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Hemoperitoneum from perforated Meckel's diverticulum
Hemoperitoneum From Perforated Meckel's Diverticulum By Carol L. Fowler, Laurie A. Ohlms, Barbara S. Reid, and Robert S. Bloss Houston, Texas 9 Approximately 4 % of patients with Meckel's diverticulum will experience complications, the most common of which are intestinal obstruction, gastrointestinal bleeding, 9 acute inflammation, and perforation. W e report an extremely rare complication of perforated Meckel's diverticulum which presented as hemoperitoneum. 9 198B by Grune & Stratton, Inc. INDEX WORDS: Meckel's diverticulum; hemoperitoneum.
T IS G E N E R A L L Y A C C E P T E D from autopsy
I studies that Meckel s diverticulum occurs in 2% of the general population. The complication rate is 4% and this incidence increases with age. 1 The most common complications include intestinal obstruction due to internal herniation or intussusception, gastrointestinal bleeding, acute inflammation, and perforation. ~'2 Less frequently encountered are sinus tract formation, internal fistulas, and tumors. Intestinal volvulus and torsion can occur around the mesodiverticular band that is associated with approximately 10% of cases. 2 We report an extremely rare complication of perforated Meckel's diverticulum which presented as hemoperitoneum. Because this occurs so infrequently, Meckel's diverticulum could be overlooked as the etiology of hemoperitoneum. CASE REPORT A 6-year-old white boy was referred to Texas Children's Hospital for lower gastrointestinal bleeding. Ten days prior to admission he had been admitted to another institution for abdominal pain, fever, and leukocytosis. He underwent operation for suspected appendicitis through a right lower quadrant abdominal incision. One hundred fifty milliliters of free intraperitoneal blood was discovered. The appendix appeared grossly normal. No definite etiology for the bleeding could be determined by palpation and the abdomen was closed. The child's hemoglobin fell to 7.3 g percent postoperatively, but increased to 8.9 g percent by the time of discharge four days later. During the postoperative period, one bowel movement containing bright red blood was noted, but this was followed by normal stools. The patient remained clinically stable and experienced no further abdominal pain.
From the Departments of Pediatric Surgery and Pediatrics, Texas Children's Hospital; and the Cora and Webb Madding Department of Surgery, Baylor College of Medicine, Houston. Address reprint requests to Carol L. Fowler, MD, Children's Hospital of Buffalo, SUNY at Buffalo, Department of Pediatric Surgery, 219 Bryant St, Buffalo, N Y 14222. 9 1988 by Grune & Stratton, Inc. 0022-3468/88/2310-0024503.00/0 982
The hemoglobin remained unchanged at 8.9 g percent when evaluated four days after discharge. On the fifth day, recurrent hematochezia was noted. A physical examination of the abdomen showed mild right upper quadrant tenderness but no guarding. Gross blood was evident by a rectal examination. Laboratory studies showed hemoglobin 7.2 g percent and normal coagulation studies. Liver spleen scan and air contrast barium enema showed no abnormalities. The patient was referred to Texas Children's Hospital where a technetium 99m pertechnetate scan was performed. This demonstrated focal accumulation of radiotracer in the lower midabdominal region. Exploratory laparotomy showed a Meckel's diverticulum with a perforation near the base that was sealed off by localized adhesions. There was no free blood within the peritoneal cavity. A diverticulectomy was performed from which the child recovered uneventfully. A histologic examination of the specimen showed heterotopic gastric mucosa. DISCUSSION
Gastrointestinal bleeding is seen in approximately 55% of patients with Meckel's diverticulum. 3 Other than obstruction, it is the most frequent presenting symptom, with 60% of hemorrhages occurring by 2 years of age. 1'2 Hemorrhage is usually caused by peptic ulceration of the ileum adjacent to ectopic gastric mucosa found within the diverticulum) '4 While 44% of all Meckel's diverticula contain ectopic gastric mucosa, 35% of asymptomatic cases and 75% of symptomatic cases harbor this tissue. 4 In the older child, perforation of the diverticulum occurs more frequently than hemorrhage, and is usually secondary to inflammatory diverticulitis and gangrene? though peptic ulceration can also lead to perforation. Amoury 5 states that one third of cases with acute diverticulitis are complicated by perforation. To our knowledge, there has been only one report in the English literature of a hemoperitoneum resulting from a perforated Meckel's diverticulum, 6 with three other reports existing in the world literature. 7"9 In addition, a torn mesodiverticular vascular band 1~and adhesions associated with Meckel's diverticulum TM also have been reported as the etiology of a hemoperitoneum. In the present case, hemoperitoneum resulted from peptic ulceration with hemorrhage and perforation. After the perforation sealed with a localized inflammatory process, continued intermittent bleeding manifested itself as gastrointestinal hemorrhage. Though it is a rare complication, a perforated Meckel's diverticulum should be included among the causes of hemoperitoneum. Journal of Pediatric Surgery, Vo123, No 10 (October), 1988: pp 982-983
HEMOPERITONEUM FROM MECKEL'S DIVERTICULUM
983
REFERENCES
1. Soltero JG, Bill AH: The natural history of Meckers diverticulum and its relation to incidental removal. Am J Surg 132:168-173, 1976 2. Rutherford RB, Akers DR: Meckers diverticulum: A review of 148 pediatric patients with special reference to the pattern of bleeding and to mesodiverticular vascular bands. Surgery 59:618626, 1966 3. Park H, Lucas C: Perforated Meckel's diverticulum following blunt abdominal trauma. J Trauma 10:706-707, 1970 4. Nerdrum H J, Karlsen S: Emergency radionuclide demonstration of Meckel's diverticulum in a patient with perforated ulcer and massive rectal bleedings. Acta Chir Scand 146:217-219, 1980 5. Amoury RA: Meckel's diverticulum, in Welch K J, Randolph JG, Ravitch MA, et al (eds): Pediatric Surgery. Chicago, Year Book Medical, 1986, pp 859-867
6. Moses WR: Meckel's diverticulum: Report of two unusual cases. N Engl J Med 237:118-121, 1947 7. Frank G, Reichel K: Intraabdominelle blutung als seltene komplikation eines Meckel'schen divertikels. Chirurg 48:238-240, 1977 8. Manters E, Maderna C: (Hemoperitoneum caused by peforation of Meckel's diverticula). Minerva Chir 15:872-876, 1960 9. Kaukonen JP: (Peptic ulcer perforation in Meckel's diverticulum and intraabdominal hemorrhage in pregnancy). Duodecim 98:207-208, 1982 10. Vellacott KD: Haemoperitoneum due to Meckel's diverticulum. J R Coil Surg Edinb 26:89-90, 1981 11. Chaffin L: Surgical emergencies during childhood caused by Meckel's diverticulum. Am Surg 113:47-56, 1941
T IS G E N E R A L L Y A C C E P T E D from autopsy
I studies that Meckel s diverticulum occurs in 2% of the general population. The complication rate is 4% and this incidence increases with age. 1 The most common complications include intestinal obstruction due to internal herniation or intussusception, gastrointestinal bleeding, acute inflammation, and perforation. ~'2 Less frequently encountered are sinus tract formation, internal fistulas, and tumors. Intestinal volvulus and torsion can occur around the mesodiverticular band that is associated with approximately 10% of cases. 2 We report an extremely rare complication of perforated Meckel's diverticulum which presented as hemoperitoneum. Because this occurs so infrequently, Meckel's diverticulum could be overlooked as the etiology of hemoperitoneum. CASE REPORT A 6-year-old white boy was referred to Texas Children's Hospital for lower gastrointestinal bleeding. Ten days prior to admission he had been admitted to another institution for abdominal pain, fever, and leukocytosis. He underwent operation for suspected appendicitis through a right lower quadrant abdominal incision. One hundred fifty milliliters of free intraperitoneal blood was discovered. The appendix appeared grossly normal. No definite etiology for the bleeding could be determined by palpation and the abdomen was closed. The child's hemoglobin fell to 7.3 g percent postoperatively, but increased to 8.9 g percent by the time of discharge four days later. During the postoperative period, one bowel movement containing bright red blood was noted, but this was followed by normal stools. The patient remained clinically stable and experienced no further abdominal pain.
From the Departments of Pediatric Surgery and Pediatrics, Texas Children's Hospital; and the Cora and Webb Madding Department of Surgery, Baylor College of Medicine, Houston. Address reprint requests to Carol L. Fowler, MD, Children's Hospital of Buffalo, SUNY at Buffalo, Department of Pediatric Surgery, 219 Bryant St, Buffalo, N Y 14222. 9 1988 by Grune & Stratton, Inc. 0022-3468/88/2310-0024503.00/0 982
The hemoglobin remained unchanged at 8.9 g percent when evaluated four days after discharge. On the fifth day, recurrent hematochezia was noted. A physical examination of the abdomen showed mild right upper quadrant tenderness but no guarding. Gross blood was evident by a rectal examination. Laboratory studies showed hemoglobin 7.2 g percent and normal coagulation studies. Liver spleen scan and air contrast barium enema showed no abnormalities. The patient was referred to Texas Children's Hospital where a technetium 99m pertechnetate scan was performed. This demonstrated focal accumulation of radiotracer in the lower midabdominal region. Exploratory laparotomy showed a Meckel's diverticulum with a perforation near the base that was sealed off by localized adhesions. There was no free blood within the peritoneal cavity. A diverticulectomy was performed from which the child recovered uneventfully. A histologic examination of the specimen showed heterotopic gastric mucosa. DISCUSSION
Gastrointestinal bleeding is seen in approximately 55% of patients with Meckel's diverticulum. 3 Other than obstruction, it is the most frequent presenting symptom, with 60% of hemorrhages occurring by 2 years of age. 1'2 Hemorrhage is usually caused by peptic ulceration of the ileum adjacent to ectopic gastric mucosa found within the diverticulum) '4 While 44% of all Meckel's diverticula contain ectopic gastric mucosa, 35% of asymptomatic cases and 75% of symptomatic cases harbor this tissue. 4 In the older child, perforation of the diverticulum occurs more frequently than hemorrhage, and is usually secondary to inflammatory diverticulitis and gangrene? though peptic ulceration can also lead to perforation. Amoury 5 states that one third of cases with acute diverticulitis are complicated by perforation. To our knowledge, there has been only one report in the English literature of a hemoperitoneum resulting from a perforated Meckel's diverticulum, 6 with three other reports existing in the world literature. 7"9 In addition, a torn mesodiverticular vascular band 1~and adhesions associated with Meckel's diverticulum TM also have been reported as the etiology of a hemoperitoneum. In the present case, hemoperitoneum resulted from peptic ulceration with hemorrhage and perforation. After the perforation sealed with a localized inflammatory process, continued intermittent bleeding manifested itself as gastrointestinal hemorrhage. Though it is a rare complication, a perforated Meckel's diverticulum should be included among the causes of hemoperitoneum. Journal of Pediatric Surgery, Vo123, No 10 (October), 1988: pp 982-983
HEMOPERITONEUM FROM MECKEL'S DIVERTICULUM
983
REFERENCES
1. Soltero JG, Bill AH: The natural history of Meckers diverticulum and its relation to incidental removal. Am J Surg 132:168-173, 1976 2. Rutherford RB, Akers DR: Meckers diverticulum: A review of 148 pediatric patients with special reference to the pattern of bleeding and to mesodiverticular vascular bands. Surgery 59:618626, 1966 3. Park H, Lucas C: Perforated Meckel's diverticulum following blunt abdominal trauma. J Trauma 10:706-707, 1970 4. Nerdrum H J, Karlsen S: Emergency radionuclide demonstration of Meckel's diverticulum in a patient with perforated ulcer and massive rectal bleedings. Acta Chir Scand 146:217-219, 1980 5. Amoury RA: Meckel's diverticulum, in Welch K J, Randolph JG, Ravitch MA, et al (eds): Pediatric Surgery. Chicago, Year Book Medical, 1986, pp 859-867
6. Moses WR: Meckel's diverticulum: Report of two unusual cases. N Engl J Med 237:118-121, 1947 7. Frank G, Reichel K: Intraabdominelle blutung als seltene komplikation eines Meckel'schen divertikels. Chirurg 48:238-240, 1977 8. Manters E, Maderna C: (Hemoperitoneum caused by peforation of Meckel's diverticula). Minerva Chir 15:872-876, 1960 9. Kaukonen JP: (Peptic ulcer perforation in Meckel's diverticulum and intraabdominal hemorrhage in pregnancy). Duodecim 98:207-208, 1982 10. Vellacott KD: Haemoperitoneum due to Meckel's diverticulum. J R Coil Surg Edinb 26:89-90, 1981 11. Chaffin L: Surgical emergencies during childhood caused by Meckel's diverticulum. Am Surg 113:47-56, 1941