Meckel’s Diverticulum
Submitted by Denise Drohobyczer MS IV

General Considerations “Rule of 2”

• Most common congenital anomaly of GI tract
• 2% of population, M=F
• Within 2 feet proximal to ileocecal valve
• 2 inches long, 2 cm wide
• 2 types of heterotopic mucosa
• Symptomatic in 2%
• M>F (2:1)
• Children > adults; often < 2 years old

Embryology and Pathology

• Incomplete atrophy of omphalomesenteric (vitelline) duct
• True diverticulum on anti-mesenteric border of ileum
• 50% contain heterotopic mucosa
• Most often gastric (50%) and pancreatic (16%)

Complications and Clinical Findings

• Hematochezia (~40% of complications)
• Most common complication in children
• Heterotopic gastric mucosa ® ulceration and hemorrhage
• Occult blood loss and iron deficiency anemia (adults)
• Small bowel obstruction (~35%)
• Most common complication in adults
• Abdominal guarding and distension, vomiting, obstipation
• Causes: Volvulus (with persistent fibrous band), torsion, foreign body, Littre’s Hernia (inclusion in hernia sac), inversion ® intussusception
• Diverticulitis (~17%)
• Second most common complication in adults
• RLQ or periumbilical acute abdominal pain
• Can result in perforation
• Enteroliths (~10%)
• Neoplasia (~3%)
  • Most often carcinoid (M>F)

Imaging Findings

• Abdominal Film, non-specific:
• Enteroliths, small bowel obstruction, perforation
• Abdominal CT
• Diverticulum off distal ileum, small bowel obstruction, intussusception, perforation, diverticulitis, necrosis, enteroliths or inversion of tic
• Sonography
• Obstruction, inversion and intussusception
• Enteroclysis
• “Triradiate” fold pattern
• Junction of omphalomesenteric duct and ileum
• Rugal pattern like stomach(heterotopic gastric tissue)
• Meckel’s scan (Technetium-99m pertechnetate scintigraphy)
• Gastric mucosa absorbs and secretes radioactive isotope
• “Hot spot” in RLQ- most commonly
• Gold standard for hemorrhagic diverticula
  • 95% specific in children, 60% specific in adults
• Angiography
• Visualization of remnant omphalomesenteric (vitellointestinal) artery
• Off distal ileal branch of superior mesenteric artery
• Vascular blush (ischemia)

Differential Diagnosis

• Appendicitis, colonic diverticulitis, acute mesenteric lymphadenitis
• Single small intestinal diverticulum
• Communicating enteric duplication
• Pseudosacculations (Crohn’s Disease)
• Cavitating malignancies (lymphoma, GIST)

Treatment

• Surgical excision if symptomatic
• Prophylactic removal  is controversial

Meckel's Diverticulum. Reflux into the small bowel has occurred during a single-contrast barium enema examination. Black arrow points to Meckel's diverticulum arising from small bowel near terminal ileum.
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Levy AD, Hobbs, CM.  Meckel Diverticulum: Radiologic Features with Pathologic Correlation.  Radiographics. 2004; 24: 565-587.

O’Neill, J, Grosfeld, J.  Principles of Pediatric Surgery.  Mosby, 2003.