Meckel's diverticulum natural history, complications and prognosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Meckel's diverticulum}}
{{Meckel's diverticulum}}
{{CMG}}
{{CMG}} {{AE}} {{Cherry}}


==Overview==
==Overview==
Intestinal torsions around the intestinal stalk may also occur, leading to obstruction, [[ischemia]], and [[necrosis]].
Meckel's diverticulum is mostly seen in male children (mostly <2 years of age). One fourth of untreated cases of Meckel's diverticulum may develop complications such as [[Bowel obstruction|intestinal obstruction]], [[Bleeding|hemorrhage]], [[diverticulitis]], bowel [[ischemia]], and [[necrosis]]. [[Bleeding|Hemorrhage]] is the most common complication in patients with [[Meckel's diverticulum]]. [[Bleeding]] in patients may be minimal, recurrent or massive and [[shock]]-producing. The rate of [[bleeding]] is assessed based on quantity of [[blood]] lost in the [[Human feces|stools]], appearance of the material passing through the [[rectum]] and [[Hemodynamics|hemodynamic]] state of the patient. Depending on the extent of the [[symptom]] progression at the time of diagnosis, the [[prognosis]] may vary. However, the [[prognosis]] is generally regarded as excellent in cases where [[symptomatic]] Meckel's diverticulum is treated in a timely manner. Complete [[Healing|recovery]] may be expected with [[surgery]] in majority of the cases.
If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].


OR
Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
OR
Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.
==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==


===Natural History===
===Natural History===
*The symptoms of (disease name) usually develop in the first/ second/ third decade of life, and start with symptoms such as ___.  
*The symptoms of [[Meckel's diverticulum]] usually develop in children, and start with painless [[lower gastrointestinal bleeding]].<ref name="urlMeckels Diverticulum | Cleveland Clinic">{{cite web |url=https://my.clevelandclinic.org/health/diseases/14738-meckels-diverticulum |title=Meckel's Diverticulum &#124; Cleveland Clinic |format= |work= |accessdate=}}</ref>
*The symptoms of (disease name) typically develop ___ years after exposure to ___.  
*If left untreated, 25% of patients with [[Meckel's diverticulum]] may progress to develop [[Bleeding|hemorrhage]], [[Ulcer|ulceration]], [[Gastrointestinal perforation|bowel perforation]], [[diverticulitis]], [[peritonitis]] and [[Bowel obstruction|small bowel obstruction]].<ref name="pmid17152574" />
*If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].


===Complications===
===Complications===
*Common complications of Meckel's diverticulum include:
*Common complications of [[Meckel's diverticulum]] include:<ref name="pmid17152574">{{cite journal |vauthors=Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, Mew D |title=Complications of Meckel's diverticula in adults |journal=Can J Surg |volume=49 |issue=5 |pages=353–7 |year=2006 |pmid=17152574 |pmc=3207587 |doi= |url=}}</ref><ref name="pmid7944666">{{cite journal |vauthors=Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ |title=Surgical management of Meckel's diverticulum. An epidemiologic, population-based study |journal=Ann. Surg. |volume=220 |issue=4 |pages=564–8; discussion 568–9 |year=1994 |pmid=7944666 |pmc=1234434 |doi= |url=}}</ref><ref name="pmid29078157">{{cite journal |vauthors=Hong J, Park SB |title=A case of retroperitoneal abscess: A rare complication of Meckel's diverticulum |journal=Int J Surg Case Rep |volume=41 |issue= |pages=150–153 |year=2017 |pmid=29078157 |doi=10.1016/j.ijscr.2017.10.012 |url=}}</ref><ref name="pmid28698005">{{cite journal |vauthors=Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A |title=Meckel's diverticulum in the adult |journal=J Visc Surg |volume=154 |issue=4 |pages=253–259 |year=2017 |pmid=28698005 |doi=10.1016/j.jviscsurg.2017.06.006 |url=}}</ref><ref name="pmid28473039">{{cite journal |vauthors=Cotter TG, Buckley NS, Loftus CG |title=Approach to the Patient With Hematochezia |journal=Mayo Clin. Proc. |volume=92 |issue=5 |pages=797–804 |year=2017 |pmid=28473039 |doi=10.1016/j.mayocp.2016.12.021 |url=}}</ref><ref name="pmid28154669">{{cite journal |vauthors=Rosat A, Pérez E, Oaknin HH, Mendiz J, Hernández G, Barrera M |title=Spontaneous hemoperitoneum caused by meckel's diverticulum in an elder patient |journal=Pan Afr Med J |volume=24 |issue= |pages=314 |year=2016 |pmid=28154669 |pmc=5267917 |doi=10.11604/pamj.2016.24.314.10384 |url=}}</ref><ref name="pmid28051045">{{cite journal |vauthors=Rattan KN, Singh J, Dalal P, Rattan A |title=Meckel's diverticulum in children: Our 12-year experience |journal=Afr J Paediatr Surg |volume=13 |issue=4 |pages=170–174 |year=2016 |pmid=28051045 |pmc=5154221 |doi=10.4103/0189-6725.194671 |url=}}</ref><ref name="pmid27492813">{{cite journal |vauthors=Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC |title=The many faces of Meckel's diverticulum and its complications |journal=J Med Imaging Radiat Oncol |volume=61 |issue=2 |pages=225–231 |year=2017 |pmid=27492813 |doi=10.1111/1754-9485.12505 |url=}}</ref><ref name="pmid27483571">{{cite journal |vauthors=Chabowski M, Szymanska-Chabowska A, Dorobisz T, Janczak D, Jelen M, Janczak D |title=A massive bleeding from a gastrointestinal stromal tumor of a Meckel's diverticulum |journal=Srp Arh Celok Lek |volume=144 |issue=3-4 |pages=219–21 |year=2016 |pmid=27483571 |doi= |url=}}</ref><ref name="pmid26932405">{{cite journal |vauthors=Srisajjakul S, Prapaisilp P, Bangchokdee S |title=Many faces of Meckel's diverticulum and its complications |journal=Jpn J Radiol |volume=34 |issue=5 |pages=313–20 |year=2016 |pmid=26932405 |doi=10.1007/s11604-016-0530-x |url=}}</ref><ref name="pmid26884080">{{cite journal |vauthors=Alfa-Wali M, Wardle S, Nizar S, Bloom IT |title=Atypical presentation of a Meckel's diverticulum |journal=BMJ Case Rep |volume=2016 |issue= |pages= |year=2016 |pmid=26884080 |doi=10.1136/bcr-2016-214464 |url=}}</ref><ref name="pmid19661646">{{cite journal |vauthors=Komlatsè AN, Komla G, Komla A, Azanledji BM, Abossisso SK, Hubert T |title=Meckel's diverticulum strangulated in an umbilical hernia |journal=Afr J Paediatr Surg |volume=6 |issue=2 |pages=118–9 |year=2009 |pmid=19661646 |doi=10.4103/0189-6725.54779 |url=}}</ref>
**Hemorrhage
**[[Bleeding|Hemorrhage]]
**Perforation of the bowel
**[[Perforation]] of the [[Intestine|bowel]]
**Diverticulitis
**[[Diverticulitis]]
**Small bowel obstruction
**[[Small intestine|Small bowel]] [[obstruction]]
**Ulceration  
**[[Ulcer|Ulceration]]
**[[Intussusception]]  
**[[Intussusception]]  
** [[Peritonitis]]
** [[Peritonitis]]


==== Hemorrhage ====
==== Hemorrhage ====
* Most common complication in patients with Meckel diverticulum  
* Most common complication in patients with [[Meckel's diverticulum|Meckel diverticulum]]
* Accounts for one fourth of all complications
* Accounts for one fourth of all complications
* More commonly seen in:
* More commonly seen in:
Line 39: Line 30:


* Presentation:  
* Presentation:  
** Patients present with the following symptoms:
** Patients present with the following symptoms:<ref name="pmid27126093">{{cite journal |vauthors=Pattni V, Wright K, Marden P, Terlevich A |title=Meckel's diverticulum in an adult: an obscure presentation of gastrointestinal bleeding |journal=BMJ Case Rep |volume=2016 |issue= |pages= |year=2016 |pmid=27126093 |doi=10.1136/bcr-2015-213852 |url=}}</ref>
*** Passage of bright red blood in the stools
*** Passage of bright red [[blood]] in the stools
*** May or may not be associated with:
*** May or may not be associated with:
**** Abdominal pain  
**** [[Abdominal pain]] (usually painless)
**** Weakness
**** [[Muscle weakness|Weakness]]
**** Anemia
**** [[Anemia]]
*** Bleeding may be:
*** [[Bleeding]] may be:
**** Minimal  
**** Minimal  
**** Recurrent  
**** Recurrent  
**** Massive, shock-producing
**** Massive, [[shock]]-producing
*** Assessment of the rate of bleeding may be done on the basis of the following:
*** Assessment of the rate of [[bleeding]] may be done on the basis of the following:
**** Quantity of blood lost in the stools  
**** Quantity of [[blood]] lost in the [[Human feces|stools]]
**** Appearance of the material passing through the rectum  
**** Appearance of the material passing through the [[rectum]]
**** Hemodynamic state
**** [[Hemodynamics|Hemodynamic]] state
*** Characteristics of hemorrhage based on the appearance of stools include the following:  
*** Characteristics of [[Bleeding|hemorrhage]] based on the appearance of [[Human feces|stools]] include the following:<ref name="pmid25540213">{{cite journal |vauthors=Anwar MO, Ahmed HI, Al Hindi S, Al Omran Y |title=Meckel's diverticulum with intussusception in a 5-year-old patient with Down's syndrome |journal=BMJ Case Rep |volume=2014 |issue= |pages= |year=2014 |pmid=25540213 |pmc=4281549 |doi=10.1136/bcr-2014-207431 |url=}}</ref><ref name="pmid25337720">{{cite journal |vauthors=Holcomb CN, Hawn MT |title=Occult gastrointestinal bleeding |journal=JAMA Surg |volume=149 |issue=12 |pages=1335–6 |year=2014 |pmid=25337720 |doi=10.1001/jamasurg.2014.109 |url=}}</ref>
**** Bright red blood in the stools: brisk hemorrhage
**** Brisk [[Bleeding|hemorrhage]]: bright red blood in the [[Human feces|stools]]
**** Tarry stools: minor upper GI bleeding, associated with delayed intestinal transit causing alteration of blood  
**** Minor [[Upper gastrointestinal bleeding|upper GI bleeding]], associated with delayed [[Intestine|intestinal]] transit causing alteration of [[blood]]: [[Melena|Tarry stools]]
**** Currant jelly stools: associated with copious mucus due to bowel ischemia; commonly observed in intussusception
**** [[Intussusception]]: Currant jelly [[Human feces|stools]] with copious amounts of [[mucus]] due to [[Intestine|bowel]] ischemia  
**** Blood-streaked stools: sign of fissure-in-ano
**** [[Fissure|Fissure-in-ano]]: [[Blood]]-streaked [[Human feces|stools]]
*** The gastric mucosa found in the diverticulum may form a chronic ulcer and may also damage the adjacent ileal mucosa because of acid production. Ectopic gastric mucosa is found in about 50% of all Meckel diverticula; and three fourths of bleeding Meckel diverticula.
*** The [[gastric mucosa]] found in the [[diverticulum]] may form a chronic [[ulcer]] and may also damage the adjacent [[Ileum|ileal]] [[Mucous membrane|mucosa]] because of acid production. [[Ectopia|Ectopic]] [[gastric mucosa]] is found in about 50% of all [[Meckel's diverticulum|Meckel's diverticula]]; and three fourths of bleeding [[Meckel's diverticulum|Meckel's diverticula]].
*** Perforation may occur, and the patient then presents with an acute abdomen, often associated with air under the diaphragm, best visualized on an erect chest radiograph.
*** [[Perforation]] may occur, and the patient then presents with an [[acute abdomen]], often associated with air under the [[Thoracic diaphragm|diaphragm]], best visualized on an erect [[Chest X-ray|chest radiograph]].  
*** When a patient presents with painless lower GI bleeding, Meckel diverticulum should always be suspected.
*** Panendoscopy helps exclude disease in the upper GI and colorectal regions, the two most common sites of GI bleeding.


=== Intestinal obstruction ===
* Characteristics of [[Bleeding|hemorrhage]] based on the appearance of stools include the following:
* observed in one fourth of patients with symptomatic Meckel diverticulum
** Brisk [[Bleeding|hemorrhage]] may present as bright red blood in the [[Human feces|stools]]
Various mechanisms of intestinal obstruction occur with Meckel diverticulum as a causative factor. Because the omphalomesenteric duct may be attached to the abdominal wall by a fibrotic band, a volvulus of the small bowel around the band may occur. The diverticulum may also form the lead point of an intussusception and cause obstruction. Infrequently, a tumor arising in the wall of the diverticulum may form the lead point for intussusception. When incarcerated in an inguinal hernia, a Meckel diverticulum is called a Littré hernia.
** Minor [[Upper gastrointestinal bleeding|upper GI]] [[bleeding]], associated with delayed [[Intestine|intestinal]] transit causing alteration of [[blood]] may present as [[Melena|tarry stools]]
Patients with intestinal obstruction due to Meckel diverticulum present with abdominal pain, vomiting, and obstipation. Radiography of the abdomen may indicate an ileus or frank stepladder air-fluid levels, as observed in dynamic intestinal obstruction.
** [[Intussusception]] may present as currant jelly [[Human feces|stools]] with copious amounts of [[mucus]] due to [[Intestine|bowel]] [[ischemia]]
In cases of intussusception, patients may also present with a palpable lump in the lower abdomen and currant jelly stools.
** [[Fissure]]-in-ano may present with [[blood]]-streaked [[Human feces|stools]]
* [[Ectopia|Ectopic]] [[gastric mucosa]] is found in about half of all cases of [[Meckel's diverticulum|Meckel's diverticula]]; and three fourths of all the cases of [[bleeding]] [[Meckel's diverticulum|Meckel's diverticulae]].
* Panendoscopy may help detect [[Gastrointestinal bleeding|GI bleeds]] from the two most common sites:
** Upper [[Gastrointestinal tract|GI tract]]
** [[Colon (anatomy)|Colorectal]] region


==== Diverticulitis ====
==== Intestinal obstruction ====
This condition develops in approximately 10-20% of patients with symptomatic Meckel diverticulum, occurring more often in the elderly population. Patients may present with symptoms of intermittent, crampy abdominal pain and tenderness in the periumbilical area. Perforation of the inflamed diverticulum leads to peritonitis.
* Presentation:<ref name="pmid27251525">{{cite journal |vauthors=Basani L, Aepala R, Reddy BM |title=Congenital diaphragmatic hernia, Meckel's diverticulum and malrotation in a 3-month-old infant |journal=Afr J Paediatr Surg |volume=13 |issue=1 |pages=47–9 |year=2016 |pmid=27251525 |pmc=4955462 |doi=10.4103/0189-6725.181708 |url=}}</ref><ref name="pmid26310428">{{cite journal |vauthors=Kunitsu T, Koshida S, Tanaka K, Nakahara S, Yanagi T, Maruo Y, Takeuchi Y, Kubota Y |title=Neonatal Meckel diverticulum: Obstruction due to a short mesodiverticular band |journal=Pediatr Int |volume=57 |issue=5 |pages=1007–9 |year=2015 |pmid=26310428 |doi=10.1111/ped.12694 |url=}}</ref><ref name="pmid25970960">{{cite journal |vauthors=Bălălău C, Bacalbaşa N, Motofei I, Popa F, Voiculescu S, Scăunaşu RV |title=Meckel's diverticulum--a rare cause of intestinal obstruction in adults |journal=Rev Med Chir Soc Med Nat Iasi |volume=119 |issue=1 |pages=162–5 |year=2015 |pmid=25970960 |doi= |url=}}</ref>
Stasis in the diverticulum, especially in one with a narrow neck, causes inflammation and secondary infection leading to diverticulitis. Diverticular inflammation can lead to adhesions, which cause intestinal obstruction.
** [[Abdominal pain]] 
** [[Nausea and vomiting|Vomiting]] 
** [[Constipation|Obstipation]]
* In case of [[intussusception]], patient may also present with:<ref name="pmid27179156">{{cite journal |vauthors=Kim KH, Kang KA, Lim JH, Lee KG, Kwon TJ |title=Inverted Meckel diverticulum as a lead point of small bowel intussusception: misinterpreting case as a lipoma |journal=Clin Imaging |volume=40 |issue=5 |pages=840–2 |year=2016 |pmid=27179156 |doi=10.1016/j.clinimag.2016.03.009 |url=}}</ref>
** Palpable lump in the lower [[abdomen]] 
** Currant jelly [[Human feces|stools]]
* [[Radiography]] of the [[abdomen]] may indicate:
** [[Ileus]] 
** Stepladder air-fluid levels, as seen in dynamic [[Bowel obstruction|intestinal obstruction]]
* Observed in one fourth of patients with symptomatic [[Meckel's diverticulum]]
* Various mechanisms of [[Bowel obstruction|intestinal obstruction]] occur with [[Meckel's diverticulum]]:<ref name="pmid28229080">{{cite journal |vauthors=Luu AM, Meurer K, Herzog T, Uhl W, Tannapfel A, Braumann C |title=Small Bowel Obstruction due to a Giant Meckel's Diverticulum |journal=Visc Med |volume=32 |issue=6 |pages=434–436 |year=2016 |pmid=28229080 |pmc=5290431 |doi=10.1159/000450589 |url=}}</ref><ref name="pmid27588829">{{cite journal |vauthors=Fiegel H, Gfroerer S, Rolle U |title=Systematic review shows that pathological lead points are important and frequent in intussusception and are not limited to infants |journal=Acta Paediatr. |volume=105 |issue=11 |pages=1275–1279 |year=2016 |pmid=27588829 |doi=10.1111/apa.13567 |url=}}</ref>
** [[Volvulus]]: The [[Vitelline duct|omphalomesenteric duct]] may be attached to the wall of the [[abdomen]] by a fibrotic band, and [[volvulus]] of the [[Small intestine|small bowel]] around the band may occur.
** [[Intussusception]]: An [[intussusception]] is a blockage in the [[Intestine|intestines]] caused by folding of the [[Intestine|intestines]]. The lead point of the [[intussusception]] may be:
*** [[Diverticulum]] 
*** [[Tumor]] arising in the wall of the [[diverticulum]]
** Littre hernia: The incarceration of a [[Meckel's diverticulum]] in an [[inguinal hernia]] is called a Littré hernia.<ref name="pmid27464282">{{cite journal |vauthors=Clasen K, Kalinski T, Meissner C, Bruns CJ, Meyer F |title=[77-year-old man with rare Littré's hernia] |language=German |journal=Dtsch. Med. Wochenschr. |volume=141 |issue=15 |pages=1099–101 |year=2016 |pmid=27464282 |doi=10.1055/s-0041-109109 |url=}}</ref><ref name="pmid25323188">{{cite journal |vauthors=Qin D, Liu G, Wang Z |title=Littre's hernia in a paediatric patient |journal=Afr J Paediatr Surg |volume=11 |issue=4 |pages=351–3 |year=2014 |pmid=25323188 |doi=10.4103/0189-6725.143168 |url=}}</ref>
==== Perforation ====
* [[Perforation]] may present as:<ref name="pmid27507693">{{cite journal |vauthors=Ahmed Z, Chhabra S, Kankaria J, Jenaw RK |title=Meckel's diverticular perforation presenting as acute abdomen in the second trimester of pregnancy |journal=BMJ Case Rep |volume=2016 |issue= |pages= |year=2016 |pmid=27507693 |doi=10.1136/bcr-2016-216643 |url=}}</ref><ref name="pmid26175810">{{cite journal |vauthors=Farah RH, Avala P, Khaiz D, Bensardi F, Elhattabi K, Lefriyekh R, Berrada S, Fadil A, Zerouali NO |title=Spontaneous perforation of Meckel's diverticulum: a case report and review of literature |journal=Pan Afr Med J |volume=20 |issue= |pages=319 |year=2015 |pmid=26175810 |pmc=4491457 |doi=10.11604/pamj.2015.20.319.5980 |url=}}</ref>
** Acute [[abdomen]]
** Erect [[Chest X-ray|CXR]]: Air under the [[Thoracic diaphragm|diaphragm]]
 
==== Neoplasm ====
* [[Neoplasm|Neoplasms]] are found in approximately 4-5% of complicated [[Meckel's diverticulum]] cases.  
* Types of [[Tumor|tumors]]:<ref name="pmid17373755">{{cite journal |vauthors=Karadeniz Cakmak G, Emre AU, Tascilar O, Bektaş S, Uçan BH, Irkorucu O, Karakaya K, Ustundag Y, Comert M |title=Lipoma within inverted Meckel's diverticulum as a cause of recurrent partial intestinal obstruction and hemorrhage: a case report and review of literature |journal=World J. Gastroenterol. |volume=13 |issue=7 |pages=1141–3 |year=2007 |pmid=17373755 |pmc=4146883 |doi= |url=}}</ref><ref name="pmid21135700">{{cite journal |vauthors=Thirunavukarasu P, Sathaiah M, Sukumar S, Bartels CJ, Zeh H, Lee KK, Bartlett DL |title=Meckel's diverticulum--a high-risk region for malignancy in the ileum. Insights from a population-based epidemiological study and implications in surgical management |journal=Ann. Surg. |volume=253 |issue=2 |pages=223–30 |year=2011 |pmid=21135700 |pmc=4129548 |doi=10.1097/SLA.0b013e3181ef488d |url=}}</ref><ref name="pmid27995004">{{cite journal |vauthors=Zhou B, Lai H, Lin Y, Mo X |title=Omphalomesenteric duct remnant adenocarcinoma in adults: a case study |journal=Springerplus |volume=5 |issue=1 |pages=2027 |year=2016 |pmid=27995004 |pmc=5126029 |doi=10.1186/s40064-016-3713-0 |url=}}</ref><ref name="pmid26936384">{{cite journal |vauthors=Metwally IH, Elalfy AF, Awny S, Megahed N |title=Meckel's diverticulum complicated with gastro-intestinal stromal tumor: Case report |journal=J Egypt Natl Canc Inst |volume=28 |issue=2 |pages=123–7 |year=2016 |pmid=26936384 |doi=10.1016/j.jnci.2016.02.002 |url=}}</ref>
** [[Leiomyoma]] is the one that is most frequently found
** [[Leiomyosarcoma]]
** [[Fibroma]]
** [[Ectopia|Ectopic]] [[Adenocarcinoma|gastric adenocarcinoma]]
** [[Lipoma]]
** [[Zollinger-Ellison syndrome|Gastrinomas]]
** [[Angioma]]
** [[Carcinoid syndrome|Carcinoid tumor]]


==== Umbilical anomalies ====
==== Umbilical anomalies ====
These occur in up to 10% of patients and consist of fistulas, sinuses, cysts, and fibrous bands between the diverticulum and the umbilicus. A patient may present with a chronic discharging umbilical sinus superimposed by infection or excoriation of periumbilical skin. There may be a history of recurrent infection, sinus healing, or abdominal-wall abscess formation. When a fistula is present, intestinal mucosa may be identified on the skin.
* Occurs in up to 10% of patients and consist of the following:<ref name="pmid19661646">{{cite journal |vauthors=Komlatsè AN, Komla G, Komla A, Azanledji BM, Abossisso SK, Hubert T |title=Meckel's diverticulum strangulated in an umbilical hernia |journal=Afr J Paediatr Surg |volume=6 |issue=2 |pages=118–9 |year=2009 |pmid=19661646 |doi=10.4103/0189-6725.54779 |url=}}</ref>
Cannulation and injection with radiographic contrast help to delineate the entire tract and aid in planning a surgical approach for cure. A discharging sinus should be approached surgically with a view toward correction. Exploratory laparotomy may be required.
** [[Cyst|Cysts]]
When found at laparotomy, a fibrous band should be excised because of the risk of internal herniation and volvulus.  
** [[Sinus|Sinuses]]
** [[Fistula|Fistulas]]
** Fibrous bands between the [[Navel|umbilicus]] and the [[diverticulum]]
* Presentation:
** Chronic discharging [[umbilical]] [[sinus]] superimposed by:
*** [[Infection]]
*** [[Excoriation]] of periumbilical [[skin]]
** [[Patient]] may have a history of:<ref name="pmid26955478">{{cite journal |vauthors=Yıldız İ, Koca YS, Barut İ |title=An unusual case of intraabdominal abscess and acute abdomen caused by axial torsion of a Meckel's diverticulum |journal=Ann Med Surg (Lond) |volume=6 |issue= |pages=74–6 |year=2016 |pmid=26955478 |pmc=4761698 |doi=10.1016/j.amsu.2016.01.082 |url=}}</ref>
*** Abdominal-wall [[abscess]] formation
*** Recurrent [[infection]]
*** [[Sinus]] healing
*** On examination, [[Gastrointestinal tract|intestinal mucosa]] may be identified over the [[skin]]
*** [[Cannula|Cannulation]] and [[Injection (medicine)|injection]] with [[Contrast|radiographic contrast]] may help in the delineation of the entire [[tract]] and aids in surgery
** Treatment:
*** [[Surgery]]
*** Exploratory [[laparotomy]]
*** In case a fibrous band is found at [[laparotomy]], it should be excised because of the risk of [[volvulus]] and internal [[Hernia|herniation]].
==== Diverticulitis ====
[[File:Itisrgif.gif|500px|right|thumb|Meckel's diverticulitis <br> Source: Wikimedia commons <ref name="urlFile:Meckels Diverticulum AFIP.jpg - Wikimedia Commons">{{cite web |url=https://commons.wikimedia.org/wiki/File:Meckel%27s_Diverticulum_AFIP.jpg |title=File:Meckel's Diverticulum AFIP.jpg - Wikimedia Commons |format= |work= |accessdate=}}</ref>]]
*Occurs in approximately 10-20% of patients with symptomatic [[Meckel's diverticulum]]
*Seen in the elderly population
* Presentation:<ref name="pmid27146826">{{cite journal |vauthors=Marwah S, Singla P, Marwah N, Gupta S, Singh VP |title=Ileal stricture following Meckel's diverticulitis: a rare cause of intestinal obstruction |journal=Clin J Gastroenterol |volume=9 |issue=3 |pages=118–23 |year=2016 |pmid=27146826 |doi=10.1007/s12328-016-0647-6 |url=}}</ref><ref name="pmid25892011">{{cite journal |vauthors=Hamilton CM, Arnason T |title=Ileitis associated with Meckel's diverticulum |journal=Histopathology |volume=67 |issue=6 |pages=783–91 |year=2015 |pmid=25892011 |doi=10.1111/his.12717 |url=}}</ref>
** Intermittent, crampy [[abdominal pain]]
** [[Tenderness]] in the periumbilical area


=== Neoplasm ===
* Mechanism:
This is the pathology least commonly associated with Meckel diverticulum and is reported in approximately 4-5% of complicated Meckel diverticulum cases. Of the various types of tumors reported, leiomyoma is the one that is most frequently found, followed by leiomyosarcoma, carcinoid tumor, and fibroma. One case of ectopic gastric adenocarcinoma has been reported. Lipoma and angioma have also been found. [4, 5]
** [[Stasis (medicine)|Stasis]] in the [[diverticulum]], particularly in one with a narrow neck leads to:
*** [[Inflammation]]
*** Secondary [[infection]]
*** [[Adhesion (medicine)|Adhesions]] may develop due to [[diverticular]] [[inflammation]] causing [[Symptom|symptoms]] of [[Bowel obstruction|intestinal obstruction]]
*** [[Peritonitis]]: [[perforation]] of the [[Inflammation|inflamed]] [[diverticulum]] may lead to [[inflammation]] of the [[peritoneum]], which is a thin [[Tissue (biology)|tissue]] that lines the inside of the [[abdomen]]. 


=== Other complications ===
==== Other complications ====
Other reported complications in Meckel diverticulum are vesicodiverticular fistulas, "daughter" diverticula (formation of a diverticulum within a Meckel diverticulum), and formation of stones and phytobezoar in the Meckel diverticulum.
* Other complications in [[Meckel's diverticulum]] include:<ref name="pmid27345602">{{cite journal |vauthors=Gasparella M, Marzaro M, Ferro M, Benetton C, Ghirardo V, Zanatta C, Zoppellaro F |title=Meckel's diverticulum and bowel obstruction due to phytobezoar: a case report |journal=Pediatr Med Chir |volume=38 |issue=2 |pages=117 |year=2016 |pmid=27345602 |doi=10.4081/pmc.2016.117 |url=}}</ref><ref name="pmid26040824">{{cite journal |vauthors=Lo T, Sagar J, Trickett J |title=A rare presentation of complication arising from Meckel's diverticulum in the form of diverticulotransverse colonic fistula in an adult |journal=BMJ Case Rep |volume=2015 |issue= |pages= |year=2015 |pmid=26040824 |pmc=4460404 |doi=10.1136/bcr-2013-203330 |url=}}</ref><ref name="pmid25309093">{{cite journal |vauthors=Wu SY, Ho MH, Hsu SD |title=Meckel's diverticulum incarcerated in a transmesocolic internal hernia |journal=World J. Gastroenterol. |volume=20 |issue=37 |pages=13615–9 |year=2014 |pmid=25309093 |pmc=4188914 |doi=10.3748/wjg.v20.i37.13615 |url=}}</ref>
Children and infants are at the highest risk for complications, and for some reason, complications occur more often in males than females. Due to this, males are more frequently diagnosed with Meckel’s Diverticulum than females.  
** Vesicodiverticular [[Fistula|fistulas]]
 
** Phytobezoar formation
The possible complications with Meckel’s Diverticulum include:
** Stone formation
 
** [[Diverticulum]] within a [[Meckel's diverticulum]]:  formation of 'daughter" [[Diverticular|diverticula]]
A blockage in the intestines caused by folding of the intestines (intussusception)
* Complications occur frequently in:
 
** Children
Abnormal and excessive bleeding arising within the diverticulum  
** Infants
 
** Males
Injury to the diverticulum may result in perforation of the bowel wall
 
Inflammation of the peritoneum, which is a thin tissue that lines the inside of the abdomen
 
Rarely, tumors can occur within a Meckel’s Diverticulum. The most common tumor includes carcinoid tumors and gastrinomas. These tumors arise from abnormal collection of neuroendocrine cells or gastrin hormone producing cells


===Prognosis===
===Prognosis===
Line 102: Line 148:
*Complete [[Healing|recovery]] may be expected with [[surgery]].<ref name="pmid20871204">{{cite journal |vauthors=Yagnik VD, Yagnik BD |title=Asymptomatic Meckel's diverticulum in adults: is diverticulectomy indicated? |journal=Saudi J Gastroenterol |volume=16 |issue=4 |pages=306 |year=2010 |pmid=20871204 |pmc=2995107 |doi=10.4103/1319-3767.70626 |url=}}</ref>
*Complete [[Healing|recovery]] may be expected with [[surgery]].<ref name="pmid20871204">{{cite journal |vauthors=Yagnik VD, Yagnik BD |title=Asymptomatic Meckel's diverticulum in adults: is diverticulectomy indicated? |journal=Saudi J Gastroenterol |volume=16 |issue=4 |pages=306 |year=2010 |pmid=20871204 |pmc=2995107 |doi=10.4103/1319-3767.70626 |url=}}</ref>
*The risk of developing complications in the postoperative period is 2-7%, the most common complication being [[bowel obstruction]].<ref name="pmid18216533">{{cite journal |vauthors=Zani A, Eaton S, Rees CM, Pierro A |title=Incidentally detected Meckel diverticulum: to resect or not to resect? |journal=Ann. Surg. |volume=247 |issue=2 |pages=276–81 |year=2008 |pmid=18216533 |doi=10.1097/SLA.0b013e31815aaaf8 |url=}}</ref>  
*The risk of developing complications in the postoperative period is 2-7%, the most common complication being [[bowel obstruction]].<ref name="pmid18216533">{{cite journal |vauthors=Zani A, Eaton S, Rees CM, Pierro A |title=Incidentally detected Meckel diverticulum: to resect or not to resect? |journal=Ann. Surg. |volume=247 |issue=2 |pages=276–81 |year=2008 |pmid=18216533 |doi=10.1097/SLA.0b013e31815aaaf8 |url=}}</ref>  
*The risk of developing complications such as [[perforation]], [[inflammation]], [[bleeding]] and [[obstruction]] in asymptomatic patients with Meckel diverticulum is 4-6.4%.<ref name="pmid7944666">{{cite journal |vauthors=Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ |title=Surgical management of Meckel's diverticulum. An epidemiologic, population-based study |journal=Ann. Surg. |volume=220 |issue=4 |pages=564–8; discussion 568–9 |year=1994 |pmid=7944666 |pmc=1234434 |doi= |url=}}</ref>
*The risk of developing complications such as [[perforation]], [[inflammation]], [[bleeding]] and [[obstruction]] in asymptomatic patients with Meckel's diverticulum is 4-6.4%.<ref name="pmid7944666">{{cite journal |vauthors=Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ |title=Surgical management of Meckel's diverticulum. An epidemiologic, population-based study |journal=Ann. Surg. |volume=220 |issue=4 |pages=564–8; discussion 568–9 |year=1994 |pmid=7944666 |pmc=1234434 |doi= |url=}}</ref>
 
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Latest revision as of 19:54, 8 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Meckel's diverticulum is mostly seen in male children (mostly <2 years of age). One fourth of untreated cases of Meckel's diverticulum may develop complications such as intestinal obstruction, hemorrhage, diverticulitis, bowel ischemia, and necrosis. Hemorrhage is the most common complication in patients with Meckel's diverticulum. Bleeding in patients may be minimal, recurrent or massive and shock-producing. The rate of bleeding is assessed based on quantity of blood lost in the stools, appearance of the material passing through the rectum and hemodynamic state of the patient. Depending on the extent of the symptom progression at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as excellent in cases where symptomatic Meckel's diverticulum is treated in a timely manner. Complete recovery may be expected with surgery in majority of the cases.

Natural History, Complications, and Prognosis

Natural History

Complications

Hemorrhage

  • Most common complication in patients with Meckel diverticulum
  • Accounts for one fourth of all complications
  • More commonly seen in:
    • Children younger than 2 years
    • Male sex

Intestinal obstruction

Perforation

Neoplasm

Umbilical anomalies

Diverticulitis

Meckel's diverticulitis
Source: Wikimedia commons [32]

Other complications

Prognosis

Prognosis of patients with Meckel's diverticulum is as follows: [38]

References

  1. ↑ "Meckel's Diverticulum | Cleveland Clinic".
  2. ↑ 2.0 2.1 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.
  3. ↑ 3.0 3.1 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ 13.0 13.1 Komlatsè AN, Komla G, Komla A, Azanledji BM, Abossisso SK, Hubert T (2009). "Meckel's diverticulum strangulated in an umbilical hernia". Afr J Paediatr Surg. 6 (2): 118–9. doi:10.4103/0189-6725.54779. PMID 19661646.
  14. ↑ Pattni V, Wright K, Marden P, Terlevich A (2016). "Meckel's diverticulum in an adult: an obscure presentation of gastrointestinal bleeding". BMJ Case Rep. 2016. doi:10.1136/bcr-2015-213852. PMID 27126093.
  15. ↑ Anwar MO, Ahmed HI, Al Hindi S, Al Omran Y (2014). "Meckel's diverticulum with intussusception in a 5-year-old patient with Down's syndrome". BMJ Case Rep. 2014. doi:10.1136/bcr-2014-207431. PMC 4281549. PMID 25540213.
  16. ↑ Holcomb CN, Hawn MT (2014). "Occult gastrointestinal bleeding". JAMA Surg. 149 (12): 1335–6. doi:10.1001/jamasurg.2014.109. PMID 25337720.
  17. ↑ Basani L, Aepala R, Reddy BM (2016). "Congenital diaphragmatic hernia, Meckel's diverticulum and malrotation in a 3-month-old infant". Afr J Paediatr Surg. 13 (1): 47–9. doi:10.4103/0189-6725.181708. PMC 4955462. PMID 27251525.
  18. ↑ Kunitsu T, Koshida S, Tanaka K, Nakahara S, Yanagi T, Maruo Y, Takeuchi Y, Kubota Y (2015). "Neonatal Meckel diverticulum: Obstruction due to a short mesodiverticular band". Pediatr Int. 57 (5): 1007–9. doi:10.1111/ped.12694. PMID 26310428.
  19. ↑ Bălălău C, Bacalbaşa N, Motofei I, Popa F, Voiculescu S, Scăunaşu RV (2015). "Meckel's diverticulum--a rare cause of intestinal obstruction in adults". Rev Med Chir Soc Med Nat Iasi. 119 (1): 162–5. PMID 25970960.
  20. ↑ Kim KH, Kang KA, Lim JH, Lee KG, Kwon TJ (2016). "Inverted Meckel diverticulum as a lead point of small bowel intussusception: misinterpreting case as a lipoma". Clin Imaging. 40 (5): 840–2. doi:10.1016/j.clinimag.2016.03.009. PMID 27179156.
  21. ↑ Luu AM, Meurer K, Herzog T, Uhl W, Tannapfel A, Braumann C (2016). "Small Bowel Obstruction due to a Giant Meckel's Diverticulum". Visc Med. 32 (6): 434–436. doi:10.1159/000450589. PMC 5290431. PMID 28229080.
  22. ↑ Fiegel H, Gfroerer S, Rolle U (2016). "Systematic review shows that pathological lead points are important and frequent in intussusception and are not limited to infants". Acta Paediatr. 105 (11): 1275–1279. doi:10.1111/apa.13567. PMID 27588829.
  23. ↑ Clasen K, Kalinski T, Meissner C, Bruns CJ, Meyer F (2016). "[77-year-old man with rare Littré's hernia]". Dtsch. Med. Wochenschr. (in German). 141 (15): 1099–101. doi:10.1055/s-0041-109109. PMID 27464282.
  24. ↑ Qin D, Liu G, Wang Z (2014). "Littre's hernia in a paediatric patient". Afr J Paediatr Surg. 11 (4): 351–3. doi:10.4103/0189-6725.143168. PMID 25323188.
  25. ↑ Ahmed Z, Chhabra S, Kankaria J, Jenaw RK (2016). "Meckel's diverticular perforation presenting as acute abdomen in the second trimester of pregnancy". BMJ Case Rep. 2016. doi:10.1136/bcr-2016-216643. PMID 27507693.
  26. ↑ Farah RH, Avala P, Khaiz D, Bensardi F, Elhattabi K, Lefriyekh R, Berrada S, Fadil A, Zerouali NO (2015). "Spontaneous perforation of Meckel's diverticulum: a case report and review of literature". Pan Afr Med J. 20: 319. doi:10.11604/pamj.2015.20.319.5980. PMC 4491457. PMID 26175810.
  27. ↑ Karadeniz Cakmak G, Emre AU, Tascilar O, Bektaş S, Uçan BH, Irkorucu O, Karakaya K, Ustundag Y, Comert M (2007). "Lipoma within inverted Meckel's diverticulum as a cause of recurrent partial intestinal obstruction and hemorrhage: a case report and review of literature". World J. Gastroenterol. 13 (7): 1141–3. PMC 4146883. PMID 17373755.
  28. ↑ Thirunavukarasu P, Sathaiah M, Sukumar S, Bartels CJ, Zeh H, Lee KK, Bartlett DL (2011). "Meckel's diverticulum--a high-risk region for malignancy in the ileum. Insights from a population-based epidemiological study and implications in surgical management". Ann. Surg. 253 (2): 223–30. doi:10.1097/SLA.0b013e3181ef488d. PMC 4129548. PMID 21135700.
  29. ↑ Zhou B, Lai H, Lin Y, Mo X (2016). "Omphalomesenteric duct remnant adenocarcinoma in adults: a case study". Springerplus. 5 (1): 2027. doi:10.1186/s40064-016-3713-0. PMC 5126029. PMID 27995004.
  30. ↑ Metwally IH, Elalfy AF, Awny S, Megahed N (2016). "Meckel's diverticulum complicated with gastro-intestinal stromal tumor: Case report". J Egypt Natl Canc Inst. 28 (2): 123–7. doi:10.1016/j.jnci.2016.02.002. PMID 26936384.
  31. ↑ Yıldız İ, Koca YS, Barut İ (2016). "An unusual case of intraabdominal abscess and acute abdomen caused by axial torsion of a Meckel's diverticulum". Ann Med Surg (Lond). 6: 74–6. doi:10.1016/j.amsu.2016.01.082. PMC 4761698. PMID 26955478.
  32. ↑ "File:Meckel's Diverticulum AFIP.jpg - Wikimedia Commons".
  33. ↑ Marwah S, Singla P, Marwah N, Gupta S, Singh VP (2016). "Ileal stricture following Meckel's diverticulitis: a rare cause of intestinal obstruction". Clin J Gastroenterol. 9 (3): 118–23. doi:10.1007/s12328-016-0647-6. PMID 27146826.
  34. ↑ Hamilton CM, Arnason T (2015). "Ileitis associated with Meckel's diverticulum". Histopathology. 67 (6): 783–91. doi:10.1111/his.12717. PMID 25892011.
  35. ↑ Gasparella M, Marzaro M, Ferro M, Benetton C, Ghirardo V, Zanatta C, Zoppellaro F (2016). "Meckel's diverticulum and bowel obstruction due to phytobezoar: a case report". Pediatr Med Chir. 38 (2): 117. doi:10.4081/pmc.2016.117. PMID 27345602.
  36. ↑ Lo T, Sagar J, Trickett J (2015). "A rare presentation of complication arising from Meckel's diverticulum in the form of diverticulotransverse colonic fistula in an adult". BMJ Case Rep. 2015. doi:10.1136/bcr-2013-203330. PMC 4460404. PMID 26040824.
  37. ↑ Wu SY, Ho MH, Hsu SD (2014). "Meckel's diverticulum incarcerated in a transmesocolic internal hernia". World J. Gastroenterol. 20 (37): 13615–9. doi:10.3748/wjg.v20.i37.13615. PMC 4188914. PMID 25309093.
  38. ↑ "Meckel diverticulum Prognosis - Epocrates Online".
  39. ↑ Yagnik VD, Yagnik BD (2010). "Asymptomatic Meckel's diverticulum in adults: is diverticulectomy indicated?". Saudi J Gastroenterol. 16 (4): 306. doi:10.4103/1319-3767.70626. PMC 2995107. PMID 20871204.
  40. ↑ Zani A, Eaton S, Rees CM, Pierro A (2008). "Incidentally detected Meckel diverticulum: to resect or not to resect?". Ann. Surg. 247 (2): 276–81. doi:10.1097/SLA.0b013e31815aaaf8. PMID 18216533.

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