1. Meckel’s Diverticulum

2. General Data I.S. 6 mos old Female Filipino Roman Catholic Pandacan, Manila

3. Bloody stools

4. History of Present Illness 4days PTC  fever (T38.8C),Paracetamol drops no fever, cough, colds, vomiting good appetite and activity no consult 2 days PTC  persistence prompted consult with AMD, Dx: acute viral illness 1 day PTC  lysis of fever 2 episode of dark stools, irrritable, decrease in appetite ER : SFA ileus; no recurrence of stools Dx : AVI, resolving; t/c Milk Allergy

5. History of Present Illness Few hrs PTC  2 episode of voluminous maroon colored stools Admitted

6. Review of System General: (-) weight loss, anorexia, easy fatigability HEENT: no trauma, no ear infection, Neck: (-) limitation of motion, mass, adenopathy Respiratory: (-) shortness of breath, easy fatigability, wheezing Cardiology: (-) palpitation or cyanosis Musculoskeletal: (-) swelling, deformities

7. Past Medical History No bronchial asthma no Primary Tuberculosis infection no known allergies This is the patient’s first admission

8. Family History (+) Diabetes: maternal grandparents (+) Hypothyroid : mother No history of cancer

9. Birth and Nutritional History Born to a 34 year old G3P2, non-smoker, non-alcoholic beverage drinker, with regular prenatal check up Denied illness during pregnancy Born Full term via Repeat Ceasarian section at Cardinal Santos Medical Center No fetomaternal complications No history of Breastfeeding Enfapro 6oz/bottle x 12 bottles/day Complimentary feeding (Cerelac): 6 mos old

10. Immunization BCG1 DOSE HEPA B2 DOSES DPT 2 DOSES OPV 2 DOSES

11. Developmental History Presently, sits with support

12. Upon arrival ER S>(+) maroon colored stool O>pale looking, irritable HR 106 RR28 clear breath sounds soft abdomen, non tender good pulses A>Lower GI bleed t/c Meckel’s Diverticulum P>lab work up PRBC 10cc/kg post transfusion Hgb 10.6

13. Laboratory Examination CBC 7.7/23.4/9090/N16 L79 M5/170,000 Retic count 0.35 Stool Exam RBC 30-40 Fecal occult Blood Positive PT 10.4 INR 0.83 181% PTT 41.8 Urinalysis <1.005 ph7.5 PBS: microcytic hypochromic Na 139 K 4.6 Cl 102 Ca 9.3

14. Laboratory Exam SFA non specific, non obstructive gas pattern Meckel's Diverticulum Scintigraphy which showed radioactive activity on the right lower quadrant which may represent ectopic gastric mucosa.

19. Upon arrival at PICU s/p Explore Laparotomy, Resection of Meckel’s diverticulum with end to end anastomosis OR findings: 1.5cm Meckel’s Diverticulum approx 25cm from appendix Estimated Blood Loss <20cc s/p 160 PRBC (20cc/kg) P> NPO D5NR x 40cc/hr Cefazolin 250mg/IV (125mkd) Ranitidine 10mg/IV q8 Nubain 2mg q6 Ketorolac 10mg q6

20. Second PICU Day S> no bleeding O>BP 90/60, afebrile Stable VS CBC 13.7/39/11680/N50 L40 M8 B1/268K P> transfer to regular room

22. Meckel’s Diverticulum remnant of the embryonic yolk sac Embyonal stage: omphalomesenteric duct connects the yolk sac to the gut, nutrition 5th and 7th wk AOG: duct separates from the intestine Yolk sac + lining epith similar to stomach Partial or complete failure of involution of the omphalomesenteric duct results in various residual structures.

23. Frequency Occurs in 2–3% of all infants a 3–6 cm outpouching of the ileum along the antimesenteric border 50–75 cm from the ileocecal valve 1 st 2 years of life, 2.5yo

24. Manifestations Intermittent painless rectal bleeding Stool: brick colored or currant jelly colored. Bleeding: self-limited, contraction of the splanchnic vessels r/o acute appendicitis Diverticulitis can lead to perforation and peritonitis

25. Diagnosis Meckel radionuclide scan: IV infusion of technetium- 99m pertechnetate: mucus secreting ectopic gastric mucosa : visualization of the Meckel diverticulum sensitivity enhanced scan : 85% specificity : 95%. Other methods of detection: abdominal ultrasound, superior mesenteric angiography, abdominal CT scan, and exploratory laparoscopy.