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Meckel diverticulum, the commonest congenital abnormality of the gastrointestinal tract, may be difficult to diagnose. Appearances on CT are often non-specific unless there is connection to the umbilicus or a complication has occurred. We report a case of an inflamed Meckel diverticulum seen on CT.
AIM: Meckel s diverticulum is the most common congenital abnormality of the small bowel. It may be silent or symptomatic when complicated by hemorrage, intestinal occlusion, diverticulitis and umbilical fistulas. Radiologic diagnosis is often difficult because abdominal plain radiography and ultrasound are not sufficiently specific; CT is most accurate in differential diagnosis. MATERIAL AND METHODS. 11 patients (age 5-69 ys) were studied. Clinical symptoms included acute abdomen (4 pts), intestinal occlusion (3 pts), abdominal pain (4 pts), fever (5 pts). Radiological studies were abdominal plain radiography (8 pts), ultrasound (5 pts), CT (9 pts). RESULTS: Abdominal plain radiography depicted signs of intestinal occlusion (4 pts) and perforation (1 pts); in 4 pts the signs were non diagnostic. Ultrasound showed an abscess in the pelvis (2 pts), dilatation and wall-thickening of an intestinal loop (2 pts), intestinal invagination (1 pts); it was not diagnostic in 3 pts. CT was not diagnostic in 3 pts; in 2 pts it showed an abscessual fluid collection in the pelvis, adherent to intestinal loops, with flogosis of the perivisceral fat; in 1 pt it revealed perforation; in 4 cases it was specific showing inversion of the diverticulum in an intestinal loop (2 pts) or a tubular fluid-filled structure, with thickened walls and contrast enhancement, which was interpreted as a inflammatory diverticulum (2 pts). DISCUSSION: Our series confirms the difficulty of diagnosing Meckel s diverticulum in an acute setting. Abdominal plain radiography only allowed to diagnose intestinal occlusion or perforation. Ultrasound revealed abscessual collections in the pelvis, fluid distention of the diverticulum, segmental thickening of the intestinal walls and invagination. CT proved to be more specific showing signs suggestive of correct diagnosis in 6 pts. In particular, evidence of an intraluminal prolonged mass with central area of fat density and peripherral collar was considered suggestive of intraluminal invagination of Meckel s diverticulum. Another diagnostic sign is the evidence of a tubular fluid-filled structure, with thickened, enhanced walls. In 2 cases CT showed an abscessual collection with gas-fluid level (complication of perforation) confirming the need for surgery. CONCLUSION: Meckel s diverticulum is a not uncommon condition that in some cases is complicated, resulting in acute abdomen. Preoperative radiological diagnosis can be suspected in the presence of suggestive signs, more often depicted by CT.
Nine cases of Meckel diverticulum presenting with intussusception were reviewed and correlated clinically, radiologically and pathologically. The appearance of intussuscepted Meckel diverticulum by small bowel series is not specific. However, by CT, a central fat density surrounded by a thick collar of soft tissue was noted in one case correlating well with the gross pathologic appearance. The pathologic material in all our cases suggests that this CT appearance is characteristic of an inverted Meckel diverticulum.
Meckel diverticulum and residual urachus have a common embryological origin: the yolk sac at the eight day of life. Their course is independent but the underlying mechanisms are identical. Meckel diverticulum occurs in 2 to 4% of the population. Clinical signs are often absent and complications occur in 4% of the cases (haemorrhage, occlusion, inflammation, and rarely tumoural formation). Residual urachus occurs as a cystic formation, a sinus or a fistulization and may degenerate into adenocarcinoma of severe prognosis. The reported association has not apparently been reported previously in the literature. Due to the risk of cancerization, it is suggested that residual urachus should be searched in cases of Meckel diverticulum.
This paper presents the appearances of inverted Meckel diverticulum with an irreducible intussusception on air enema in four children. The inverted Meckel diverticulum appeared as a bulbous (3) or triangular (1) filling defect in the air column projecting off the distal end of the soft tissue mass of the irreducible intussusceptum. The bulbous defect appears to be highly suggestive, and may be specific, for inverted Meckel diverticulum. Earlier recognition of the presence of the Meckel diverticulum as the lead point of the intussusception could have changed the management in two of the children.
Meckel diverticulum was diagnosed preoperatively as the cause of recurrent rectal bleeding in a 2-year-old child by means of a sodium pertechnetate Tc 99m scan. Although false-negative scans have been reported to occur in approximately 50% of all cases of Meckel diverticulum, the procedure should be considered in any case of unexplained, painless rectal bleeding, especially in pediatric patients.
We report a case of adenomyoma of the small intestine arising in a Meckel diverticulum. The patient was a 22-month-old boy who presented with signs and symptoms of intussusception. At surgery, a Meckel diverticulum was found and removed. On histologic examination, a tumor consisting of dilated cystic glands and smooth muscle bundles was identified. A diagnosis of adenomyoma arising in a Meckel diverticulum was made. A review of the literature showed that only six other pediatric cases of adenomyoma of the small intestine have been reported. The presence of an adenomyoma in a young patient within a Meckel diverticulum favors the view that adenomyomas are a variant of pancreatic heterotopia.
Intestinal obstruction caused by internal hernia due to Meckel diverticulum is a rare disease. The condition is seldom diagnosed preoperatively. In this paper, we present a 10-month-old boy who suffered from abdominal pain, persistent vomiting, and mild fever for 2 days. Abdominal sonography, plain abdomen X-ray, and computed tomography merely showed mechanical ileus and partial malrotation. However, exploratory laparotomy revealed a Meckel diverticulum through which the small bowel had herniated. We introduce the Meckel diverticulum and internal hernia and discuss intestinal obstructions.
PURPOSE: To determine the clinical, radiologic, and pathologic findings of inverted Meckel diverticulum by retrospectively reviewing a large series of cases. MATERIALS AND METHODS: Among 84 cases of Meckel diverticulum, 18 (21%) were found at surgery to be inverted into the lumen of the bowel. Thirteen of these 18 (72%) cases were associated with small bowel intussusception and five (28%) were not. RESULTS: All 18 patients (median age at time of diagnosis, 32 years) were symptomatic, but the symptoms were subacute or chronic in 14 (78%). At barium examination in 15 cases, inverted diverticulum was depicted in 10 (67%) as a solitary, elongated, smoothly marginated, often club-shaped intraluminal mass in the distal ileum. At computed tomography (CT) in three cases, a central area of fat attenuation was surrounded by a thick collar of soft-tissue attenuation. At ultrasound (US) in two cases, a target-like mass contained a central area of increased echogenicity. At pathologic examination in all cases, the inverted sac contained mesenteric fat. CONCLUSION: Inverted Meckel diverticulum occurs more commonly than previously recognized and is associated with characteristic findings at barium examination, CT, and US.
Thirteen patients with surgically confirmed Meckel diverticula encountered in a 30 month period are reported. Of 11 symptomatic patients, all had lower gastrointestinal bleeding, except one who had recurrent abdominal pain only. Two diverticula were incidental, coexisting with Crohn disease of the distal ileum. One of these had occasional diarrhea and hematochezia. The diagnosis was established preoperatively by enteroclysis in 11 of these cases. The enterographic demonstration of the mucosal triangular plateau or the triradiate fold pattern indicating the site of exit of the omphalomesenteric duct should lead to a diagnosis of Meckel diverticulum. Pitfalls in interpretation due to the pseudotriangular plateau appearance formed by superimposition of two intestinal loops and the pseudosaccule produced by the axial projection of a fixed loop of bowel and the differential diagnosis are discussed. Enteroclysis seems to be the most dependable method currently available for preoperative demonstration of Meckel diverticulum.
Radiological diagnosis of Meckel diverticulum is a difficult task. Here we report a patient with hereditary sphaerocytosis who complained of a chronic periumbilical pain and in whom antegrade barium enema suggested Meckel diverticulum. The diagnosis had been proven both surgically and histologically. This observation indicates that so called traditional x-ray still has its role even in the era of modern (and expensive) radiology.
Inversion is a potentially serious complication of Meckel diverticulum. Since inversion provokes gangrene and small bowel obstruction, diagnosis by enteroclysis or imaging studies can conflict with the need for timely surgical intervention. We have noted that plain films may predict this lesion when a solitary mottled polypoid lesion occupies the ileum at the site of a small bowel obstruction.
BACKGROUND: Complicated Meckel diverticulum (MD) in children does not always present with painless rectal bleeding and its presentation can then produce a difficult diagnostic dilemma. In this clinical setting, sonography (US), CT or even air enema may be the first modality chosen to evaluate these children rather than the radionuclide Meckel scan (RNMS). PURPOSE: To assess the value of US, CT and air enema for detection of complicated MD. MATERIALS AND METHODS: Review of clinical, imaging, surgical and pathological findings in 64 children (55 males, 9 females) aged 4 days -14 years (mean = 3.7 years) with MD seen during an 8-year period, 1990-1997. RESULTS: (a) In 33 patients with rectal bleeding, MD was detected on RNMS in 32. Ten of these 32 had other imaging studies, all of which were negative. (b) The other 31 patients, with varied clinical presentations, did not undergo RNMS. In these 31 and the 1 with a negative RNMS, 14 (44 %) had imaging features highly suggestive for the diagnosis of MD on US in all 14, on CT in 1, and on air enema in 3. The radiological spectrum of the inflamed, hemorrhagic MD is illustrated. CONCLUSION: The inflamed, hemorrhagic and the inverted, intussuscepted MD have a spectrum of features recognizable on US, CT and air enema. Some of these appearances are specific, others are not. Knowledge of and recognition of these features will facilitate detection of complicated MD in larger numbers of children presenting with symptoms other than the classic history of painless rectal bleeding and also in those with normal RNMS.
Meckel's diverticulum is a cause of significant morbidity and mortality. Often this is related to the delay in diagnosis. Based on a US population of 200 million people and a 2% incidence, there are 4 million Meckel's diverticula present waiting to cause symptoms. Considering that most Meckel's diverticula are asymptomatic and that many authors have described the condition as a great mimic, the diagnosis is often quite elusive. Therefore, a high index of suspicion is needed to diagnose Meckel's diverticulum correctly and expeditiously as the source of disease in the patient with an often unclear abdominal presentation. The difficulty with diagnosis should be lessened if one considers that Meckel's diverticulum presents largely in the male and younger age groups with the three major symptom complexes of bowel obstruction, gastrointestinal bleeding, and inflammation. Use of 99mTc pertechnetate scintigraphy appears to be the diagnostic study of choice if Meckel's diverticulum is suspected and the patient is clinically stable. When one considers the potential for bad outcome if Meckel's diverticulum is missed in the setting of possible obstruction or hemorrhage (i.e., bowel infarction or exsanguination), a high index of suspicion and diagnostic aggressiveness is warranted. Lastly, if one thought is to be left behind, it should be: "Meckel's is a great mimic that must be considered in all cases of intra-abdominal disease in which the cause is not readily apparent."
Intestinal obstruction due to a phytobezoar within a Meckel diverticulum is exceedingly rare, with only seven reported cases in the surgical literature. The most important precipitating factor is the ingestion of agents high in fiber and cellulose. Small bowel obstruction in all but one case was due to retrograde propagation of the bezoar into the small bowel lumen. We report the clinical and CT findings in such a patient following a vegetarian diet.
This study illustrates the sonographic findings of inverted Meckel diverticulum acting as a lead point of an intussusception in five patients. In four patients, the inverted diverticulum was seen as a segment of blind-ending, thick-walled bowel projecting for a variable distance from the apex of the intussusceptum. The larger diverticula had a characteristic bulbous shape. The central serosal surface of the inverted diverticulum was filled with fluid in one patient, with fluid and fat in another, and with echogenic fat only in the other two. The presence of fat was confirmed by CT in one patient. The features illustrated in these four patients appear to be specific. In the fifth patient, the sonogram revealed a nonspecific echogenic mass at the apex of the intussusceptum. Recognition of these features on sonography may obviate the need for further investigation.
Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. Approximately 2 to 3% of all individuals have a Meckel's diverticulum and one third of them experience clinical symptoms. Until a decade ago, the correct diagnosis of the lesion was rarely established prior to abdominal surgery or autopsy. However, the introduction of modern imaging techniques and the refinement of gastrointestinal contrast studies have facilitated the preoperative recognition of this entity. This article reviews the radiographic pathology of Meckel's diverticulum and the spectrum of its associated complications.
Meckel's diverticulum, which is the most common congenital anomaly of the gastrointestinal tract, occurs when the vitelline duct persists past the 7th week of gestation. Although complications may occur in 8% to 22% of patients with Meckel's diverticula, adenocarcinoma is very uncommon. We describe a patient with early gastric cancer who was incidentally found to have a superficial adenocarcinoma arising from ectopic gastric mucosa within a Meckel's diverticulum. To the best of our knowledge, synchronous gastric adenocarcinoma in a patient with Meckel's diverticulum has not been previously reported.