Case Presentation

1
Case Presentation

• CC vomiting, abdominal pain
• PI 49 y/o man who 36 hours prior to admission
  had the onset RUQ abdominal pain. Pain worsened,
  went to ER 4 hours later.
• CBC, SMA, LFTs, amylase, lipase all normal.
• Abdominal sono normal.
• Some relief after GI cocktail, discharged.

2
Case Presentation

• Night prior to admission, pain recurred
  associated with vomiting.
• Next am, ER- repeat testing normal, discharged.
• Admitted PHD due to continuing pain and vomiting.
• No hematemesis or blood in stool, fever,
  diarrhea or constipation. No prior history of
  similar symptoms.

3
Case Presentation

• PMHx- no prior abdominal surgery, only history of
  GI problems is occasional GERD.
• History of seizure disorder and mild depression.
• Meds- Tegretol, Celexa, ASA 81mg, Pepcid prn
• ETOH- avg 1 drink/ day

4
Case Presentation

• PE- 120/72, HR 66, T 98.4
• Normal exam except abdomen tender, voluntary
  guarding RUQ and periumbilical. No rebound.
• No hepatosplenomegaly, mass. BSs reduced.
• Labs- normal abd. sono, LFTs, amylase, lipase.
• Normal lytes. Bun/Cr 11/1.2. WBC 7.2K, Hgb
  14.6
• Normal HIDA scan.
• Obstructive series- multiple air/ fluid levels
  seen throughout the small bowel consistent with
  partial small bowel obstruction

5
Case Presentation

• Working diagnosis distal small bowel obstruction
  of uncertain etiology
• Initial course- NG tube placed, IV fluids, IV
  PPI.
• CT scan- distended small bowel consistent with
  distal partial small bowel obstruction. Appendix
  and colon normal.
• Surgery consult obtained.

6
Causes of Intestinal Obstruction

• 1. Intrinsic Bowel Lesions
• A. Congenital- atresia / stenosis,
  malrotation, duplications/cysts
• B. Inflammatory
• Diverticulitis, TB, actinomycosis   
• Crohns disease    
• Ischemia    
• Radiation injury    
• Chemical (e.g., potassium chloride)    
• Endometriosis    
• Postanastomotic  
• C. Intussusception  
• D. Obturation    
• Polypoid neoplasms    
• Gallstones    
• Foreign bodies    
• Bezoars    
• Feces  
• E. Neoplastic stricture
• II. Extrinsic Bowel Lesions  

7
Case Presentation

• Next day- no improvement in x-ray findings,
  patient taken to surgery.
• Surgical findings dilated prox sm. bowel with
  bruising and torsion of the small bowel due to a
  Meckels diverticulum as the lead point for the
  torsion. The Meckels diverticulum was resected.

8
Meckels Diverticulum

• Phillip M Aronoff, M.D.

9
Meckels Diverticulum

• Most common congenital abnormality of the
  gastrointestinal tract
• Remnant of the vitelline duct
• antimesenteric border of the ileum
• Often contain heterotropic tissue- gastric,
  occasionally pancreatic
• Vast majority of Meckels diverticuli are
  clinically silent

10
Meckels Diverticulum

• Rule of 2s
• 2 of the population have one
• 1/2 of symptomatic lesions usually present before
  the age of 2 years old, others most commonly in
  the first 2 decades of life
• Diveriticuli in adult patients only become
  symptomatic in about 2
• 2 times more common in males than females
• Usually found within 2 feet of the ileocecal
  valve
• Usually are about 2 inches in length
• 1/2 contain heterotrophic mucosa (usually
  gastric, occasionally pancreatic)

11
Meckels Diverticulum

• Clinical presentation
• Lower GI bleeding due to ulceration by
  heterotopic gastric mucosa
• Intestinal obstruction due to internal segmental
  volvulus or intussusception
• Local inflammation with or without perforation
  resembling appendicitis due to diverticulitis
• Rare presentations Neoplasms

12
Meckels Diverticulum

• Lower GI bleeding due to ulceration by
  heterotrophic gastric mucosa
• 25-50 of symptomatic presentations
• Usually painless
• Episodic
• Hematochezia (usually maroon but may be tarry or
  bright red)
• Not infrequently massive bleeding- occult
  bleeding is rare
• Most common cause of small intestinal hemorrhage
  in patients under 30 y/o
• Meckels scan is often positive patients

13
Meckels Diverticulum

• Intestinal obstruction due to internal segmental
  
  volvulus or intussusception
• 20-30 of symptomatic presentations
• More common in older patients
• Diverticulum acts as a lead point causing
  entero-entero or entero-colonic intussusception
  which often cannot be reduced hydrostatically.
  This may present with currant jelly like stool
  and a palpable mass may be present
• If volvulus can be reduced hydrostatically, the
  patient should still have a surgical resection.
• If diverticulum is connected to umbilicus by
  fibrous cord, this may act as a focal point for
  internal herniation of the small bowel or
  secondary volvulus.
• Volvulus is acute and may result in strangulation
  of the bowel if not treated

14
Meckels Diverticulum

• Local inflammation with or without perforation
  due to Meckels diverticulitis
• 10-20 of symptomatic presentations
• Usually adult patients
• Usually due to ectopic acid producing gastric
  mucosa causing significant ulceration and
  possible perforation. This may occasionally be
  related to H. Pylori infection of the mucosa.
• Rarely caused by perforation due to a foreign
  body in the diverticulum.
• Usually these patients are thought to have
  appendicitis prior to surgery

15
Meckels Diverticulum

• Rare Presentations- neoplasms arising in the
  diverticulum
• Benign- (most common)
• Leiomyomas
• Angiomas
• Lipomas
• Malignant-
• Adenocarcinoma- usually from the gastric
  mucosa
• Sarcoma
• Carcinoid tumor

16
Meckels Diverticulum

• Diagnostic studies
• Difficult diagnosis
• Most accurate test, especially in children, is
  Meckels scan- sodium 99-Tc-pertechinetate,
  taken up by gastric mucosa
• (sensitivity 85, specificity 95, accuracy
  90 in pediatric patients)
• Less accurate in adults due to reduced prevalence
  of ectopic gastric mucosa in the diverticulum
  causing false negatives. Accuracy improved by
  giving pentagastrin (increases metabolism of
  mucus producing cells), glucagon or H2 blockers
  (reduce peristalsis and secretions that may flush
  out the radionuclide)
• In adults with a negative scan, abdominal CT scan
  is often helpful in cases of obstruction by
  showing a site of high grade partial bowel
  obstruction in the distal ileum.
• If CT is negative barium studies should be
  performed which may show the diverticulum (do
  not do prior to Meckels scan as barium may
  interfere)
• If bleeding with a negative scan, angiography may
  be helpful

17
Meckels Diverticulum

• Treatment
• If symptomatic, prompt surgical intervention to
  resect the diverticulum or segment of ileum
  containing the diverticulum. If bleeding, the
  source of bleed is often in the segment of ileum
  adjacent to the diverticulum.
• If not symptomatic and found incidentally at
  surgery in children under 2 y/o, resection is
  recommended. In asymptomatic adults, resection
  is controversial since only about 2 of these
  patients will become symptomatic and there is
  about a 2 incidence of short or long term
  complications (stenosis, adhesions) after
  prophylactic resection.

18
Meckels Diverticulum

• Phillip M Aronoff, M.D.