Symptomatic Meckel’s diverticulum in children: a 16-year review

Meckel’s diverticulum (MD) has varied presentations and often becomes a diagnostic challenge. The purpose of this study was to review the various presentations of symptomatic MD and to assess the sensitivity of the Meckel’s scan as a diagnostic tool

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  ORIGINAL ARTICLE Symptomatic Meckel’s diverticulum in children: a 16-year review Maria Menezes   Farhan Tareen   Atif Saeed   Nasir Khan   Prem Puri Accepted: 21 November 2007/Published online: 6 March 2008   Springer-Verlag 2008 Abstract  Meckel’s diverticulum (MD) has varied pre-sentations and often becomes a diagnostic challenge. Thepurpose of this study was to review the various presenta-tions of symptomatic MD and to assess the sensitivity of the Meckel’s scan as a diagnostic tool in patients withbleeding MD. The hospital records of 71 consecutivepatients with a diagnosis of MD from 1990 to 2005 wereretrospectively reviewed. The data was assessed for age atpresentation, sex, clinical features, investigations per-formed, surgical intervention and histopathologicalfindings. There were 71 patients with a diagnosis of MD(age 2 days–14 years). In eight patients, MD was an inci-dental finding at laparotomy. The remaining 63 patientswere symptomatic and presented with various clinicalfeatures. Ten patients (15.8%) had clinical features of peritonitis; of these, six had perforated MD and four hadMeckel’s diverticulitis at laparotomy. Nine patients(14.2%) were diagnosed as intestinal obstruction, and atlaparotomy, a Meckel’s band was found to be the cause of the obstruction. Nine patients (14.2%) had a patent vitello-intestinal duct and presented with umbilical discharge.Thirty-five patients (55.5%) presented with episodes of bleeding per rectum or malaena. Ultrasound scans revealedintussusception in six patients requiring open reduction. Of the remaining 29 patients with bleeding per rectum, 27underwent a Meckel’s Tc99 scan that showed a positivetracer in 18 patients (66.6%) and negative in 9 (33.3%). Allpatients with a symptomatic MD underwent resection of the diverticulum. Histology revealed ectopic gastricmucosa in 43 patients (68.3%). MD has various presenta-tions and can be easily misdiagnosed. It is necessary tomaintain a high index of suspicion in the paediatric agegroup. The Meckel’s scan has a poor positive predictivevalue and cannot be relied upon for a diagnosis in cases of bleeding MD if Tc99 scan is negative. Keywords  Meckel’s diverticulum    Symptomatic   Meckel’s scan    Children Introduction Meckel’s diverticulum (MD) is one of the most commoncongenital anomalies of the gastrointestinal tract, and itwas Johann Friedrich Meckel (the younger) who firstcharacterized its clinicopathological features and potentialfor causing disease. Harper et al. suggested that ableeding MD should be identifiable scintigraphicallyusing 99mTc pertechnetate, since it is concentrated bygastric mucosa [1]. Embryologically, the yolk sac isattached to the primitive gut by the omphalomesentericduct, which is normally obliterated between the fifth andninth week of gestation. MD is caused by failure of obliteration of this duct. A spectrum of anomalies mayresult depending on the stage of arrest of normal invo-lution. MD has a reported incidence of 2–3% [2]. It hasvaried presentations as several authors have previouslydemonstrated [3–6]. However, it often becomes quite a diagnostic challenge, and it is important for the paedia-trician and paediatric surgeon to be well aware of itspossible presentations. The Tc99 Meckel’s scan has a M. Menezes    F. Tareen    A. Saeed    N. Khan    P. Puri ( & )Children’s Research Centre,Our Lady’s Hospital for Sick Children,Crumlin, Dublin-12, Irelande-mail: prem.puri@ucd.ieM. Menezese-mail:  1 3 Pediatr Surg Int (2008) 24:575–577DOI 10.1007/s00383-007-2094-4  reported sensitivity of 25–92% [3, 4, 7–11]. The purpose of this study was to review the various presentations of symptomatic MD and to assess the sensitivity of theMeckel’s scan as a diagnostic tool in patients withbleeding MD. Methods The hospital records of 71 consecutive patients with adiagnosis of MD from 1990 to 2005 were retrospectivelyreviewed. The data was assessed for age at presentation,sex, clinical features, investigations performed, surgicalintervention and histopathological findings. Results There were 71 patients with a diagnosis of MD (age2 days–14 years). There were 52 males and 19 females. Ineight patients, MD was an incidental finding at laparotomyfor some other pathology. The remaining 63 patients weresymptomatic and presented with various clinical features.Ten patients (15.8%) had clinical features of peritonitis; of these, six had perforated MD and four had Meckel’s div-erticulitis at laparotomy. Nine patients (14.2%) werediagnosed as intestinal obstruction, and at laparotomy, aMeckel’s band was found to be the cause of the obstruc-tion. Nine patients (14.2%) had a patent vitello-intestinalduct and presented with umbilical discharge. Thirty-fivepatients (55.5%) presented with episodes of bleeding perrectum or melaena. These patients had 1–4 episodes(average 1.8) of per rectal bleeding and had a haemoglobinrange of 4–14 g/dL (mean 8.4 g/dL) at presentation. Six-teen patients required blood transfusion for resuscitation.Ultrasound scans revealed intussusception in six patientsrequiring open reduction. Of the remaining 29 patients withbleeding per rectum, 27 underwent a Meckel’s Tc99 scan,which showed a positive tracer in 18 patients (66.6%) andnegative in 9 (33.3%). Of these 27 patients, six hadreceived pentagastrin prior to the scan, and among these,the scan showed a positive tracer in four cases (66.6%).Five patients with a negative tracer underwent a diagnosticlaparoscopy and laparoscopic-assisted Meckel’s diverticu-lectomy. All patients with a symptomatic MD underwentresection of the diverticulum. In the early postoperativeperiod, there were no complications and only one patientpresented with subacute intestinal obstruction 4 years laterthat was conservatively managed.Histology revealed ectopic gastric mucosa in 43 patients(68.3%) of which 19 had ulceration and 5 had perforation.The ectopic gastric tissue was located at the distal end of the diverticulum in 14 patients and at the proximal area in29. Six patients had ectopic pancreatic tissue. Discussion MD is the most common congenital anomaly of the gas-trointestinal tract. Only 4–6% of MD is known to besymptomatic [4, 12] and the presentations can be quite varied. Some series found that ileus due to adhesive bandswas the most common presentation in patients below10 years of age and haemorrhage was seen in patientsbelow 20 years of age [5]. However, in our series, haem-orrhage was the most common presentation of a MD,especially in children below 10 years of age. The male tofemale ratio is reported to be 2:1 to 4:1 [3, 4, 13], which is similar to our series. Although most authors would rec-ommend resection of an incidentally detected MD atlaparotomy [2, 13], others advocate their resection only in selected cases of MD suspected to have ectopic gastricmucosa or forming adhesive bands [3]. In our series, alleight patients who had MD detected incidentally at lapa-rotomy underwent resection of the same. Those patientswho had clinical features of peritonitis are often mistakenlydiagnosed as perforated appendicitis. In our series, out of the ten patients with peritonitis, six had a perforated MDand four had Meckel’s diverticulitis at laparotomy. Theappendix was found to be normal in all these cases. Sim-ilarly, in cases with intestinal obstruction due to a Meckel’sband, the cause is often identified at laparotomy. The realchallenge with regards to diagnosis occurs in patients whohave per rectal bleeding or melaena. Swaniker et al. [8]found that in patients with a haemoglobin level less than11 g/dL, the Meckel’s scan had a false negative rate of 50%. However, in our series, the haemoglobin level rangedfrom 4 to 14 g/dL and no such correlation was found.The prerequisite for the detection of a MD by Tc99sodium pertechnetate scintigraphy is the presence of ecto-pic gastric mucosa. The high affinity of the isotope forparietal cells of gastric mucosa permits visualisation of both eutopic as well as ectopic gastric tissue. The residualisotope is concentrated in the urinary bladder. A positivescan shows abnormal uptake of the isotope outside thestomach and urinary bladder. The Meckel’s scan has areported sensitivity of 25–92% [3, 4, 7–11]. However, our series showed a sensitivity of only 66.6%, giving a falsenegative rate of 33.3%. Certain substances, such as pen-tagastrin, histamine-2 (H-2) blockers and glucagons, havebeen reported to increase the diagnostic yield of the Mec-kel’s scan. Pentagastrin stimulates uptake of the isotope bythe gastric mucosa; H-2 blockers inhibit the excretion of the isotope into the bowel lumen and cause its concentra-tion in the parietal cell [11]. Glucagon reduces intestinal 576 Pediatr Surg Int (2008) 24:575–577  1 3  peristalsis, thereby preventing the isotope from beingwashed away in the bowel lumen. Some authors havesuggested that the combination of pentagastrin and H-2blockers would produce an even better yield [14]. How-ever, in our series, out of those that received pentagastrin,only 66.6% showed a positive tracer. False negative resultscould be attributed to the ‘washout’ phenomenon [7]. Insituations where the intestinal transit is relatively rapid, thetechnetium pertechnetate excreted by the surface cells of the MD may be diluted and washed out so rapidly that adefinite positive emission image is not visualised. Activebleeding may also cause a similar washout phenomenon.Some authors have shown experimentally that an area of ectopic gastric mucosa less than 2 cm 2 cannot be visualisedusing the Meckel’s scan [15], producing a false negativeresult. Mucosal ischemia or necrosis may also result in afalse negative scan. False positive results may be obtaineddue to intestinal duplications, ectopic kidney, intussus-ception, vascular tumors and inflammatory foci.The incidence of ectopic gastric tissue in MD insymptomatic patients is reported to be 45–80% [5, 6, 16], which compares well with our series. Some authors haveshown that the length of the MD and the location of ectopic gastric mucosa play an important role in thesurgical resection of the diverticulum [16, 17]. In patients with a short diverticulum, there is a high likelihood thatthe ectopic gastric mucosa is located at the base of theMD, and in such cases, diverticulectomy alone might beinadequate, as it might leave behind part of the ectopicgastric mucosa. This is likely to occur if laparoscopicdiverticulectomy is performed, without palpating the di-verticlum. In our series, five patients with negativeMeckel’s scans underwent diagnostic laparoscopy, andwhen the diagnosis was confirmed, the diverticulum wasbrought out of the abdomen via the umbilical port andresection–anastomosis was performed outside the abdo-men, thus avoiding the possibility of inadequate resection.As the Meckel’s scan has a high false negative rate,diagnostic laparoscopy may perhaps be more cost effec-tive and beneficial in the diagnosis of a bleeding MD [9,10]. It has the added benefit of treating the pathologyunder the same general anaesthetic.In conclusion, MD has various presentations and can beeasily misdiagnosed. It is necessary to maintain a highindex of suspicion in the paediatric age group. The Mec-kel’s scan has a poor positive predictive value and cannotbe relied upon for a diagnosis in cases of bleeding MD if Tc99 scan is negative. Laparoscopy is a useful diagnosticas well as therapeutic tool in cases of bleeding MD. References 1. Harper PV, Andros G, Lathop K (1962) Preliminary observationson the use of six-hour  99m Tc as a tracer in biology and medicine.Semiannual Report, Argonne Cancer Research Hospital, vol 18,p 762. Ludtke FE, Mende V, Kohler H (1989) Incidence and frequencyof complications and management of Meckel’s diverticulum.Surg Gynecol Obstet 169:537–5423. St-Vil D, Brandt ML, Panic S, Bensoussan AL, Blanchard H(1991) Meckel’s diverticulum in children: a 20-year review.J Pediatr Surg 26(11):1289–12924. Yahchouchy EK, Marano AF, Etienne JF, Fingerhut AL (2001)Meckel’s diverticulum. J Am Coll Surg 192(5):658–6615. Bemelman WA, Huhenholtz E, Heij HA, Wiersma PH (1995)Meckel’s diverticulum in Amsterdam: experience in 136 patients.World J Surg 19:734–7376. Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR (2005)Meckel’s diverticulum: the Mayo Clinic experience with 1476patients (1950–2002). Ann Surg 241(3):529–5337. Cooney DR, Duszynski DO, Camboa E, Karp MP, Jewett TC Jr(1982) The abdominal technetium scan (a decade of experience).J Pediatr Surg 17(5):611–6198. Swaniker F, Soldes O, Hirschl RB (1999) The utility of techne-tium 99 m pertechnetate scintigraphy in the evaluation of patientswith Meckel’s diverticulum. J Pediatr Surg 34(5):760–7659. Lee KH, Yeung CK, Tam YH, Ng WT, Yip KF (2000) Lapa-roscopy for definitive diagnosis and treatment of gastrointestinalbleeding of obscure srcin in children. J Pediatr Surg 35(9):1291–129310. Poulsen KA, Qvist N (2000) Sodium pertechnetate scintigraphyin detection of Meckel’s diverticulum: is it usable? Eur J PediatrSurg 10:228–23111. Rerksuppaphol S, Hutson JM, Oliver MR (2004) Ranitidine-enhanced 99 m technetium pertechnetate imaging in childrenimproves the sensitivity of identifying heterotopic gastric mucosain Meckel’s diverticulum. Pediatr Surg Int 20:323–32512. Soltero JH, Bill AH (1976) The natural history of Meckel’sdiverticulum and its relation to incidental removal. Am J Surg32:168–17313. Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR,Melton LJ III (1994) Surgical management of Meckel’s diver-ticulum: an epidemiologic, population-based study. Ann Surg220(4):564–56914. Heyman S (1994) Meckel’s diverticulum: possible detection bycombining pentagastrin with histamine H 2  receptor blocker.J Nucl Med 35(10):1656–165815. Priebe CJ, Marsden DS, Lazarevic B (1974) The use of 99 mtechnetium pertechnetate to detect transplanted gastric mucosa inthe dog. J Pediatr Surg 9:605–61316. Shalaby RY, Soliman SM, Fawy M, Samaha A (2005) Laparo-scopic management of Meckel’s diverticulum in children.J Pediatr Surg 40:562–56717. Mukai M, Takamatsu H, Noguchi H, Fukushige T, Tahara H,Kaji T (2002) Does the external appearance of a Meckel’sdiverticulum assist in choice of the laparoscopic procedure?Pediatr Surg Int 18:231–233Pediatr Surg Int (2008) 24:575–577 577  1 3
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