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Meckel’s Diverticulum

Epidemiology

  • Rule of 2
    • Occurs in 2% of the population
    • 2 inches in length
    • 2 feet from ileocaecal valve
    • 2% of cases become symptomatic
    • 2 types of ectopic tissue are present – mostly gastric and pancreatic
  • More common in females
  • May be associated with oesophageal atresia, exomphalos and anorectal malformations

Etiology

  • Congenital diverticulum arising from the terminal ileum
  • Due to unobliterated proximal portion of the vitello intestinal duct
  • Vitello intestinal duct – connects midgut with the yolk sac during fetal development
    • Normally this duct obliterates during the 9th gestational week
    • Failure to obliterate can result in several types of vitelline fistula
  • Meckel’s diverticulum (MD) is a viteline fistula which arises when the proximal portion (intestinal end) of the duct fails to obliterate
    • Can be attached to the umbilicus by a fibrous cord

Pathophysiology

  • MD is a true diverticulum – contains all layers of the bowel
    • i.e. mucosa, muscularis propria and serosa
  • The mucosa contains heterotrophic epithelium
    • Most commonly gastric, colonic and pancreatic tissue
  • It lies on the antimesenteric border of the ileum
  • Has its own blood supply – via the vitelline artery (arises from an ileal branch of the superior mesenteric artery)

Clinical Presentation

  • Can be asymptomatic – silent MD
  • Painless rectal bleeding
  • Intestinal obstruction due to
    • Adhesions/band
    • Volvulus
    • Intussusception
    • Littre’s hernia – a hernia containing a Meckel’s diverticulum
  • Diverticulitis – mimics acute appendicitis
  • Severe epigastric pain

Complications

  • Peptic ulceration – form heterotrophic gastric epithelium
  • Severe haemorrhage
  • Perforation
  • Neoplasm – carcinoid or GIST tumour

Diagnosis

  • Tc99m radioisotope scan – identifies heterotropic gastric mucosa
  • XR abdomen – to see complications like obstruction and perforation
  • Small bowel enema under fluoroscopy
  • CT angiography – to show patent vitelline artery

Treatment (see pic)

  • Asymptomatic cases not require treatment
  • Meckel’s diverticulectomy – in MD without complications
  • Resection of MD and adjacent ileum with end-to-end anastomosis – in MD with complications (e.g. bleeding, strangulation, bowel obstruction)

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