Meckel's diverticulum medical therapy
Jump to navigation
Jump to search
|
Meckel's diverticulum Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Meckel's diverticulum medical therapy On the Web |
|
American Roentgen Ray Society Images of Meckel's diverticulum medical therapy |
|
Risk calculators and risk factors for Meckel's diverticulum medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
Initially, the medical management of a symptomatic case of Meckel's diverticulum is directed toward management of clinical manifestations of complications. Intravenous lines for fluid and electrolyte therapy, nasogastric decompression for patients with symptoms and signs of intestinal obstruction, proton-pump inhibitors and Aluminum hydroxide for patients with gastrointestinal bleeding are preferred. The process of initial resuscitation in patients with lower gastrointestinal bleeding due to Meckel's diverticulum) is similar to the steps followed in any case of lower GI bleeding.
Medical Therapy
- Initial medical management of symptomatic Meckel's diverticulum is directed toward management of clinical manifestations of complicated cases of Meckel's diverticulum associated with:[1][2][3][4][5][6][7][8][9][10][11]
- In order to manage complications, treatment administered is as follows:
- Intravenous lines for:
- Fluid therapy
- Electrolyte therapy
- Nasogastric decompression for patients with symptoms and signs of intestinal obstruction
- For patients with gastrointestinal bleeding:
Initial Resuscitation in patients with lower gastrointestinal bleed due to Meckel's diverticula
The process of initial resuscitation in patients with lower gastrointestinal bleeding due to any pathology (including Meckel's diverticulum) is similar and includes the steps enlisted below.
Initial Evaluation
- In patients with acute lower gastrointestinal bleeding who are unstable, rapid assessment and resuscitation should be initiated even before diagnostic evaluation.[12][13][14][12][15][16][17][18]
- The initial steps in the management of a patient with lower gastrointestinal bleeding are to assess the severity of bleeding, and then institute fluid and other measures of resuscitation as needed.
- Once hemodynamic stability is achieved, nasogastric lavage should be performed to rule out an upper GI source.
- Equilibration between the intravascular and extravascular volumes cannot be achieved until 24 to 72 hours after bleeding has occurred.
Role of Nasogastric tube (NGT)
- Nasogastric tube (NGT) lavage is recommended in all patients with lower gastrointestinal bleeding, once the patient is stabilized.
- A carefully placed nasogastric tube (NGT) with irrigation and aspiration of bile is necessary to ensure sampling of duodenal contents.
- If there is a bloody NGT aspirate, then an esophagogastroduodenoscopy (EGD) is warranted (11 to 15% of cases of “negative” NGT aspirates are due to upper GI bleeding).
- Obtaining clear fluid favors a lower GI source of bleeding.
| Workup and Initial Management | |
|---|---|
| Initial Evaluation |
|
| Supportive Therapy |
|
| Blood transfusion |
|
Assessment of severity of bleeding
| Bleeding severity | Vital signs | Blood loss |
|---|---|---|
| Minor | Normal | <10% |
| Moderate | Postural hypotension | 10-20% |
| Severe | Shock | >25% |
Fluid resuscitation
- Two large caliber (16-gauge) peripheral catheters or a central venous line should be inserted in patients who are hemodynamically unstable.
- The rate of fluid resuscitation is proportional to the severity of bleeding with the goal of restoring and maintaining the patient’s blood pressure.
- Infusion of 500 mL of normal saline or lactated Ringer's solution over 30 minutes is the preferred treatment for patients with active bleeding before blood type matching and blood transfusion.
- Intensive monitoring with a pulmonary artery catheter is recommended to monitor the response of initial resuscitation efforts and any complications of fluid overload.
- If the blood pressure fails to respond to initial resuscitation, the rate of fluid administration should be increased and urgent intervention (eg, angiography) should be considered.
Blood transfusion
- Patients with severe bleeding need to be transfused.[19][20]
- Fresh frozen plasma, platelets, or both should be given to patients with coagulopathy who are actively bleeding and to those who have received more than 10 units of packed erythrocytes.
| Indications for transfusion | |
|---|---|
| Age | Target Hematocrit |
| Elderly patient ( >45) | 30% |
| Younger patient (<45) | 25% |
| Patients with portal hypertension | 28% |
Triage and consultations
- Visible rectal bleeding warrants an immediate evaluation in all cases. The timing and setting of the evaluation depends upon the severity of bleeding and the patient comorbidities.
- A gastroenterology consultation should be obtained early in the hospital course of patients with acute lower GI bleeding.
| Evaluation setting | Patient catagories |
|---|---|
| ICU | Patients with high-risk features |
| Outpatient | Patients with low-risk features† |
| Regular Ward | Most other patients can be admitted to a regular medical ward♦ |
| |
Risk stratification
- Clinical features can predict the risk of complications in patients with presumed acute lower GI bleeding. These features may also be used to categorize patients as either low or high risk.
- The presence of more number of high-risk features directly correlate with the likelihood of a poor outcome.
| High-risk features |
|---|
|
Medical Therapy
Pharmacotherapy is only used as an adjuvant therapy for patients with lower GI bleed due to Meckel's diverticulum. Epinephrine is used alone or in conjunction with other surgical techniques. Local injection of epinephrine stops bleeding by both pressure tamponade and the vasoconstrictor effect. In patients with re-bleeding, surgery should be considered.[21][16][17][18]
Dosage
- Preferred regimen (1): Local injection of 1:10,000 to 20,000 solution (Intra-arterial epinephrine infusions begin at a rate of 0.2 U/min. If the bleeding persists, the rate of the infusion is increased to 0.4-0.6 U/min).
- Note:- The bleeding stops in about 91% of patients receiving intra-arterial epinephrine but recurs in up to 50% of patients when the infusion is stopped.
Major contraindications
Complications
During vasopressin infusion, patients must be monitored for:
- Recurrent hemorrhage
- Myocardial ischemia (Nitroglycerine drip can be used to overcome cardiac complications)
- Arrhythmias
- Hypertension
- Volume overload with hyponatremia
References
- ↑ Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, Mew D (2006). "Complications of Meckel's diverticula in adults". Can J Surg. 49 (5): 353–7. PMC 3207587. PMID 17152574.
- ↑ Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ (1994). "Surgical management of Meckel's diverticulum. An epidemiologic, population-based study". Ann. Surg. 220 (4): 564–8, discussion 568–9. PMC 1234434. PMID 7944666.
- ↑ Hong J, Park SB (2017). "A case of retroperitoneal abscess: A rare complication of Meckel's diverticulum". Int J Surg Case Rep. 41: 150–153. doi:10.1016/j.ijscr.2017.10.012. PMID 29078157.
- ↑ Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A (2017). "Meckel's diverticulum in the adult". J Visc Surg. 154 (4): 253–259. doi:10.1016/j.jviscsurg.2017.06.006. PMID 28698005.
- ↑ Cotter TG, Buckley NS, Loftus CG (2017). "Approach to the Patient With Hematochezia". Mayo Clin. Proc. 92 (5): 797–804. doi:10.1016/j.mayocp.2016.12.021. PMID 28473039.
- ↑ Rosat A, Pérez E, Oaknin HH, Mendiz J, Hernández G, Barrera M (2016). "Spontaneous hemoperitoneum caused by meckel's diverticulum in an elder patient". Pan Afr Med J. 24: 314. doi:10.11604/pamj.2016.24.314.10384. PMC 5267917. PMID 28154669.
- ↑ Rattan KN, Singh J, Dalal P, Rattan A (2016). "Meckel's diverticulum in children: Our 12-year experience". Afr J Paediatr Surg. 13 (4): 170–174. doi:10.4103/0189-6725.194671. PMC 5154221. PMID 28051045.
- ↑ Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC (2017). "The many faces of Meckel's diverticulum and its complications". J Med Imaging Radiat Oncol. 61 (2): 225–231. doi:10.1111/1754-9485.12505. PMID 27492813.
- ↑ Chabowski M, Szymanska-Chabowska A, Dorobisz T, Janczak D, Jelen M, Janczak D (2016). "A massive bleeding from a gastrointestinal stromal tumor of a Meckel's diverticulum". Srp Arh Celok Lek. 144 (3–4): 219–21. PMID 27483571.
- ↑ Srisajjakul S, Prapaisilp P, Bangchokdee S (2016). "Many faces of Meckel's diverticulum and its complications". Jpn J Radiol. 34 (5): 313–20. doi:10.1007/s11604-016-0530-x. PMID 26932405.
- ↑ Alfa-Wali M, Wardle S, Nizar S, Bloom IT (2016). "Atypical presentation of a Meckel's diverticulum". BMJ Case Rep. 2016. doi:10.1136/bcr-2016-214464. PMID 26884080.
- ↑ 12.0 12.1 Strate LL, Gralnek IM (2016). "ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding". Am. J. Gastroenterol. 111 (4): 459–74. doi:10.1038/ajg.2016.41. PMC 5099081. PMID 26925883.
- ↑ Barnert J, Messmann H (2009). "Diagnosis and management of lower gastrointestinal bleeding". Nat Rev Gastroenterol Hepatol. 6 (11): 637–46. doi:10.1038/nrgastro.2009.167. PMID 19881516.
- ↑ Barnert J, Messmann H (2008). "Management of lower gastrointestinal tract bleeding". Best Pract Res Clin Gastroenterol. 22 (2): 295–312. doi:10.1016/j.bpg.2007.10.024. PMID 18346685.
- ↑ Raphaeli T, Menon R (2012). "Current treatment of lower gastrointestinal hemorrhage". Clin Colon Rectal Surg. 25 (4): 219–27. doi:10.1055/s-0032-1329393. PMC 3577609. PMID 24294124.
- ↑ 16.0 16.1 Ghassemi KA, Jensen DM (2013). "Lower GI bleeding: epidemiology and management". Curr Gastroenterol Rep. 15 (7): 333. doi:10.1007/s11894-013-0333-5. PMC 3857214. PMID 23737154.
- ↑ 17.0 17.1 Beck DE, Margolin DA, Whitlow CB, Hammond KL (2007). "Evaluation and management of gastrointestinal bleeding". Ochsner J. 7 (3): 107–13. PMC 3096402. PMID 21603524.
- ↑ 18.0 18.1 Triadafilopoulos G (2012). "Management of lower gastrointestinal bleeding in older adults". Drugs Aging. 29 (9): 707–15. doi:10.1007/s40266-012-0008-1. PMID 23018607.
- ↑ Al-Jaghbeer M, Yende S (2013). "Blood transfusion for upper gastrointestinal bleeding: is less more again?". Crit Care. 17 (5): 325. doi:10.1186/cc13020. PMC 4056793. PMID 24063362.
- ↑ Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C (2013). "Transfusion strategies for acute upper gastrointestinal bleeding". N. Engl. J. Med. 368 (1): 11–21. doi:10.1056/NEJMoa1211801. PMID 23281973.
- ↑ Liou TC, Lin SC, Wang HY, Chang WH (2006). "Optimal injection volume of epinephrine for endoscopic treatment of peptic ulcer bleeding". World J. Gastroenterol. 12 (19): 3108–13. PMC 4124392. PMID 16718798.