1. Case Presentation
CC: vomiting, abdominal pain
PI: 49 y/o man who 36 hours prior to admission
had the onset RUQ abdominal pain. Pain
worsened, went to ER 4 hours later.
CBC, SMA, LFTâs, amylase, lipase all normal.
Abdominal sono normal.
Some relief after GI cocktail, discharged.
2. Case Presentation
Night prior to admission, pain recurred associated with
vomiting.
Next am, ER- repeat testing normal, discharged.
Admitted PHD due to continuing pain and vomiting.
No hematemesis or blood in stool, fever, diarrhea or
constipation. No prior history of similar symptoms.
3. Case Presentation
PMHx- no prior abdominal surgery, only history of GI
problems is occasional GERD.
History of seizure disorder and mild depression.
Meds- Tegretol, Celexa, ASA 81mg, Pepcid prn
ETOH- avg 1 drink/ day
4. Case Presentation
PE- 120/72, HR 66, T 98.4
Normal exam except abdomen tender, voluntary
guarding RUQ and periumbilical. No rebound.
No hepatosplenomegaly, mass. BSâs reduced.
Labs- normal abd. sono, LFTâs, amylase, lipase.
Normal lytes. Bun/Cr= 11/1.2. WBC 7.2K, Hgb 14.6
Normal HIDA scan.
Obstructive series- multiple air/ fluid levels seen
throughout the small bowel consistent with partial
small bowel obstruction
5. Case Presentation
Working diagnosis: distal small bowel obstruction of
uncertain etiology
Initial course- NG tube placed, IV fluids, IV PPI.
CT scan- distended small bowel consistent with distal
partial small bowel obstruction. Appendix and colon
normal.
Surgery consult obtained.
6. Causes of Intestinal Obstruction
1. Intrinsic Bowel Lesions
A. Congenital- atresia / stenosis, malrotation, duplications/cysts
B. Inflammatory
Diverticulitis, TB, actinomycosis
Crohnâs disease
Ischemia
Radiation injury
Chemical (e.g., potassium chloride)
Endometriosis
Postanastomotic
C. Intussusception
D. Obturation
Polypoid neoplasms
Gallstones
Foreign bodies
Bezoars
Feces
E. Neoplastic stricture
II. Extrinsic Bowel Lesions
A. Congenital bands
B. Adhesions (usually postoperative)
C. Hernias (inguinal, femoral, ventral, umbilical, diaphragmatic)
D. Volvulus/ torsion
E. Carcinomatosis, extraintestinal neoplasm
F. Intra-abdominal abscess
7. Case Presentation
Next day- no improvement in x-ray findings, patient
taken to surgery.
Surgical findings: dilated prox sm. bowel with bruising
and torsion of the small bowel due to a Meckelâs
diverticulum as the lead point for the torsion. The
Meckelâs diverticulum was resected.
9. Meckelâs Diverticulum
⢠Most common congenital abnormality of the
gastrointestinal tract
⢠Remnant of the vitelline duct
⢠antimesenteric border of the ileum
⢠Often contain heterotropic tissue- gastric, occasionally
pancreatic
⢠Vast majority of Meckelâs diverticuli are clinically silent
10. Meckelâs Diverticulum
Rule of 2âs
⢠2% of the population have one
⢠1/2 of symptomatic lesions usually present before the
age of 2 years old, others most commonly in the first 2
decades of life
⢠Diveriticuli in adult patients only become symptomatic
in about 2%
⢠2 times more common in males than females
⢠Usually found within 2 feet of the ileocecal valve
⢠Usually are about 2 inches in length
⢠1/2 contain heterotrophic mucosa (usually gastric,
occasionally pancreatic)
11. Meckelâs Diverticulum
Clinical presentation
Lower GI bleeding due to ulceration by heterotopic
gastric mucosa
Intestinal obstruction due to internal segmental volvulus
or intussusception
Local inflammation with or without perforation
resembling appendicitis due to diverticulitis
Rare presentations: Neoplasms
12. Meckelâs Diverticulum
Lower GI bleeding due to ulceration by heterotrophic gastric
mucosa
⢠25-50% of symptomatic presentations
⢠Usually painless
⢠Episodic
⢠Hematochezia (usually maroon but may be tarry or bright red)
⢠Not infrequently massive bleeding- occult bleeding is rare
⢠Most common cause of small intestinal hemorrhage in patients
under 30 y/o
⢠Meckelâs scan is often positive patients
13. Meckelâs Diverticulum
Intestinal obstruction due to internal segmental
volvulus or
intussusception
⢠20-30% of symptomatic presentations
⢠More common in older patients
⢠Diverticulum acts as a lead point causing entero-entero or entero-colonic
intussusception which often cannot be reduced hydrostatically. This may
present with âcurrant jellyâ like stool and a palpable mass may be present
⢠If volvulus can be reduced hydrostatically, the patient should still have a
surgical resection.
⢠If diverticulum is connected to umbilicus by fibrous cord, this may act as a
focal point for internal herniation of the small bowel or secondary volvulus.
14. Meckelâs Diverticulum
Local inflammation with or without perforation
due to Meckelâs diverticulitis
⢠10-20% of symptomatic presentations
⢠Usually adult patients
⢠Usually due to ectopic acid producing gastric mucosa
causing significant ulceration and possible perforation.
This may occasionally be related to H. Pylori infection
of the mucosa.
⢠Rarely caused by perforation due to a foreign body in
the diverticulum.
⢠Usually these patients are thought to have
appendicitis prior to surgery
15. Meckelâs Diverticulum
Rare Presentations- neoplasms arising in the
diverticulum
⢠Benign- (most common)
Leiomyomas
Angiomas
Lipomas
⢠Malignant-
Adenocarcinoma- usually from the gastric
mucosa
Sarcoma
Carcinoid tumor
16. Meckelâs Diverticulum
Diagnostic studies
⢠Difficult diagnosis
⢠Most accurate test, especially in children, is âMeckelâs scanâ-
sodium 99-Tc-pertechinetate, taken up by gastric mucosa
(sensitivity 85%, specificity 95%, accuracy 90% in pediatric
patients)
⢠Less accurate in adults due to reduced prevalence of ectopic
gastric mucosa in the diverticulum causing false negatives.
Accuracy improved by giving pentagastrin (increases
metabolism of mucus producing cells), glucagon or H2 blockers
(reduce peristalsis and secretions that may flush out the
radionuclide)
⢠In adults with a negative scan, abdominal CT scan is often
helpful in cases of obstruction by showing a site of high grade
partial bowel obstruction in the distal ileum.
⢠If CT is negative barium studies should be performed which may
show the diverticulum (do not do prior to Meckelâs scan as
barium may interfere)
⢠If bleeding with a negative scan, angiography may be helpful
17. Meckelâs Diverticulum
Treatment
⢠If symptomatic, prompt surgical intervention to resect the
diverticulum or segment of ileum containing the
diverticulum. If bleeding, the source of bleed is often in
the segment of ileum adjacent to the diverticulum.
⢠If not symptomatic and found incidentally at surgery in
children under 2 y/o, resection is recommended. In
asymptomatic adults, resection is controversial since only
about 2% of these patientâs will become symptomatic and
there is about a 2% incidence of short or long term
complications (stenosis, adhesions) after prophylactic
resection.
49 year old man 3 wks prior to admission had 1 episode of vomiting 3 hours after eating foie de gras and had not felt completely normal since but no further n/v or abdominal pain. On the day prior to admission (4/29/04) he had sudden onset of right upper abd pain with no know cause. The pain was sharp and radiated to the back. The pain subsided after a n hour and he proceeded to go on a planned trip to Fredricksburg but his pain intensified and he went to the ER there. In the ER he had a negative workup including abdominal ultrasound, CBC, chemistries, amylase and lipase. He had a partial relief after a GI cocktail and was sent home to his hotel with Phenergan and Lortab.
That night he had n/v x2 with increased pain so he went back to the ER the next morning but all tests were again negative. He drove back to Dallas where he was directly admitted on 4/30 due to ongoing vomiting and pain. He denied having diarrhea, constipation or fever. No SOB or chest pain.
PMHx- no prior abdominal surgeries. No history of abdominal pain other than that in the present illness but has had some reflux symptoms, especially with fatty foods. Positive history of seizure disorder and depression, controlled with meds
Pain and nausea resolved after placement of NG tube. Surgical consult was obtained.
Meckelâs diverticlum is the most common congenital abnormality of the gastrointestinal tract. Remnant of the vitelline duct which attaches the fetal small intestine to the umbilicus. First described in detail by Johann Meckel in 1809, it is found withing 45 to 60cm of the ileocecal valve and is located on the antimesenteric border of the ileum. Size of the diverticulum varies from a small bump to a long projection which may connect to the umbilicus by a fibrous cord. Some vitelline duct cells are pluripotent so it is common for the diverticulum to contain heterotropic tissue, the most common being gastric mucosa (50% of all Meckelâs diverticulum), pancreatic tissue in 5% and less commonly colonic mucosa.
(Our patient presented with obstruction. On pathology, no acute inflammation was seen in the diverticulum and no heterotrophic epithelium was found.)
Our patient would have had a negative scan and not at risk for bleeding or inflammation due to lack of heterotropic gastric mucosa.
