverpool
Further reading
- Tisol W and Pearl R. Meckel's diverticulum. In: Glick P, Pearl R, Irish M and Caty M (eds). Pediatric Surgery Secrets. Philadelphia: Hanley & Belfus; 2001
- Schropp K and Garey C. Meckel's Diverticulum. In: Holocomb III G, Murphy J (eds). Ashcraft's Pediatric Surgery (5th ed). Philadelphia: Saunders Elsevier; 2010
Alder Hey is one of Europe's busiest children's hospitals, providing care for over 275,000 patients each year. Alder Hey has a broad range of hospital and community services for direct referral from primary care. It is the designated national centre for head and face surgery and a centre of excellence for children with cancer, spinal and brain disease. Alder Hey has been chosen to be a national centre for heart surgery, a respiratory ECMO surgery centre and one of just four specialist centres to provide surgery for drug-resistant epilepsy. More information can be found at alderhey.nhs.uk.
