1. Meckel’s Diverticulitis
Case of the Month: October 2018
Claire Burrows, R2
McMaster University
Di Muzio, B. & Jha, P. (2018) Meckel diverticulitis. Radiopedia. Retrieved September 30, 2018 from

2. Case Presentation 65 M presents to the ER: Chief Complaint:
RLQ pain x 2 days, rule out appendicitis vs. diverticulitis
Past Medical/Surgical History:
Otherwise well, no prior abdominal surgeries
Investigations:
Labs: elevated WBC count
Imaging: CT Abdo/Pelvis C+
Wang, W. (2018). Radiology Case: Meckel diverticulitis. Radiopaedia. Retrieved September 30, 2018 from

3. No evidence of appendicitis or colonic diverticulitis on CT
Di Muzio, B. & Jha, P. (2018) Meckel diverticulitis. Radiopedia. Retrieved September 30, 2018 from
Wang, W. (2018). Radiology Case: Meckel diverticulitis. Radiopaedia. Retrieved September 30, 2018 from

4. In the RLQ there is fat stranding associated with a tubular, blind-ending structure favoured to be arising from the small bowel.
Wang, W. (2018). Radiology Case: Meckel diverticulitis. Radiopaedia. Retrieved September 30, 2018 from

5. There is suspected perforation. No drainable collection identified.
Wang, W. (2018). Radiology Case: Meckel diverticulitis. Radiopaedia. Retrieved September 30, 2018 from

6. Findings in keeping with perforated Meckel’s diverticulitis
Findings in keeping with perforated Meckel’s diverticulitis. OR confirmed this.
Wang, W. (2018). Radiology Case: Meckel diverticulitis. Radiopaedia. Retrieved September 30, 2018 from

7. Pathophysiology of Meckel’s Diverticulum
Most common congenital anomaly of GI tract (2% population)
Remnant of vitelline/omphalomesenteric duct that connects yolk sac with primitive midgut
Vitelline duct should normally be obliterated between 8-10 weeks gestation
There may be a fibrous band connecting the Meckel’s diverticulum to the umbilicus
Gulwani, H. (2018 February 9). Meckel diverticulum. PathologyOutlines.com. Retrieved September 30th,
Kuwajerwala, N.K. & Silva, Y. J. (2017, April 11). Meckel Diverticulum. Medscape. Retrieved September 30, 2018 from

8. It is a true diverticulum (contains all layers of bowel wall)
Located on antimesenteric border of ileum, 1-8 cm long, 20 cm proximal to ileocecal valve
May contain gastric, pancreatic, duodenal, colonic or even biliary mucosa
Usually contains intestinal mucosa, but 50% have gastric or pancreatic heterotopia
Remember these details by “Rule of 2’s”:
Affects 2% of the population
2:1 M:F ratio
Patients often present by 2 years of age
Found within 2 feet of ileocecal valve
2 inches in length and 2 inches in diameter
Symptomatic in 2% of cases
Often 2 types of tissue found: gastric and pancreatic
Gulwani, H. (2018 February 9). Meckel diverticulum. In PathologyOutlines.com. Retrieved September 30th,

9. Patient’s with Meckel’s Diverticulum can present in multiple ways:
Bright red blood per rectum
40% Meckel complications occur in children <10 years old: GI bleeding most common
Inflammation (10-20%)/perforation
Small bowel volvulus
Bowel obstruction (20-25%)
Adults more prone to obstructions
Meckel’s can act as lead point for intussusception
Littre’s hernia (incarcerated Meckel’s in inguinal canal)
Neoplasm (4-5%)
Gulwani, H. (2018 February 9). Meckel diverticulum. PathologyOutlines.com. Retrieved September 30th,
Hartung, Michael. (2018). Radiology CaseL Meckel diverticulitis. In Radiopaedia. Retrieved September 30, 2018 from

10. EXAMPLE: Imaging: Meckel’s causing SBO; Intraoperative Findings: gangrenous torted Meckel’s
Cartanese C, Petitti T, Marinelli E, Pignatelli A, Martignetti D, Zuccarino M, Ferrozzi L. Intestinal obstruction caused by torsed gangrenous Meckel’s diverticulum encircling terminal ileum. World J Gastrointest Surg 2011; 3(7):

11. Lifetime risk of complication requiring surgery: 6.4%
Diagnosing a Meckel’s as the cause of these presentations can be challenging based on imaging: for example, case below: negative nuclear medicine scan, OR findings positive for Meckel’s
Gulwani, H. (2018 February 9). Meckel diverticulum. PathologyOutlines.com. Retrieved September 30th,
Hartung, M. (2018). Radiology Case: Meckel diverticulitis. Radiopaedia. Retrieved September 30, 2018 from
Kuwajerwala, N.K. & Silva, Y. J. (2017, April 11). Meckel Diverticulum. Medscape. Retrieved September 30, 2018 from

12. Imaging
Asymptomatic
Upper GI series with Small Bowel follow through findings: blind-ending loop filled with contrast on antimesenteric border of ileum, 50 cm proximal to IC valve
Fukushima, Masashi & Kawanami, Chiharu & Inoue, Satoko & Okada, Akihiko & Imai, Yukihiro & Inokuma, Tetsuro. (2014). A case series of Meckel's diverticulum: Usefulness of double-balloon enteroscopy for diagnosis. BMC gastroenterology / X

13. Technetium-99m pertechnetate radioisotope scan
Symptomatic
Technetium-99m pertechnetate radioisotope scan
radioisotope taken up by gastric mucosa
need approximately 1.8 cm2 of ectopic gastric mucosa to see positive result
negative scan does not exclude Meckel’s diverticulum
Radswiki. (2018). Radiology Case: Meckel diverticulum. Radiopaedia. Retrieved September 30, 2018 from

14. Symptomatic CT SMA angiography Treatment Surgery
For acute GI bleeding when blood loss >0.5 mL/min
Treatment
Surgery
Wikipedia contributors. (2015, November 10). “Angiography of a Meckel’s diverticulum that presented with bleeding.jpg.” Wikipedia, The Free Encyclopedia. Retrieved September 30, 2018, from ented_with_bleeding.jpg

15. References
Cartanese C, Petitti T, Marinelli E, Pignatelli A, Martignetti D, Zuccarino M, & Ferrozzi L. (2011). Intestinal obstruction caused by torsed gangrenous Meckel’s diverticulum encircling terminal ileum. World J Gastrointest Surg, 3(7):
Kuwajerwala, N.K. & Silva, Y. J. (2017, April 11). Meckel Diverticulum. Medscape. Retrieved September 30, 2018 from
Di Muzio, B. & Jha, P. (2018) Meckel diverticulitis. Radiopedia. Retrieved September 30, 2018 from
Fukushima, Masashi & Kawanami, Chiharu & Inoue, Satoko & Okada, Akihiko & Imai, Yukihiro & Inokuma, Tetsuro. (2014). A case series of Meckel's diverticulum: Usefulness of double-balloon enteroscopy for diagnosis. BMC gastroenterology, / X
Gulwani, H. (2018, February 9). Meckel diverticulum. PathologyOutlines.com. Retrieved September 30, 2018 from

16. References continued
Hartung, M. (2018). Radiology Case: Meckel diverticulitis. Radiopaedia. Retrieved September 30, 2018 from
Radswiki. (2018). Radiology Case: Meckel diverticulum. Radiopaedia. Retrieved September 30, 2018 from
Wang, W. (2018). Radiology Case: Meckel diverticulitis. Radiopaedia. Retrieved September 30, 2018 from
Wikipedia contributors. (2015, November 10). Angiography of a Meckel’s diverticulum that presented with bleeding.jpg. Wikipedia, The Free Encyclopedia. Retrieved September 30, 2018, from