Chapter 50: Meckel’s Diverticulum

HIGH YIELD FACTS

Although bleeding per rectum is a common complaint among children seeking care at an emergency department (ED), the bleeding is often limited. In general, the differential diagnosis of hematochezia can be divided into conditions causing painful versus painless rectal bleeding. Large volume, painless rectal bleeding suggests a specific, localizable lesion. The most common causes of such painless rectal bleeding in children are Meckel’s diverticulum and colonic juvenile polyps.

Meckel’s diverticulum is a persistent remnant of the omphalomesenteric duct that is seen in 2% of the population.¹ A typical Meckel’s diverticulum is approximately 2 inches (5 cm) long and is located on the antimesenteric border of the ileum, most commonly within 2 feet (approximately 60 cm) of the ileocecal valve, and thus is usually located in the right lower quadrant. More than 60% of patients who develop symptoms are younger than 2 years of age, and there are two types of mucosa, gastric and pancreatic, seen in the diverticulum. These findings of Meckel’s diverticulum are commonly referred to as the “rule of twos.”

Approximately 4% to 35% of affected individuals experience symptoms associated with Meckel’s diverticulum.² The most common presentation in children younger than age 4 is painless rectal bleeding secondary to acid secretion of functional ectopic gastric mucosa. This results in ulceration of the adjacent ileal mucosa and bleeding, which may present as hematochezia, or less commonly, as melena, and can be episodic and sometimes massive. Less frequent presentations include Meckel’s diverticulitis (which can mimic appendicitis), intestinal obstruction from intussusception, herniation of bowel through a patent omphalomesenteric fistula, or volvulus of bowel around a fibrous omphalomesenteric remnant attachment, the abdominal wall, and (rarely) perforation from an ingested foreign body trapped in the diverticulum.^3–6

PRESENTATION AND MANAGEMENT

Management of a Meckel’s diverticulum consists of hemodynamic stabilization followed by surgical resection. A child who experiences gastrointestinal bleeding from a Meckel’s diverticulum typically presents acutely with large volume (>30 mL) rectal bleeding that may require transfusion. The diagnostic imaging modality of choice is a technetium-99m pertechnetate scan (Meckel’s scan).⁷ It localizes ectopic gastric mucosa that is found within the Meckel’s diverticulum (Fig. 50-1) and elsewhere, such as in enteric duplication cysts.^2,8 Pentagastrin and histamine blockers may enhance the accuracy of scanning. A Meckel’s scan identifies the lesion in approximately 80% to 90% of cases. False positive results can occur with ureteral obstruction, inflammatory masses such as those seen in Crohn’s disease, abscess, arteriovenous malformation, or intussusception. A negative scan should not delay surgical intervention if bleeding from a Meckel’s diverticulum is strongly suspected.