Saudi Journal of Gastroenterology
Home About us Instructions Submission Subscribe Advertise Contact Login    Print this page  Email this page Small font sizeDefault font sizeIncrease font size 
Users Online: 2143 


 
ARTICLES Table of Contents   
Year : 1997  |  Volume : 3  |  Issue : 1  |  Page : 46-48
Meckel diverticulum revisited


Department of Surgery, College of Medicine and Asir Central Hospital, Abha, Saudi Arabia

Click here for correspondence address and email

Date of Submission23-Jan-1996
Date of Acceptance04-Jun-1996
 

   Abstract 

Nine cases of Meckel diverticulum seen over a period of four years are presented. Six presented with gangrene, perforation, intestinal obstruction, intraabdominal abscess and pain related to Meckel diverticulum. The remaining three were incidental findings. Seven of the patients were males and two females. Average age of the patients was 25.5 years. The paper reaffirms the well-known practice that Meckel diverticulum should be looked for at laparotomies and resected when seen.

How to cite this article:
Malatani TM. Meckel diverticulum revisited. Saudi J Gastroenterol 1997;3:46-8

How to cite this URL:
Malatani TM. Meckel diverticulum revisited. Saudi J Gastroenterol [serial online] 1997 [cited 2020 Feb 23];3:46-8. Available from: http://www.saudijgastro.com/text.asp?1997/3/1/46/33945


Meckel diverticulum, a persistent vitello-intestinal duct, is not usually diagnosed before laparotomy for another condition or for one of its complications. Since the condition is not often diagnosed, it tends to be a "forgotten" entity until it perforates, bleeds or becomes gangrenous.

In a four years period from 1991 to 1995, nine cases of Meckel diverticulum were encountered at Asir Central Hospital. During this period 1955 laparotomies were performed. None of the patients were diagnosed preoperatively.

The purpose of this paper is to call attention to this "forgotten" pathology which can cause serious morbidity and mortality if it is not treated adequately when any of its complications occurs.


   Case 1 Top


A three-and-a-half-year-old Saudi boy was presented with one day history of abdominal pain, vomiting and loose watery stools. Clinical findings showed a toxic-looking, dehydrated child, temperature 39.8°C with generalized abdominal guarding and rigidity, but more severe in the right iliac fossa. WBC was 11.5 x 109/L. Initial diagnosis showed perforated appendix.

Laparotomy showed a relatively normal appendix but a gangrenous Meckel diverticulum with a band of adhesions. Appendectomy with diverticulectomy was performed with satisfactory results. Histopathology showed periappendicitis and transmural acute Meckel diverticulitis.


   Case 2 Top


An 18-year-old Saudi male presented with one day history ofperiumbilical and suprapubic pain associated with vomiting. Clinical features were suggestive of perforated appendix. Appendix was found to be normal, but Meckel diverticulum was found to be grossly inflamed. Also, intestinal herniation of small intestinal loops around a patent vitello-intestinal duct from Meckel diverticulum to the umbilicus was noted. The twisted, kinked intestinal loop around the band was released. Appendectomy with Meckel diverticulectomy was performed. Histopathology showed the appendix to be normal, but Meckel diverticulum showed early gangrene, and the adjacent loop of the resected small bowel showed congestion and hemorrhage.


   Case 3 Top


A 48-year-old Saudi national was referred to Asir Central Hospital with a four-day history of peritonitis, sepsis and jaundice. Clinical features showed a toxic looking man. X-ray of the abdomen showed multiple fluid levels.

Laparotomy showed a gangrenous Meckel diverticulum with perforation at the base, and about 300 cc of pus drained from the peritoneal cavity. Resection of the diverticulum was performed. Apart from postoperative wound infection, the recovery was uneventful.


   Case 4 Top


A 54-year-old Saudi woman presented with a three­day history of generalized abdominal pain and vomiting. Clinical features of peritonitis with marked tenderness in the left lower quadrant were present and plain X-ray showed multiple fluid levels. As the patient was obese, (weighed 236 lbs) and the area of tenderness was more in the left lower quadrant, sigmoid diverticulitis with perforation was suspected.

Diagnosis showed a perforated gangrenous Meckel diverticulum, walled by a loop of small bowel and omentum forming an abscess cavity. This was resected and the patient had an uneventful recovery.


   Case 5 Top


A 14-year-old Saudi boy presented with clinical features of acute appendicitis. Laparotomy showed periappendicitis and a gangrenous Meckel diverticulum with perforation at the tip. Resection of both appendix and Meckel diverticulum were performed with uneventful recovery.


   Case 6 Top


A 14-year-old female presented with an atypical presentation of acute appendicitis. On laparotomy, a normal appendix and a fibrosed Meckel diverticulum were removed. Histopathological studies showed the removed appendix to be unremarkable, but Meckel diverticulum contained numerous ganglionic cells in the muscle layer of the wall. It is not known whether these ganglionic cells bore any relevance to the pain the patient had before laparotomy.

The remaining three patients were incidentally discovered at laparotomy with other pathology.

In another case, a 30-year-old Saudi male was presented with acute appendicitis and a normal Meckel diverticulum. Both were removed. Another patient, a one-month-old Saudi baby boy was examined for an undiagnosed abdominal mass. The baby had duplication cyst of jejuno-ileal segment and an uninflamed Meckel diverticulum. Both were surgically treated.

The third patient was a 48 years old Saudi male who had laparotomy for splenic abscess, found incidentally to have an uninflamed Meckel diverticulum which was removed.


   Discussion Top


Meckel diverticulum results from the failure of complete obliteration of the omphalomesenteric duct. It arises from antimesenteric border of the terminal ileum within two feet of the ileocaecal junction, it occurs in two percent of the general population and about two inches long.

The structure may contain intestinal cells, as in all these cases, or cells similar to the stomach or pancreas. This series agrees with others [1] that Meckel diverticulum does not necessarily have to contain ectopic gastric or pancreatic tissue before a complication occurs. Complications that have been reported include inflammation simulating appendicitis [2],[3] fistula formation with other internal organ [1] , intestinal obstruction from the congenital bands associated with the diverticulum or from intussusception of a Meckel diverticulum [3],[4],[5] perforation [6] , hemorrhage from ulceration secondary to ectopic gastric mucosa [7] and umbilical discharge from a patent omphalomesenteric duct. Six cases in this series presented with gangrene, perforation, intestinal obstruction, intraabdominal abscess and abdominal pain.

The female-male ration of Meckel diverticulum in one report was 1:1.7 with a mean age of 46.7 years [7] . However, in a report by Al-Shawan et al [8] from the Eastern Province of Saudi Arabia showed a female to male ratio of 1:2.9. In this series, the female-male ratio is 1:3.5 with an average age of 25.5 years. It is not known why it is more common in males than females, but its complication can occur at any age and in both sexes.

All the patients were Saudi nationals. None of them was diagnosed as having Meckel diverticulum before laparotomy. Although, a preoperative diagnosis of a Meckel diverticulum causing intestinal obstruction by ultrasonography has been reported [3] . Jewett et al introduced the use of 99m TC pertechnetate scan to demonstrate the presence of the diverticulum [9] . The technique is based on the affinity of the isotope for parietal cells in a normal or ectopic gastric mucosa. It can establish the diagnosis in patients with minimal symptoms.

The presence of Meckel diverticulum in itself carries no morbidity when there are no complications from the structure. However, when found at laparotomy it should be removed as complications may occur at any time. This option is also shared by others [7],[10] .

The guidelines set out in an editorial in Lancet [11] in 1983 are useful to follow, however, two points mentioned in the guidelines are not universally accepted. We have seen a case of inflamed appendix at surgery associated with Meckel diverticulitis (Case No. 5). This turned out to be periappendicitis after histological examination. The practice of some surgeons in our hospital is to search for Meckel diverticulum after appendicectomy even if the appendix is inflamed. A grossly inflamed appendix may not be the source of pain as periappendicitis may be difficult to differentiate from acute appendicitis on gross examination. Also, we do not believe in not removing an incidental Meckel diverticulum when seen at laparotomy for other causes, regardless of the age of the patients because we can never predict if and when it will cause problem in the future.

There is no sufficient scientific evidence in the literature and in our hospital's experience to support the views that, in the presence of acute appendicitis, one should not look for Meckel diverticulum, and that incidental Meckel diverticulum found during laparotomy in a patient above 40 years of age should be left alone.

In conclusion, Meckel diverticulum should be looked for during laparotomies and should be resected when found, regardless of the age of the patient. Perforated or gangrenous Meckel diverticulum should always be considered in any case of undiagnosed acute abdomen.

 
   References Top

1.Hudson HM, Millham FH, Dennis R. Vesico-diverticular fistula: a rare complication of Meckel diverticulum. Am surg 1992;58:784-6.  Back to cited text no. 1    
2.Dimitrov G. Two cases of the simultaneous occurrence of acute appendicitis and acute Meckel diverticulum. Khirurgiia-Sofia 1991;44:16-8.  Back to cited text no. 2    
3.Goyal MK, Bellah RD. Neonatal small bowel obstruction due to Meckel diverticulitis: diagnosis by ultrasonography. J Ultrasound-Med 1993;12:11-22.  Back to cited text no. 3    
4.Koudelka J, Kralova M, Preis J. Giant Meckel diverticulum. J Pediatr Surg 1982;27:1589-90.  Back to cited text no. 4    
5.Albu E, Solomon L, Shah AK, Murthy RM, Gerst PH. Double Meckel diverticulum. South Med J 1992;85:1142-4.  Back to cited text no. 5  [PUBMED]  
6.Ford EG. Woolley MM. Tracheoesophageal fistula associated with perforated Meckel diverticulum. J Pediat Surg 1992;27:1223-4.  Back to cited text no. 6    
7.Dermatines N, Herzog U, Tondelli P, Harder F. Meckel diverticulum: surgical complications. Helv Chir Acta 1992;59:325-9.  Back to cited text no. 7    
8.Al-Shawan S, Al-Mulhim A, Khatib E, Gumaa R, Al-Awad N, Abdul-Hadi M, Wosornu L. Meckel diverticulum in Eastern province: a clinical study of 39 patients and a review of literature. Saudi Med Journal 1996;17(1):47-50.  Back to cited text no. 8    
9.Jewett TC, Dusznyski DO, Allan JE. The visualization of Meckel diverticulum with 99m TC pertechnetate. Surgery 1970;68:567­-71.  Back to cited text no. 9    
10.Michas CA, Cohen SE, Wolfman EF. Meckel diverticulum; should it be excised incidentally at operation ? Am J Surg . 1975;129:682-5.  Back to cited text no. 10    
11.Meckel diverticulum, Surgical guidelines at last. Lancet 1983;2:438-9.  Back to cited text no. 11    

Top
Correspondence Address:
Tarek M Malatani
P.O.Box 575, Abha
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None


PMID: 19864813

Rights and PermissionsRights and Permissions




 

Top
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Case 1
    Case 2
    Case 3
    Case 4
    Case 5
    Case 6
    Discussion
    References

 Article Access Statistics
    Viewed2810    
    Printed101    
    Emailed2    
    PDF Downloaded121    
    Comments [Add]    

Recommend this journal