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Perforation of Meckel's diverticulum in infancy
Perforation of Meckel’s Diverticulum in Infancy By Timothy Canty, Michael M. Meguid, and Angelo J. Eraklis
P
ERFORATION IS THE LEAST common complication of Meckel’s diverticulum, but continues to present a challenge both diagnostically and therapeutically in infants and small children. l-3 Because evaluation of the infant with an acute abdominal illness is difficult, diagnosis and treatment are often delayed. This may result in further progression of the disease and increasing mortality and morbidity. The mortality for perforation of Meckel’s diverticulum is high. In 1939, prior to the advent of antibiotics, Thompson reported a mortality of 60% for children under 1 yr of age.* Other recent series continue to report mortalities of 30%50% for perforation in the very young.2.3*5-7 MATERIAL
From 1950 to July, 1972,60 patients under age 2 yr were treated for complications of Meckel’s diverticulum at the Children’s Hospital Medical Center, Boston.g There were nine patients with perforation. Five patients presented before the age of 6 mo, the youngest being 21 s mo old. There were eight males and one female (Table 1). CLINICAL
SYMPTOMS
AND SIGNS
On admission, all the infants appeared acutely ill. Seven infants were referred because of a failure to respond to treatment for diagnosis other than perforation of a Meckel’s diverticulum. Lethargy, irritability, and anorexia, followed by vomiting, fever, abdominal distention, and passage of blood in the stools were the most common presenting symptoms. Of interest in the past history of six children were bouts of vague abdominal complaints, fussiness, and fevers, accompanied by the passage of occult or gross blood in the stools. On examination, seven of the patients were febrile, pale, dehydrated, in mild to moderate hypovolemic shock, with obvious signs of overwhelming sepsis. In two babies, the clinical picture was dominated by bleeding per rectum, but on examination abdominal tenderness and distention were also apparent. A right lowerquadrant mass was palpable in one infant. LABORATORY
INVESTIGATIONS
Laboratory investigations confirmed the severe nature of the illness in each case. Admission hematocrit values were less than 30% in six patients, and all cases had white blood cell counts elevated to above 10,000/mm3 with a shift to the left. Urinalysis, serum electrolytes, and acid-base determinations were of value in pre- and postoperative management but were of no diagnostic aid.
From the Departments o/Surgery. Children’s Hospital Medical Center, Harvard Medical School. Boston, Mass. Address for reprint requests: Timothy Canty. Surgeon-in-Chief; Children’s Hospital. Louisville. KI 40201 Journal of Pediatric Surgery, Vol 10. No 2 (April), 1975
189
9
8
5
4
3
*
recra,
a”Orexla.
,rr,
shock. melena *,ooI
rectal bleedmg
bleeding 1 da”
I da”
temp 100” F
*“orexla. abd pa,“.
temp 102°F
fabollty 1 day ~rnr
,O admlsslo”
Lethargy Hrltablll,”
Abdomnal ,,a,” nrn
red blood per rectum
dune**
a”ore~a*. pale abd. ten
M
,mo,toadm~ss~o”
bleeding
One epl*Ode reC,al
admlsslo”
da”* p,,or 10
recral bleedbng5
d,arrhea ‘or 3 wk
I”te”n#,,e”, vommng
nega,,ve
Barium enema
negatwe
Banurn enema
Nat clone
“FJg*tlW
A”orex,a.
Earlurn enema
obstruct,“”
Small-bawl
diaphragm
AM under
ob*,ruct,o”
Small-bowel
? R”0 ma**
ob*,ruc,,o”
Small-bowel
obstrucw,”
Small-bowel
truta-
+
Oeeult
+
GRXS
+
G”l**
+
24 Hr
2 Days
24 H,
3 Da”*
None
5 Day*
None
NOM’
to Operatton
St001 X-ray Fmdlngs
Delay
Blood in
b&t” 2 days. rectal
dehydrated.
mitab,,,,”
d,*,e”l,on
Lethargy.
dwrhea
mmrexla. “onxflng.
diarrhea
,nltab~ll,y.
1wt. vom~nng and
Letharg”. Irrr,ab,l”“.
guardmg. temp 102’ F.
rc.r3 mo. rpotry
Mala,*e. fever.
a”Orexl*. abd pal”.
vommng. abd pal”
b,l,,y ‘or 1wk 104aF.ShcJCk ,rr,,abMy lntemlmen, fever Lethargy.
a”DreXl*. vommng temp
21 mo
M
16mo
M
6rna
M
6mo
M
lnf.xml,,e”, fever. “om,tl”g. ,rr,,a
Lethargy ,rr,,ab,l,t”.
“lass. clots per recrum
pal” for 1 Wk
d,*,e”,~on. pale. RUO
pnor 10 adm In
fermntent abd
3 rnos
anorexia. abd pain and
bleedmg 5 days
M
Lefharg”. ,rr,,ab,l”y.
One ep’sods rectal
3 “lo
d,*,e”,,o”. 2 day*
shock. recta, bleeding
tabMy. abd pal” and
Lethargy.
datenuon. temp 104’F
7 and 8
days w,or 10 a&n
bleeding
F
1
and Symptoms
Abd lx,,“. ‘e”*r.
Two epwdes
2 I/*mm
Past HlSfOry
Age/Sex
Case
Sag”* Oiagnosls
Preoperative Fmdmgs
Operative Procedure
Operatwe
Table 1. Summary of Nine Patients with Perforation of a Meckel’s Diverticulum
AdmIssIon Hlstopafhology
Suwved
Result
delwcence
Earl” 5th day
Compluzations
F
z D
8
MECKEL’S
DIVERTICULUM
191
Roentgenographic examinations including upright views of the abdomen suggested intestinal obstruction in four cases and free air under the diaphragm was noted in one case. Barium enema examinations were performed in three cases and were of no aid in making the diagnosis. INDICATIONS
FOR OPERATION
The preoperative diagnosis did not include perforation of a Meckel’s diverticulum in any of the nine cases. Six patients were operated on within 24 hr of admission: four with a diagnosis of intestinal obstruction secondary to intussusception, one with a diagnosis of a perforated appendix, and one with a diagnosis of peritonitis of unknown etiology. One child was operated on during the second day after admission because of continued rectal bleeding. Two other children underwent surgery 2 and 3 days, respectively, after admission for persistent rectal bleeding. A bleeding Meckel’s diverticulum was considered in the differential diagnosis in each case. Preoperative management was individualized and directed toward correcting existing deficits. Intravenous fluids in the form of crystalloid, colloid, or whole blood were administered through carefully placed cutdown catheters. Fluid replacement was guided by clinical monitoring of vital signs, central venous pressure, and urine output, and laboratory monitoring of hematocrit. serum electrolytes, and acid-base determinations. Intestinal decompression was accom-. plished by nasogastric tube suction. Fever was controlled with rectal aspirin or Tylenol, and antibiotics were started after blood cultures were obtained. When the patient’s condition was stable, operative intervention was undertaken. OPERATIVE
FINDINGS
Well-localized abscesses were found in five patients, and diffuse peritonitis was found in four cases. The site of perforation was found at the base of the diverticulum in seven cases, at the tip in one case, and along the lateral border of the diverticulum in another. Ectopic gastric mucosa with the perforation at the site of peptic ulceration was found in each instance. In the earlier years of the series (1950- 1960), these critically ill infants were treated by Mikulicz exteriorization. Since then, all were treated primarily by either sleeve resection of the small bowel and primary end-to-end anastomosis in three cases, or by simple diverticulectomy in two cases. RESULTS There was no mortality. Four patients had five postoperative complications. Early complications mcluded prolonged ileus in one patient with a Mikulicr iieostomy; a second patient with a Mikulicz ileostomy gutTered a wound dehiscence on the fifth postoperative day. Late complications included the development of a blind loop at the Mikulicz ileostomy closure site I yr postoperatively in the first of the above patients. This required resection. Two patients developed mechanical small-bowel obstruction 6 wk and I yr, respectively, after initial surgery. One of these had a previous Mikulicl ileostom?. the other a primary small-bowel resection. Both required lysis of adhesions.
DISCUSSION Surgical disease arising from a Meckel’s diverticulum is not infrequent in childhood. Well over 50% of these children present before the age of 2 yr when rectal
192
CANTY.
MEGUID.
AND
ERAKLIS
bleeding and intestinal obstruction are the most common. Perforation of Meckel’s diverticulum is rare but continues to account for a significant proportion of the morbidity and mortality associated with these diverticula in the young infant. At our institution, perforation of a Meckel’s diverticulum was as frequent a cause for an acute abdomen as appendicitis during the first year of life, and even more frequent during the first 6 mo of life.8*g The infant with advanced peritonitis and sepsis presents a grave surgical risk at the time of admission. Preoperative stabilization of the clinical condition is mandatory before surgery is undertaken. Frequent clinical monitoring of vital signs, urine output, central venous pressure, and fever, guide our therapy of the hypovolemic septic state. Intravenous fluids and antibiotics are given by well-placed cutdown catheters. Nasogastric suction is also immediately instituted. Acid-base imbalance is corrected with the use of intravenous sodium bicarbonate. Throughout the operative procedure close monitoring of the above parameters is continued, and therapy altered accordingly. Success depends on expert anesthesia and the performance of a proper operation. Although this series reports the use of the Mikulicz exteriorizing ileostomy in four of the early cases, today we favor resection with primary anastomosis, or when possible, simple diverticulectomy. The correct diagnosis is not made preoperatively in any of our cases. There were usually delays of hours, days, or even weeks between onset of symptoms and definitive treatment. Early suspicion and more exact diagnosis may result in many of these infants coming to surgical attention at a time when both their illness and their risk of surgery is much less severe. Consideration of the pathophysiology of this disease brings up several points that may help in early recognition. While inflammatory diverticulitis leading to gangrene and perforation may occur in the older child, perforations in this young age group are secondary to peptic ulceration. Thompson believed that if a peptic etiology is not found, there is inadequate histopathologic examination of the specimen.* A detailed history from the parents further emphasizes the importance of an ulcerative process as the etiology of this disease. The majority of these infants have a past history of episodic abdominal complaints often associated with bloody stools days, weeks, or even months prior to the onset of the present perforative disease.lO It is during these episodes that the child is often first seen by a physician and frequently dismissed. These symptoms, however, should alert the physician to the possibility of Meckel’s diverticulum. The perforation itself may be preceded by nausea, vomiting, and the onset of crampy pain. This is followed by increasing abdominal findings of tenderness, guarding, spasm, and loss of bowel sounds as the perforation occurs and peritonitis becomes generalized. This phase of the disease may not be as “knife like” as with a perforated duodenal ulcer or perforated appendicitis, as the luminal contents of the small bowel are not under as much pressure and, therefore, only pass slowly into the peritoneal cavity.4 Recently, an isotopic scanning technique using 99 technetium pertechnetate was described.” This isotope is selectively taken up by normal and ectopic gastric mucosa. Virtually all perforated diverticula in this age group contain ectopic gastric mucosa. This test was modified somewhat and used at this institution.‘2
MECKEL’S
DIVERTICULUM
193
Although experience to date is limited, it seems to be of value in localizing a Meckel’s diverticulum in infants with rectal bleeding and may lead to earlier diagnoses before perforation occurs. Since the presence of barium in the GI tract obscures scanning with this isotope, the test should be undertaken before radiologic contrast studies are done in the evaluation of infants with rectal bleeding or other abdominal complaints. Careful management is mandatory for survival of these very sick infants. The peptic etiology of this disease is a key to early diagnosis. The occurrence of an acute abdominal illness in a nontraumatized infant, beyond the newborn period, with a past history of blood in the stools, should alert the physician to this diagnosis. In these nine cases of perforated Meckel’s diverticulum, there was no mortality and minimal postoperative morbidity. SUMMARY
Nine infants underwent operations for perforation of a Meckel’s diverticulum over a 21-yr period. All of the infants were acutely ill when initially seen by the surgical service. Lethargy, irritability, anorexia, fever, abdominal tenderness, and passage of blood in the stools were common clinical manifestations. The preoperative diagnosis of perforated Meckel’s diverticulum was not made in any of the cases. Skilled preoperative and postoperative management is important for the survival of these infants. There was no mortality and minimal morbidity. In retrospect, the peptic etiology of perforation in this age group is a key to early recognition. The past history of most of the patients includes previous episodes of blood in the stools and episodic abdominal complaints. REFERENCES 1. Gross Childhood. 21 l-219
RE: The Surgery of Infancy and Philadelphia, Saunders, 1953, pp
2. Benson CD. Linkner LM: The surgical complications of Meckel’s diverticulum in infants and children. Arch Surg. 73:393. 1956 3. Benson CD: Surgical implications of Meckel’s diverticulum, in Mustard WT. Ravitch MM, Snyder WH, et al (eds): Pediatric Surgery, Chicago, Year Book, 1969. pp 864 868 4. Thompson JB: Perforated peptic ulcer in Meckel‘sdiverticulum. Am Surg., 105:44, 1936 5. Rutherford RB, Akers DR: Meckel’s diverticulum: A review of 148 pediatric patients with special reference to the pattern of bleeding and to meso-diverticular vascular bands. Surgery 59:618, 1966 6. Seagram
CGF, Lough RE, Stephens
CA. et
al: Meckel’s diverticulum: A ten-year review of 218 cases. Can J Surg. 11:369. 1968 7. Wansbrough RM, Thomson S, Leckey RG: Meckel’s diverticulum: A 42 year review of 273 cases at the Hospital for Sick Children, Toronto. Can J Surg. 1:15, 1957 8. Bartlett RH, Eraklis AJ. Wilkinson RH: Appendicitis in infancy. Surg Gynecol Obstet 130:1, 1970 9. McGuid MM, Canty TG. Eraklis 45: Meckel’s diverticulum Complications in the inpant. Surg Gynec Obstet 139:541. 1974 IO. Brookes VS: Meckel‘s diverticulum in children. Br J Surg 42:57, 1954 1 I. Jewitt TC, Dusczynski DO, Allen JE: The visualization of Meckel’s diverticulum with T~99~pertechnetate. Surgery 68:567. 1970 12. Lebowitz R. Treves S: Letter to the editor. Surgery 721492, 1972
P
ERFORATION IS THE LEAST common complication of Meckel’s diverticulum, but continues to present a challenge both diagnostically and therapeutically in infants and small children. l-3 Because evaluation of the infant with an acute abdominal illness is difficult, diagnosis and treatment are often delayed. This may result in further progression of the disease and increasing mortality and morbidity. The mortality for perforation of Meckel’s diverticulum is high. In 1939, prior to the advent of antibiotics, Thompson reported a mortality of 60% for children under 1 yr of age.* Other recent series continue to report mortalities of 30%50% for perforation in the very young.2.3*5-7 MATERIAL
From 1950 to July, 1972,60 patients under age 2 yr were treated for complications of Meckel’s diverticulum at the Children’s Hospital Medical Center, Boston.g There were nine patients with perforation. Five patients presented before the age of 6 mo, the youngest being 21 s mo old. There were eight males and one female (Table 1). CLINICAL
SYMPTOMS
AND SIGNS
On admission, all the infants appeared acutely ill. Seven infants were referred because of a failure to respond to treatment for diagnosis other than perforation of a Meckel’s diverticulum. Lethargy, irritability, and anorexia, followed by vomiting, fever, abdominal distention, and passage of blood in the stools were the most common presenting symptoms. Of interest in the past history of six children were bouts of vague abdominal complaints, fussiness, and fevers, accompanied by the passage of occult or gross blood in the stools. On examination, seven of the patients were febrile, pale, dehydrated, in mild to moderate hypovolemic shock, with obvious signs of overwhelming sepsis. In two babies, the clinical picture was dominated by bleeding per rectum, but on examination abdominal tenderness and distention were also apparent. A right lowerquadrant mass was palpable in one infant. LABORATORY
INVESTIGATIONS
Laboratory investigations confirmed the severe nature of the illness in each case. Admission hematocrit values were less than 30% in six patients, and all cases had white blood cell counts elevated to above 10,000/mm3 with a shift to the left. Urinalysis, serum electrolytes, and acid-base determinations were of value in pre- and postoperative management but were of no diagnostic aid.
From the Departments o/Surgery. Children’s Hospital Medical Center, Harvard Medical School. Boston, Mass. Address for reprint requests: Timothy Canty. Surgeon-in-Chief; Children’s Hospital. Louisville. KI 40201 Journal of Pediatric Surgery, Vol 10. No 2 (April), 1975
189
9
8
5
4
3
*
recra,
a”Orexla.
,rr,
shock. melena *,ooI
rectal bleedmg
bleeding 1 da”
I da”
temp 100” F
*“orexla. abd pa,“.
temp 102°F
fabollty 1 day ~rnr
,O admlsslo”
Lethargy Hrltablll,”
Abdomnal ,,a,” nrn
red blood per rectum
dune**
a”ore~a*. pale abd. ten
M
,mo,toadm~ss~o”
bleeding
One epl*Ode reC,al
admlsslo”
da”* p,,or 10
recral bleedbng5
d,arrhea ‘or 3 wk
I”te”n#,,e”, vommng
nega,,ve
Barium enema
negatwe
Banurn enema
Nat clone
“FJg*tlW
A”orex,a.
Earlurn enema
obstruct,“”
Small-bawl
diaphragm
AM under
ob*,ruct,o”
Small-bowel
? R”0 ma**
ob*,ruc,,o”
Small-bowel
obstrucw,”
Small-bowel
truta-
+
Oeeult
+
GRXS
+
G”l**
+
24 Hr
2 Days
24 H,
3 Da”*
None
5 Day*
None
NOM’
to Operatton
St001 X-ray Fmdlngs
Delay
Blood in
b&t” 2 days. rectal
dehydrated.
mitab,,,,”
d,*,e”l,on
Lethargy.
dwrhea
mmrexla. “onxflng.
diarrhea
,nltab~ll,y.
1wt. vom~nng and
Letharg”. Irrr,ab,l”“.
guardmg. temp 102’ F.
rc.r3 mo. rpotry
Mala,*e. fever.
a”Orexl*. abd pal”.
vommng. abd pal”
b,l,,y ‘or 1wk 104aF.ShcJCk ,rr,,abMy lntemlmen, fever Lethargy.
a”DreXl*. vommng temp
21 mo
M
16mo
M
6rna
M
6mo
M
lnf.xml,,e”, fever. “om,tl”g. ,rr,,a
Lethargy ,rr,,ab,l,t”.
“lass. clots per recrum
pal” for 1 Wk
d,*,e”,~on. pale. RUO
pnor 10 adm In
fermntent abd
3 rnos
anorexia. abd pain and
bleedmg 5 days
M
Lefharg”. ,rr,,ab,l”y.
One ep’sods rectal
3 “lo
d,*,e”,,o”. 2 day*
shock. recta, bleeding
tabMy. abd pal” and
Lethargy.
datenuon. temp 104’F
7 and 8
days w,or 10 a&n
bleeding
F
1
and Symptoms
Abd lx,,“. ‘e”*r.
Two epwdes
2 I/*mm
Past HlSfOry
Age/Sex
Case
Sag”* Oiagnosls
Preoperative Fmdmgs
Operative Procedure
Operatwe
Table 1. Summary of Nine Patients with Perforation of a Meckel’s Diverticulum
AdmIssIon Hlstopafhology
Suwved
Result
delwcence
Earl” 5th day
Compluzations
F
z D
8
MECKEL’S
DIVERTICULUM
191
Roentgenographic examinations including upright views of the abdomen suggested intestinal obstruction in four cases and free air under the diaphragm was noted in one case. Barium enema examinations were performed in three cases and were of no aid in making the diagnosis. INDICATIONS
FOR OPERATION
The preoperative diagnosis did not include perforation of a Meckel’s diverticulum in any of the nine cases. Six patients were operated on within 24 hr of admission: four with a diagnosis of intestinal obstruction secondary to intussusception, one with a diagnosis of a perforated appendix, and one with a diagnosis of peritonitis of unknown etiology. One child was operated on during the second day after admission because of continued rectal bleeding. Two other children underwent surgery 2 and 3 days, respectively, after admission for persistent rectal bleeding. A bleeding Meckel’s diverticulum was considered in the differential diagnosis in each case. Preoperative management was individualized and directed toward correcting existing deficits. Intravenous fluids in the form of crystalloid, colloid, or whole blood were administered through carefully placed cutdown catheters. Fluid replacement was guided by clinical monitoring of vital signs, central venous pressure, and urine output, and laboratory monitoring of hematocrit. serum electrolytes, and acid-base determinations. Intestinal decompression was accom-. plished by nasogastric tube suction. Fever was controlled with rectal aspirin or Tylenol, and antibiotics were started after blood cultures were obtained. When the patient’s condition was stable, operative intervention was undertaken. OPERATIVE
FINDINGS
Well-localized abscesses were found in five patients, and diffuse peritonitis was found in four cases. The site of perforation was found at the base of the diverticulum in seven cases, at the tip in one case, and along the lateral border of the diverticulum in another. Ectopic gastric mucosa with the perforation at the site of peptic ulceration was found in each instance. In the earlier years of the series (1950- 1960), these critically ill infants were treated by Mikulicz exteriorization. Since then, all were treated primarily by either sleeve resection of the small bowel and primary end-to-end anastomosis in three cases, or by simple diverticulectomy in two cases. RESULTS There was no mortality. Four patients had five postoperative complications. Early complications mcluded prolonged ileus in one patient with a Mikulicr iieostomy; a second patient with a Mikulicz ileostomy gutTered a wound dehiscence on the fifth postoperative day. Late complications included the development of a blind loop at the Mikulicz ileostomy closure site I yr postoperatively in the first of the above patients. This required resection. Two patients developed mechanical small-bowel obstruction 6 wk and I yr, respectively, after initial surgery. One of these had a previous Mikulicl ileostom?. the other a primary small-bowel resection. Both required lysis of adhesions.
DISCUSSION Surgical disease arising from a Meckel’s diverticulum is not infrequent in childhood. Well over 50% of these children present before the age of 2 yr when rectal
192
CANTY.
MEGUID.
AND
ERAKLIS
bleeding and intestinal obstruction are the most common. Perforation of Meckel’s diverticulum is rare but continues to account for a significant proportion of the morbidity and mortality associated with these diverticula in the young infant. At our institution, perforation of a Meckel’s diverticulum was as frequent a cause for an acute abdomen as appendicitis during the first year of life, and even more frequent during the first 6 mo of life.8*g The infant with advanced peritonitis and sepsis presents a grave surgical risk at the time of admission. Preoperative stabilization of the clinical condition is mandatory before surgery is undertaken. Frequent clinical monitoring of vital signs, urine output, central venous pressure, and fever, guide our therapy of the hypovolemic septic state. Intravenous fluids and antibiotics are given by well-placed cutdown catheters. Nasogastric suction is also immediately instituted. Acid-base imbalance is corrected with the use of intravenous sodium bicarbonate. Throughout the operative procedure close monitoring of the above parameters is continued, and therapy altered accordingly. Success depends on expert anesthesia and the performance of a proper operation. Although this series reports the use of the Mikulicz exteriorizing ileostomy in four of the early cases, today we favor resection with primary anastomosis, or when possible, simple diverticulectomy. The correct diagnosis is not made preoperatively in any of our cases. There were usually delays of hours, days, or even weeks between onset of symptoms and definitive treatment. Early suspicion and more exact diagnosis may result in many of these infants coming to surgical attention at a time when both their illness and their risk of surgery is much less severe. Consideration of the pathophysiology of this disease brings up several points that may help in early recognition. While inflammatory diverticulitis leading to gangrene and perforation may occur in the older child, perforations in this young age group are secondary to peptic ulceration. Thompson believed that if a peptic etiology is not found, there is inadequate histopathologic examination of the specimen.* A detailed history from the parents further emphasizes the importance of an ulcerative process as the etiology of this disease. The majority of these infants have a past history of episodic abdominal complaints often associated with bloody stools days, weeks, or even months prior to the onset of the present perforative disease.lO It is during these episodes that the child is often first seen by a physician and frequently dismissed. These symptoms, however, should alert the physician to the possibility of Meckel’s diverticulum. The perforation itself may be preceded by nausea, vomiting, and the onset of crampy pain. This is followed by increasing abdominal findings of tenderness, guarding, spasm, and loss of bowel sounds as the perforation occurs and peritonitis becomes generalized. This phase of the disease may not be as “knife like” as with a perforated duodenal ulcer or perforated appendicitis, as the luminal contents of the small bowel are not under as much pressure and, therefore, only pass slowly into the peritoneal cavity.4 Recently, an isotopic scanning technique using 99 technetium pertechnetate was described.” This isotope is selectively taken up by normal and ectopic gastric mucosa. Virtually all perforated diverticula in this age group contain ectopic gastric mucosa. This test was modified somewhat and used at this institution.‘2
MECKEL’S
DIVERTICULUM
193
Although experience to date is limited, it seems to be of value in localizing a Meckel’s diverticulum in infants with rectal bleeding and may lead to earlier diagnoses before perforation occurs. Since the presence of barium in the GI tract obscures scanning with this isotope, the test should be undertaken before radiologic contrast studies are done in the evaluation of infants with rectal bleeding or other abdominal complaints. Careful management is mandatory for survival of these very sick infants. The peptic etiology of this disease is a key to early diagnosis. The occurrence of an acute abdominal illness in a nontraumatized infant, beyond the newborn period, with a past history of blood in the stools, should alert the physician to this diagnosis. In these nine cases of perforated Meckel’s diverticulum, there was no mortality and minimal postoperative morbidity. SUMMARY
Nine infants underwent operations for perforation of a Meckel’s diverticulum over a 21-yr period. All of the infants were acutely ill when initially seen by the surgical service. Lethargy, irritability, anorexia, fever, abdominal tenderness, and passage of blood in the stools were common clinical manifestations. The preoperative diagnosis of perforated Meckel’s diverticulum was not made in any of the cases. Skilled preoperative and postoperative management is important for the survival of these infants. There was no mortality and minimal morbidity. In retrospect, the peptic etiology of perforation in this age group is a key to early recognition. The past history of most of the patients includes previous episodes of blood in the stools and episodic abdominal complaints. REFERENCES 1. Gross Childhood. 21 l-219
RE: The Surgery of Infancy and Philadelphia, Saunders, 1953, pp
2. Benson CD. Linkner LM: The surgical complications of Meckel’s diverticulum in infants and children. Arch Surg. 73:393. 1956 3. Benson CD: Surgical implications of Meckel’s diverticulum, in Mustard WT. Ravitch MM, Snyder WH, et al (eds): Pediatric Surgery, Chicago, Year Book, 1969. pp 864 868 4. Thompson JB: Perforated peptic ulcer in Meckel‘sdiverticulum. Am Surg., 105:44, 1936 5. Rutherford RB, Akers DR: Meckel’s diverticulum: A review of 148 pediatric patients with special reference to the pattern of bleeding and to meso-diverticular vascular bands. Surgery 59:618, 1966 6. Seagram
CGF, Lough RE, Stephens
CA. et
al: Meckel’s diverticulum: A ten-year review of 218 cases. Can J Surg. 11:369. 1968 7. Wansbrough RM, Thomson S, Leckey RG: Meckel’s diverticulum: A 42 year review of 273 cases at the Hospital for Sick Children, Toronto. Can J Surg. 1:15, 1957 8. Bartlett RH, Eraklis AJ. Wilkinson RH: Appendicitis in infancy. Surg Gynecol Obstet 130:1, 1970 9. McGuid MM, Canty TG. Eraklis 45: Meckel’s diverticulum Complications in the inpant. Surg Gynec Obstet 139:541. 1974 IO. Brookes VS: Meckel‘s diverticulum in children. Br J Surg 42:57, 1954 1 I. Jewitt TC, Dusczynski DO, Allen JE: The visualization of Meckel’s diverticulum with T~99~pertechnetate. Surgery 68:567. 1970 12. Lebowitz R. Treves S: Letter to the editor. Surgery 721492, 1972