Meckel’s Diverticulum

Ranjit Kumar Makaju

• It is the congenital diverticulum arising from the antimesenteric border of terminal ileum

• During the eighth week of gestation, the omphalomesenteric (vitelline) duct normally undergoes obliteration

• Failure or incomplete obliteration of vitelline duct results in some congenital abnormalities, the most common of which is Meckel's diverticulum.

Meckel’s Diverticulum

• Sometimes this diverticulum can be attached to the umbilical region by the vitelline ligament, with the possibility of vitelline cysts, or even a patent vitelline canal forming a vitelline fistula when the umbilical cord is cut

• Most common congenital abnormality of the gastrointestinal tract

• Contains all three layers of bowel with independent blood supply

• Often contain heterotropic tissue- gastric, occasionally pancreatic

• Sometime Meckel’s Diverticulum is found in an inguinal or femoral sac – Littre’s hernia

Rule of 2’s• 2% of the population• Usually found 2 feet proximal to the ileocecal

valve • About 2 inches long • 2 times more common in males than females• Symptomatic mostly before 2 years of age• In adult patients it symptomatic in only about

2%

Clinical presentations• Majority of Meckel’s diverticuli are clinically

silentSymptoms in order of frequencies— a) Severe haemorrhage b) Intussuception c) Meckel’s Diverticulitis d) Chronic peptic ulceration e) Intestinal obstruction

Pathophysiology• Severe Hemorrhage -painless per rectal bleeding, maroon coloredHemorrhage may be caused by:• Ectopic gastric or pancreatic mucosa: When

diverticulum contains embryonic remnants of mucosa of other tissue types.

• Secretion of gastric acid or alkaline pancreatic juice from the ectopic mucosa leads to ulceration in the adjacent ileal mucosa i.e. peptic or pancreatic ulcer

• Perforation and bleeding from ulcer

• Meckel’s DiverticulitisInflammation of the diverticulum can mimic symptoms of appendicitisDiverticulitis results from----Peptic ulceration resulting from ectopic gastric mucosa of the diverticulum-Following perforation by trauma or ingested food residue-Luminal obstruction due to tumors, foreign body, causing stasis or bacterial infection

• During perforation, the symptoms may resemble those of a perforated duodenal ulcer

• Whether perforated or not, urgent surgery is required

• In non perforated cases, an inflamed diverticulum should be sought as soon as it has been demonstrated that the appendix and fallopian tubes are not at fault

• Intestinal obstructionCauses—• Volvulus of the intestine around the fibrous band

attaching the diverticulum to the umbilicus• Entrapment of intestine by a mesodiverticular

band• Intussusception with the diverticulum acting as a

lead point• Stricture secondary to chronic diverticulitis • Tumors e.g. Carcinoid, adenocarcinoma, GIST

arising in the diverticulum

Diagonosis

• A technetium-99m (99mTc) pertechnetate scan, also called Meckel scan.positive only when the diverticulum contains associated ectopic gastric mucosa that is capable of uptake of the tracer

• Laparoscopy• Enteroclysis/ small bowel enema under fluoroscopy• CT scan• Angiography

Indications of surgery

• When the base is narrow, and lengthy diverticulum

• Presence of adhesions or band which may precipitate obstruction, intussusception or volvulus

• Symptomatic patients or presence of complications

• If it is found in children below 2 years

Management

• Meckelian Diverticulectomy:

Meckel’s diverticulum with the broad base should not be amputated and invaginated

A linear stapler device may be used. If induration of base, hetrotropic gastric tissue extending to adjacent ileum is present then- short segment of ileum is resected and end to end anastomosis is done restoring the continuity

Thank you