Meckel's diverticulum natural history, complications and prognosis: Difference between revisions
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** 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> | ** 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> | ||
==== Diverticulitis ==== | ==== Diverticulitis ==== | ||
[[File:File:Itisrgif.gif|500px|center|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]] | *Occurs in approximately 10-20% of patients with symptomatic [[Meckel's diverticulum]] | ||
*Seen in the elderly population | *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> | * 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> | ||
Revision as of 19:51, 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
- The symptoms of Meckel's diverticulum usually develop in children, and start with painless lower gastrointestinal bleeding.[1]
- If left untreated, 25% of patients with Meckel's diverticulum may progress to develop hemorrhage, ulceration, bowel perforation, diverticulitis, peritonitis and small bowel obstruction.[2]
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
- Presentation:
- Patients present with the following symptoms:[14]
- Passage of bright red blood in the stools
- May or may not be associated with:
- Abdominal pain (usually painless)
- Weakness
- Anemia
- Bleeding may be:
- Minimal
- Recurrent
- Massive, shock-producing
- Assessment of the rate of bleeding may be done on the basis of the following:
- Quantity of blood lost in the stools
- Appearance of the material passing through the rectum
- Hemodynamic state
- Characteristics of hemorrhage based on the appearance of stools include the following:[15][16]
- Brisk hemorrhage: bright red blood in the stools
- Minor upper GI bleeding, associated with delayed intestinal transit causing alteration of blood: Tarry stools
- Intussusception: Currant jelly stools with copious amounts of mucus due to bowel ischemia
- Fissure-in-ano: Blood-streaked 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's diverticula; and three fourths of bleeding 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.
- Patients present with the following symptoms:[14]
- Characteristics of hemorrhage based on the appearance of stools include the following:
- Brisk hemorrhage may present as bright red blood in the stools
- Minor upper GI bleeding, associated with delayed intestinal transit causing alteration of blood may present as tarry stools
- Intussusception may present as currant jelly stools with copious amounts of mucus due to bowel ischemia
- Fissure-in-ano may present with blood-streaked stools
- Ectopic gastric mucosa is found in about half of all cases of Meckel's diverticula; and three fourths of all the cases of bleeding Meckel's diverticulae.
- Panendoscopy may help detect GI bleeds from the two most common sites:
- Upper GI tract
- Colorectal region
Intestinal obstruction
- Presentation:[17][18][19]
- In case of intussusception, patient may also present with:[20]
- Radiography of the abdomen may indicate:
- Ileus
- Stepladder air-fluid levels, as seen in dynamic intestinal obstruction
- Observed in one fourth of patients with symptomatic Meckel's diverticulum
- Various mechanisms of intestinal obstruction occur with Meckel's diverticulum:[21][22]
- Volvulus: The omphalomesenteric duct may be attached to the wall of the abdomen by a fibrotic band, and volvulus of the small bowel around the band may occur.
- Intussusception: An intussusception is a blockage in the intestines caused by folding of the 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.[23][24]
Diverticulitis
Source: Wikimedia commons [25]
- Occurs in approximately 10-20% of patients with symptomatic Meckel's diverticulum
- Seen in the elderly population
- Presentation:[26][27]
- Intermittent, crampy abdominal pain
- Tenderness in the periumbilical area
- Mechanism:
- Stasis in the diverticulum, particularly in one with a narrow neck leads to:
- Inflammation
- Secondary infection
- Adhesions may develop due to diverticular inflammation causing symptoms of intestinal obstruction
- Peritonitis: perforation of the inflamed diverticulum may lead to inflammation of the peritoneum, which is a thin tissue that lines the inside of the abdomen.
- Stasis in the diverticulum, particularly in one with a narrow neck leads to:
Perforation
Neoplasm
- Neoplasms are found in approximately 4-5% of complicated Meckel's diverticulum cases.
- Types of tumors:[30][31][32][33]
- Leiomyoma is the one that is most frequently found
- Leiomyosarcoma
- Fibroma
- Ectopic gastric adenocarcinoma
- Lipoma
- Gastrinomas
- Angioma
- Carcinoid tumor
Umbilical anomalies
- Occurs in up to 10% of patients and consist of the following:[13]
- Cysts
- Sinuses
- Fistulas
- Fibrous bands between the umbilicus and the diverticulum
- Presentation:
- Chronic discharging umbilical sinus superimposed by:
- Infection
- Excoriation of periumbilical skin
- Patient may have a history of:[34]
- Abdominal-wall abscess formation
- Recurrent infection
- Sinus healing
- On examination, intestinal mucosa may be identified over the skin
- Cannulation and injection with 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 herniation.
- Chronic discharging umbilical sinus superimposed by:
Other complications
- Other complications in Meckel's diverticulum include:[35][36][37]
- Vesicodiverticular fistulas
- Phytobezoar formation
- Stone formation
- Diverticulum within a Meckel's diverticulum: formation of 'daughter" diverticula
- Complications occur frequently in:
- Children
- Infants
- Males
Prognosis
Prognosis of patients with Meckel's diverticulum is as follows: [38]
- 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.[39]
- The risk of developing complications in the postoperative period is 2-7%, the most common complication being bowel obstruction.[40]
- The risk of developing complications such as perforation, inflammation, bleeding and obstruction in asymptomatic patients with Meckel's diverticulum is 4-6.4%.[3]
References
- ↑ "Meckel's Diverticulum | Cleveland Clinic".
- ↑ 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.
- ↑ 3.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Holcomb CN, Hawn MT (2014). "Occult gastrointestinal bleeding". JAMA Surg. 149 (12): 1335–6. doi:10.1001/jamasurg.2014.109. PMID 25337720.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "File:Meckel's Diverticulum AFIP.jpg - Wikimedia Commons".
- ↑ 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.
- ↑ Hamilton CM, Arnason T (2015). "Ileitis associated with Meckel's diverticulum". Histopathology. 67 (6): 783–91. doi:10.1111/his.12717. PMID 25892011.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ "Meckel diverticulum Prognosis - Epocrates Online".
- ↑ 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.
- ↑ 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.
