1. Who was Hilidanus A. Adegbesan,

2. Case 1 68 year old lady admitted with a 2 day history of diffuse abdominal pain and vomiting. Acute onset intermittent sharp epigastric pain, rated 7/10 with no aggravating or relieving factors. Bowel motion and flatus last passed 3 day previously Poor appetite. No recent alcohol ingestion as per patient.

3. Case History Past Medical History: –PUD –Hiatus hernia –Chronic Kidney Disease –COPD Past Surgical History –Hysterectomy –Cholecystectomy –Appendectomy

4. Case History Family History – Nil significant Social History –Ex smoker ROS: –Nil significant

5. On Examination Vital Signs: –BP 111/74 –HR 92 –Temp 36.2 –RR 16 –O2 SATS 100% on RA Abdomen was not distended. Tenderness in epigastrium with mild guarding. No rebound. Bowel sounds exaggerated. Hernial orifices were intact.

6. Investigations WCC 7.4; Hb 13.3; Plts 433; CRP 17 Urea 42; Na 125; K 7.4; Creat 609 (baseline 60-120) ABG: pH 7.38, pCO2 4.57, pO2 12.4, HCO3 20 Amylase 160 ECG: NSR; tachycardic; tented T waves CXR: no free air under diaphragm. PFA: prominent small bowel loops

7. Management Initially admitted medically with –Acute on chronic renal failure –Dehydration Upon surgical review: –Features of small bowel obstruction for conservative management.

8. Management Day 1 post admission: –Abdomen now distended, non tender, BS present. PFA showed progression - ? small bowel obstruction 2 o to adhesions. Day 2 post admission: –Medical review re: acute renal failure, hyperkalaemia and hyponatraemia. –Surgical team review –To continue conservative management –NG tube and urinary catheter placed

9. Management Day 5 post admission: –Renal failure indices resolved –Abdominal distension still persistent –Obstipated –PFA showed increasing bowel dilatation –NG tube active –Proceeded to laparotomy

10. Operative findings Small bowel volvolus with fulcrum around meckel’s diverticulum adherent to pelvic sidewall. Merckel’s diverticulum and adjacent small bowel were resected and sent for histology. Side to side anastomosis

11. Post Operative The post operative period was uneventful. Histology –Gastric body type mucosa –No helicobacter pylori –No evidence of malignancy

12. Case 2 31 year old gentleman admitted with: – 1 / 7 history of sudden onset non-radiating colicky lower abdominal pain. –No associated nausea, vomiting or altered bowel habit. –No previous medical/surgical hx. –ROS – nil significant

13. On Examination Vital Signs: BP 115/68 HR 93 O 2 SATS 99% on RA Apyrexial 36.2 o C On examination: Tenderness and guarding in lower abdomen Reduced bowel sounds.

14. Investigations Urinalysis –NAD Bloods –WCC 13.4 (neuts 10.58), Hb 13.4, CRP 49, Amylase 107 –Sickle cell screen negative CXR –No air under the diaphragm PFA –Bowel gas pattern normal. No bowel distension or obstruction. No free air.

15. Investigations CT Abdomen/Pelvis –Minor stranding of fat around a loop of small bowel in right lower quadrant (differential included inflammatory change around a meckel’s diverticulum) –Small nodes in the adjacent mesentery. –No evidence of large colonic diverticulitis and normal appearance of the appendix.

16. CT Abdo/Pelvis

17. Management On admission: –IV fluids, co-amoxiclav and analgesia Day 2 post admission: –Proceeded to Laparoscopy: Operative findings: –Perforated merckel’s diverticulum which was resected at its base using Endo GIA and sent for histology –Appendix long and injected but not acutely inflamed - most likely not the cause of his symptoms but removed.

18. Histological Findings Ectopic gastric tissue at the fundus of the meckel’s diverticulum. The excised edge was free of ectopic gastric tissue

19. Introduction A true congenital diverticulum, a congenital bulge in the small intestine. It is a vestigial remnant of the omphalomesenteric duct is the most frequent malformation of the gastrointestinal tract It was first described by Fabricius Hildanus, German surgeon, in 1598 Johann Friedrich Meckel, described the embryological origin of this type of diverticulum in 1809

20. Pathophysiology It is a vestigial remnant of the omphalomesenteric (vitellointestinal) duct Human embryos initially have convex umbilical loops of primitive gut that communicate freely with the yolk sac through the omphalomesenteric (vitellointestinal) duct As development proceeds, the duct normally becomes occluded and disappears entirely by weeks 8-10 of gestation Results from the failure of the vitelline duct to obliterate during the fifth week of fetal development

21. Pathophysiology The following anomalies are caused by the persistence of the omphalomesenteric (vitellointestinal) duct

22. Epidemiology Autopsy records show an incidence of about 2% in the general population. For asymptomatic diverticula there is no gender predominance,. For symptomatic diverticula some studies give a 3:1 male to female ratio, while others have detected little difference. The risk of complications ranges from 4- 25% in various studies.

23. Anatomic Considerations Meckel's diverticulum is located in the distal ileum, on its antimesenteric border. usually within about 60-100 cm of the ileocecal valve It can also be present as an indirect hernia, typically on the right side, where it is known as a "Hernia of Littre."

24. Anatomic consideration Topography of abdomen

25. Anatomic Considerations A memory aid is the rule of 2's: 2% (of the population) 2 feet (from the ileocecal valve) 2 inches (in length) 2% are symptomatic 2 types of common ectopic tissue (gastric 80%, pancreatic, colonic and other tissues 20%), The most common age at clinical presentation is 2, and males are 2 times as likely

26. Clinical features Asymptomatic in majority of cases Painless rectal bleeding, Intestinal obstruction, Volvulus and Intussusception. Meckel's diverticulitis may present with all the features of acute appendicitis. Epigastric pain & Bloating Neoplasm - lipoma, leiomyoma, neurofibroma and angioma, leiomyosarcoma and carcinoid, which represent about 80% & adenocarcinoma and metastatic lesions

27. Diagnosis A technetium-99m (99mTc) pertechnetate scan is commonly used to diagnose Meckel's diverticulum – Gastric tissue. Abd CT Barium studies to out rule enterocolitis and intussuception Laparoscopy A bleeding scan. Selective arteriography Wireless capsule endoscopy Abd USS

28. Treatment Surgical for symptomatic Merckel’s diverticulum Incidental Meckel’s diverticulum in asymptomatic patients remains controversial – Narrow vs wide Excision is carried out by performing a wedge resection of adjacent ileum and anastomosis a primitive persistent right vitelline artery originating from the mesentery has been found during operation - Bleeding

29. Histology Heterotropic gastric mucosa 62% pancreatic tissue 6%, Both pancreatic tissue and gastric mucosa were found in 5%, Jejunal mucosa was found in 2%, Brunner tissue was found in 2%, and Both gastric and duodenal mucosa were found in 2%

30. Take home message Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. it is often difficult to diagnose It may remain asymptomatic it may mimic disorders such as Crohn's disease, appendicitis, peptic ulcer disease, obstruction and bleeding.

31. Thank you Who should take credit for this clinical entity Fabricius Hildanus,, in 1598 Johann Friedrich Meckel, 1809