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Meckel's diverticulum
MECKEL’S DIVERTICULUM A. V.
MIGLIACCIO, M.D. AND CHARLES BEGG,
M.D.
Providence, Rhode Island
T
HIS review covers the experience of the Rhode IsIand HospitaI with MeckeI’s diverticuhrm and its comphcations during a tweIve-year period beginning January I, 1935 and ending purpose of December 3 I, 1946. The the review is twofoId: First, severa of the cases are of unusua1 interest; second, the review as a whoIe provides a means of seIfanaIysis and seIf-criticism. It is our opinion that the Rhode IsIand HospitaI represents an average, genera1 hospita1 in a non-teaching center. For this reason our reffections, concIusions and experiences may benefit or at Ieast interest simiIar institutions. HISTORIC
AND
EMBRYOLOGIC
BACKGROUND
This aspect of the subject has been adequateIy treated in many pubIications.‘,2,3 The embryoIogic facts of pertinent interest may be briefly summarized: The omphaIomesenteric duct, which connects the yoIk sac with the intestine, begins to be obIiterated in about the fifth week of feta1 Iife. ObIiteration is compIete at about the seventh week. Various degrees of faiIure of obIiteration Iead to various disease entities. First, if the entire duct remains patent, a feca1 fistuIa opening at the umbiIicus resuIts. Second, when the d&a1 end faiIs to cIose, intestina1 mucosa is seen at the umbiIicus where the secretions of the gIanduIar eIements form a discharge. Third, a retention cyst is formed if the mid-section persists. Fourth, persistence of the proxima1 end may be seen as an outpouching of the intestina1 tract usuaIIy of the termina1 iIeum. This is what is commonIy referred to as MeckeI’s diverticuIum. It differs from other diverticuIa in that it contains a11 the Iayers of the muscuIaris of the intestina1 waI1. OccasionaIIy associated with it is persistence of a fibrous staIk connecting its tip with the
inner aspect of the anterior abdomina1 waI1 in the region of the umbiIicus. This is the resuIt of incompIete regression of the omphaIomesenteric duct. The bIood suppIy of the diverticuIum usuaIIy comes from its mesentery, which arises from the mesentery of the bowe1, or it may come from the bowe1 waI1 itself in some instances. GENERAL
CONSIDERATIONS
Site of Diverticuhn. MeckeI’s diverticuIum may arise from any portion of the intestina1 tract aIthough the termina1 iIeum is the usua1 site; it may arise from any point in the circumference of the bowe1, incIuding that area between the Ieaves of the mesentery. The usua1 point of origin is the anti-mesenteric border. In this series the extremes were a diverticulum arising onIy $5 inch from the iIeoceca1 vaIve and one arising 2 feet proxima1 to the vaIve. Size. The size varies greatIy. The Iargest recorded in the Iiterature is 104 cm.4 aIthough an average diverticuIum is about the size of a thumb, no unusuaIIy Iarge diverticuIa were encountered in this series. Incidence and other Statistics. Figures derived from autopsy materia1 show an incidence ranging from I to 2..5 per cent of patients coming to autopsy.2’3*6 Various series show that the condition is more common in maIes than in femaIes, the ratio ranging from 2. I to 4.1.~ In the author’s series the ratio is three maIes to two femaIes. It is of interest to note the percentage of patients in whom MeckeI’s diverticuIum was discovered and which was responsibIe for the symptoms. This figure varies from 20 to 35 per cent in other series.415v7 In ours it is 42 per cent. The age incidence in this series paraIIeIs that of other series. A notabIe finding in
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Begg-MeckeI’s
reIation to age incidence is that the percentage of patients showing a pathoIogic condition of the diverticuIum is higher in the first two decades. Twenty-two of our cases occurred. in the first two decades; fifteen of these, or 68 per cent showed AGE
Age
INCIDENCE
NO.
(Years)
Less than z
5’ 8
2-10
I I-20 r-30 31-40 4’-$0 5 1-60 Over 60 2
TotaIs
pathoIogic 32 per cent, in patients pathoIogic
No. Showing Pathologic Changes
: 4 5
9 ‘3 7 3 5 o
0
I 2 0
-
-
50
21
changes, whereas only nine, or of twenty-eight cases occurring after the second decade showed changes. CLASSIFICATION
GreenbIatt’s cIassifications of disorders of the omphaIomesenteric duct is one of the most adequate and incIusive. We have modified it to a certain extent by removing the heterotopic cases from the tumor group and cIassifying them as a separate group in which we incIude cases of peptic uIcer which Greenblatt has cIassified separateIy. The revised cIassification foIIows : I. Obstructive Group.. (a) Intussusception........................ (b) VoIvulus.. (c) Bands and adhesions.. (d) Contents of hernia.. 2. Diverticulitis Group.. (a) Simple acute inflammation. (b) Acute with perforation and gangrene. (c) Chronic inff ammation. 3. Ejeterotopic Group. . . (a) Gastric mucosa.. (I) with uker and hemorrhage. (2) with ulcer and perforation. (3) with ulceration.. (4) without ulceration.. (b) Other tissues (I) pancreas. . . (2) duodenum.. (3) colon..
II 2
4
3
2 3 3 o
I IO 7 I 4
o 2 2
o I
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A n&can Journalof Surgery
4. UmbilicaI Group.. (a) Fecal fistula.. (b) Umbilical adenoma.. J. Tumor Group.. (a) Mahgnant. (b) Benign.. 1 6. Incidental Group..
I 89
o o
o o o o 29
Figures in the right hand coIumn show the number of cases in this series faIIing into each group. One of our own cases remains uncIassified. None of the cases in our series feI1 into groups 4 and 5 or into 2(b). Obstructive Group. EIeven of our cases are incIuded in this group. (TabIe I.) There were two cases of intussusception (cases 6 and 23). In both cases invaginated MeckeIs’ diverticuIum was the Ieading point of the intussusception. It is interesting that each of these diverticula contained a sizeable noduIe of pancreatic tissue and these were the onIy cases in which pancreatic tissue was found. It seems possibIe that peristaItic movements of the diverticuIum in attempting to expeI its contents or an intrinsic mass couId be responsibIe for invagination. Such a chain of events is suggested by Atwood in a recent paper.g Hunt and BonesteeI Iist four such cases in their compiIation.” Ladd and GrosslO report that of 372 cases of intussusception occurring in chiIdren fourteen were associated with MeckeI’s diverticuIum. Another case of intussusception occurred in this series but there was no evidence that the diverticuIum in this case was more than an incidenta finding. There were four cases of voIvuIus (Cases I, 15, 20 and 33). In the Iast three a stalk was present running from the tip of the diverticuIum to the inner surface of the abdomina1 waI1 in the region of the umbiIicus about which Ioops of smal1 bowe1 had become twisted. Figure I shows the diverticuIum and staIk in Case 20. In case 15 the entire smaI1 intestine was twisted about the band. In Case I the voIvuIus invoIved a two-foot Ioop of termina1 iIeum. In the mid-point of this Ioop was an inflamed MeckeI’s diverticuIum but it cannot be ascertained from the operative
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FIG. I. Meckel’s diverticulum can be seen attached to the under surface of the umbiIicus; x, umbilicus; A, B and c, Meckel’s diverticuIum; X-Y, ileum.
note whether or not the diverticuIum was an integra1 part of the disorder. (Figs. 2, 3 and 4.) Disturbances as the resuIt of bands and adhesions are iIIustrated by Cases 8, 24 and 25. Case 8 is of interest in that the patient showed signs of obstruction eight days after the remova of an acute appendix and operation showed a MeckeI’s diverticuIum Iooped over the iIeum and compressing it. Two other points of obstruction, the resuIt of adhesions, were freed and the diverticuIum was Ieft in pIace because of the patient’s poor condition. Three months Iater the patient returned to the hospita1 compIaining of frequent crampy periumbiIica1 pains with nausea and vomiting. An operation reveaIed distention above the point of origin of the diverticuIum. Adhesions so distorted and kinked the iIeum that obstruction had resuIted. Resection of the Ioop bearing the diverticuIum was then carried out. In the other two cases the position of the diverticuIum so roIIed and kinked the iIeum that there was narrowing of the Iumen at the point of origin with symptoms of intermittent partia1 obstruction. In three cases a MeckeI’s diverticuIum was found in a hernia. In one case it was an incidenta finding but in Case 5 the pa-
tient had symptoms consistent with stranguIation and a Iarge, infarcted Meckel’s diverticuIum was the soIe content of the hernia1 sac. In Case 43 an omphaIoceIe was noted at birth and an operation carried out before the chiid was four hours oId. It was found that adhesion of a MeckeI’s diverticuIum to the waI1 of the cord prevented retraction of a Ioop of the iIeum. The diverticuIum was removed and the bowe1 restored. Group. MeckeI’s divertiDiverticulitis cuIum is subject -to inffammatory changes in much the same manner as the appendix but with this difference: The Iumen and ostium of the diverticuIum is usuaIIy greater than that of the appendix and obstructive types of inffammation are Iess frequent. Cases 16, 22 and 28 represent acute inffammation. Each had an abrupt, progressive history indistinguishabIe from appendicitis. One man had previousIy had his appendix removed and the diagnosis of acute diverticuIitis of MeckeI’s diverticuIum was made preoperativeIy. Chronic diverticuIitis as a diagnosis is about as unsatisfactory as the diagnosis of chronic Case 27 showed pathoIogic appendicitis. changes consistent with this diagnosis. The patient had had the history and physica signs usuaIIy associated with acute appen-
VOL. LXXVI.
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Begg-MeckeI’s TABLE
Case No.
OBSTRUCTIVE
-
Type of Adhesions
Age
Symptoms
1[r tussusception
23
1[ntussusception
I5
5
VoIvulus
IO
20
v01vu1us
29
33
v01vu1us
9
8
Bands and adhesions
19
24
Bands and adhesions
26
25
Bands and adhesions
27
01f
54
Contents 01f omphalocele
hr:.
Contents hernia
43
-
GROUP
Operative Findings
?eriumbiIical 1Right lower pain with nausea L quadrant and vomiting spasm and tenderness
lleo-iIea1 intussusception with Meckel’s Ieading
v’omiting 24 hr.
lleocolic intussusception with MeckeI’s leading v01vu1us of 2 ft. Ioop of iIeum with gangrene
1Melenae, visible peristalsis
mo.
22
5
I9 I
PathoIogic Findings
RX.
‘_
1VolvuIus
I
A mericanJournalof Surgery
I
Signs
~~ 8
DiverticuIum
-
*ower abdomina1 cramps with nausea and vom iting 24 hr. Periumbilical cramps with vomiting 2 days
Right lower quadrant spasm and tenderness Right lower quadrant and periumbiIica1 tenderness and spasm ,Generalized spasm and tenderness; absent arisstaIsis
PeriumbiIicaI cramps and vomiting 24 hr.; attack 3 yr. before Periumbilical pain and vomiting; 2 previous attacks PeriumbilicaI pain and vomiting 4 days; 2 previous operations Episodes of right lower quadrant pain and nausea I mo. Episodes of epigastric pain, obstipation and nausea 5 yr.
Right Iower quadrant spasm and tenderness Negative
Right lower quadrant tenderness and spasm Tenderness and spasm to right of umbiIicus
Incarcerated hernia
IrreducibIe tender mass; inguina1 region
Omphalocele noted at birth
OmphaIoceIe noted at birth
-
Venous infarcLoop with tion; pancreatic c MeckeI’s diverticutissue Ium resected MeckeI’s Venous infarction; pancreatis c diverticuIum retissue sected Venous infarcLoop resected tion
Entire smaI1 bow,el formed volvulus about staIk of Meckel’
.Tissue Iost
Meckel’s diverticulum resected
VolvuIus of terminal ileum about MeckeI’s and its staIk
inff amAcute mation of Meckel’s diver ticulum
Meckel’s diverticulum resected
IIeum twisted about band running from Meek el’s to umbilicus Bowel at base of MeckeI’s kinked and rolled on mesentery; lumen small Tip of MeckeI’: heId down by fibrous band am ileum kinked Arose from latera aspect of ileum: iIeum kinked and Iumen nar. rowed
Chronic inflam- Meckel’s diverticumation of Ium reMeckeI’s diver ticuIum sected Peridiverticuliti s Loop with Meckel’s of Meckel’s didiverticuverticuIum Ium resected Meckel’s diver- Meckel’s diverticuticuIum lum resected MeckeI’s MeckeI’s diver. diverticuticuIum lum and loop of iIeum resected infarc :- Meckel’s Red swolIen Venous Meckel’s sole tion of Meckel’ 2 diverticucontents of her, Ium rediverticuIum niae sac sected Meckel’s adher. Tissue Iost Meckel’s ent to waI1 01 diverticusac, preventec Ium reretraction of sected ileum -
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DiverticuIum
AUGUST,
1948
2 3 FIG. 2. A plain film of the abdomen showing the presence of dilated loops of sma11 intestine which Ied to the making of serial studies of the small intestine. FIG. 3. Meckel’s diverticulum is present at the constricted area. The roentgenologist beIieved that this represented a retroperitoneal tumor which was encroaching on the Iumen of the termina1 ileum. Note the dilatation of the proximal loop.
TABLE
-
T
Operative Findings
PathoIogic Findings
Red, angry Meckel’s diverticuIum 4.2 cm by 1.2 cm.
Acute inflammation
Spasm and tenderness in right Iower quadrant; tender on right on recta1 examination
InfIamed diverticuIum Meckel’s 435 inches long
Acute inflammation
Spasm and tenderness in right Iower quadrant
InAamed Meckel’s diverticulum I .T cm long
Acute inflammation
MeckeI’s diverticuIum resected
Chronic tion
Meckel’s diverticuIum resected
Case No.
Age
Symptoms
16
$2
No history recorded
No history
22
41
28
9
Previous appendectomy; severe right Iower quadrant pain with nausea and vomiting 24 hr. abdomina1 Upper pain shifting to right lower quadrant 24 hr
Signs
recorded
Chronic 27
II
DIVERTICULITIS SimpIc Acute InA ammation
16
Right lower quadrant pain with nausea and vomiting 12 hr.
_1
RX.
Meckel’s diverticuIum resected Meckel’s diverticuIum resected
Inflammation
Spasm and tender- Large Meckel’s diness in right Iower verticulum packed quadrant; tender on with feces right on rectal examination
inff amma-
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dicitis. A MeckeI’s diverticuIum was found to be soIidIy packed with hard feca1 material. (TabIe II.) Heterotopic Group. Gastric mucosa, jejuna1, duodena1 or coIonic mucosa and pancreatic tissue may be found in MeckeI’s
DiverticuIum
A mericanJournalof Surgery 193
53 per cent; 74 per cent of these patients were under the age of fifteen. No statistics are to be found which iIIustrate the percentage of those patients having gastric mucosa in a diverticuIum who aIso have peptic uIceration. In addition to hemor-
FIG. 4. A, Meckel’s diverticulum hanging free in abdomina1 cavity; B, Meckel’s diverticuIum falling from the site of origin of its mesentery; note obstruction; c, Meckel’s diverticulum falling toward side of origin of its mescntery; no obstruction.
diverticuIum. Gastric mucosa is by far the most frequentIy found of those mentioned and is the onIy type consistently associated with symptoms. It is present in 16 per cent of a11 cases with MeckeI’s diverticuIum according to Schaetz.2 In children heterotopic gastric mucosa in the most frequent cause of symptoms; uIcer is the most frequent complication resuIting from this disorder. Cobb2 has reported a series of I IO cases showing uIceration in MeckeI’s diverticuIum associated with the presence of gastric mucosa. The uIcer usuaIIy occurred in the immediateIy adjacent iIea1 mucosa, that is, near the base of the diverticuIum. In Cobb’s series hemorrhage occurred in 72 per cent and perforation in
rhage and uIceration a third compIication is reported by Waugh et aI.12 These authors describe two patients in whom the scarring, resuIting from the uIceration, so reduced the Iumen of the adjacent bowe1 that obstruction resuIted. The mechanism of uIceration is discussed by Cobb2 and may be briefly summarized: Acid secretion of the gastric mucosa of the diverticuIum paraIIeIs that of the stomach; it, therefore, occurs at a time when the ileum Iacks the protection of neutraIizing food and secretions. Thus favorabIe conditions are found for uIceration. Acute perforation, comparabIe to that which occurs in the stomach, is found in
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Begg-Meckel’s TABLE
Diverticuhm
III
HETEROTOPIC Case No.
Age
Symptoms
Operative Findings
Signs
Pathologic Findings
RX
_ Gastric 48
8 mo.
Anemia and z eoisodes of melena I
6
Right lower quadrant pain with vomiting, I day
3’
17
46
9
Crampy right lower quadrant pain spreading through abdomen 2 days, vomiting GeneraIized abdom inal pain with vomiting 12 hr.
49
24
Upper abdomina1 cramps 8 days; right lower quadrant pain, 20 hr.; no nausea, vomiting
I MeckeI’s
diverticuIum 1.7 by 1.6 cm.
Mucosa
10
17
21
I Ulcer
on oroxima1 edge of gastric mucosa Iining diverticulum
I Meckel’s diverticulum resected
with Ulcer and Perforation
Spasm and tenderFree fluid perforation ness in right lower of Meckel’s diverquadrant; tender or ticulum right on rectal examination Generalized spasm Free fluid; perforate< ulcer of MeckeI’s; and tenderness; recstaIk ran to umbiltal tenderness icus GeneraIized spasm and tenderness
Generalized spasm and right lower quadrant tendernes:
Gastric 14
with UIcer and Hemorrhage
I Pallor
Gastric 2
Mucosa
Mucosa
Perforation at tip of Meckel’s diverticuIum; free fluid in abdomen Free fluid in abdomen; perforation at base of Meckel’s diverticulum
without
Meckel’s diverticuIum lined with gastric mucosa; perforated uIcer near base MeckeI’s diverticuIum Iined with gastric mucosa; perforated uIcer near base MeckeI’s diverticuIum lined with gastric mucosa; ulcer at tip Gastric mucosa presuIcer perforent; ated at junction prox. and mid. +$
Meckel’s diverticuIum resected Meckel’s diverticuIum resected Meckel’s diverticulum resected MeckeI’s diverticulum resected
UIceration
Periumbilical pain with vomiting 48 hr.
Right Iower quadrant spasm and tenderness
Appendix acuteIy inAamed; Meckle’s diverticuIum present
Hirsutism
Hirsutism
Meckel’s diverticuIum found durexpl. Iaporotomy for casue of hirsutism
Acute appendicitis; MeckeI’s diverticuIum contained gastric mucosa in diverticulum of its own Gastric mucosa found in tip of MeckeI’s diverticulum
Meckle’s diverticuIum resected
Meckel’s diverticuIum resected
Pancreas 6
23
I5
5 mo.
Periumbilical with nausea vomiting
Vomiting,
pain and
24 hr.
Right Iower quadrant spasm and tenderness
IIeo-ilea intussusception with MeckeI’s diverticuIum Ieading
Venous Infarction; pancreatic tissue
MeIena, visibIe Peristalsis
IIeocoIic intussusception with Meckel’s diverticulum Ieadine:
Venous infarction; pancreatic tissue
Loop with MeckeI’s diverticuIum resected Meckel’s diverticuIum resected
CoIon Meckel’s
diverticu-
) ,!;~c;~~nccefrom
Meckel’s
( f;zhnt:ozth
diverticuco-
Meckel’s
( 5$x-
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MeckeI’s diverticuIum usuaIIy in the growing chiId under eighteen. Perforation in the older age group is rare. Gastric mucosa was present in seven of our cases and possibIy in an eighth. (TabIe III.) In Cases 14 and 17 there was no associated uIceration; in both of these cases the diverticuIum had given no symptoms and was an incidenta finding. One patient, Case 48, had uIceration with bIeeding and no perforation. This patient was an infant who was studied because of a severe bIood-Ioss type of anemia. The condition was suspected and proved at operation. Four cases and possibIy a fifth had gastric mucosa and peptic uIceration with perforation. These Cases are 2, 31, 46, 4g and 50. The Iast case cannot be incIuded StatisticaIIy, for the poor condition of the patient precIuded remova of the diverticuIum. A perforated uIcer was present, but the type of mucosa Iining the diverticuIum wiI1 not be known unti1 a second operation is performed for the remova1 of the diverticuIum. In none of the cases of perforation was there any cIue as to the origin of the perforation preoperativeIy. The patients presented themseIves with signs of perforation of a hoIIow viscus but with no signs which wouId IocaIize the site of the perforation. NoduIes of pancreatic tissue were present in MeckeI’s diverticuIum in our Cases 6 and 23; In both of these cases intussusception had occurred, with an invaginated diverticuIum as the Ieading point. A casua1 reIationship is suggested but cannot be proved. CoIon mucosa was present in the diverticuIum in Case 32. In this instance the finding of MeckeI’s diverticuIum was incidenta to other conditions and had no reIation to the patient’s illness. DIAGNOSIS
The diagnosis is rareIy made preoperativeIy with any degree of certainty. Symptoms are as varied as the compIications and are, in fact, the symptoms of the compIications. Patients in whom obstruction
DiverticuIum
A me&an Journal of Surgery 195
is the manifestation cannot be differentiated from those with obstruction due to other causes, nor can patients in whom perforation occurs be separated symptomaticaIIy from those with perforation of other hoIIow viscera. An exception might be made in the Iatter instance. Perforation of a MeckeI’s diverticulum has usuaIIy a Iess abrupt onset than perforation of a gastric or duodena1 uIceration and is Iess IikeIy to show the presence of air beneath the diaphragm. However, it cannot be distinguished from appendicea1 perforation unIess the appendix has been removed previousIy. In chiIdren peptic uIceration of Meckel’s diverticuIum is an important cause of intestina1 bIeeding, and such a diagnosis shouId be entertained in every case. X-ray has IittIe to offer diagnosticaIIy. According to PfahIer,13 the diagnosis was not made by x-ray prior to 1934. However, since the advent of seria1 studies of the smaI1 bowe1, the roentgenoIogists have on rare occasions been abIe to show the presence of residua1 barium in MeckeI’s diverticuIum. The cases in this series were reviewed with the intention of discovering any symptoms and signs which wouId Iead one to suspect a diagnosis of Meckel’s diverticuIum. No specific diagnostic criteria were found. TREATMENT
The treatment of choice is resection; an attempt should be made to take as wide a base as possibIe in an effort to remove a11 heterotopic tissue. This form of treatment was carried out in thirty-eight of our cases. In four cases the diverticuIum was invaginated by simpIe purse-string sutures. Two criticisms of this procedure may be made: First, it creates a poIypoid mass which may be the Ieading point of an intussusception aIthough no such cases have been reported; second, it may Ieave heterotopic tissue. In eight of our cases the diverticuIum was not removed. In four of these the process was extremeIy smaI1; the serious condition of the remaining .four
196
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patients precluded any more manipuIation than was absoIuteIy necessary. CONCLUSION
It has been the authors’ experience that the incidence of MeckeI’s diverticuIum has shown an increase paraIIeIing the diIigence with which it is sought. We note that the incidence in our series in which MeckeI’s diverticuIum actuaIIy caused the patient’s iIIness is considerabIy higher than the incidence in simiIar series. Perhaps the structure must IiteraIIy cry for attention before we seek it. More carefu1 search at operation may perhaps increase our percentage of “ incidental” Meckel’s diverticuIum but at the same time prevent future iIIness. The authors were surprised to discover that onIy one case in their series was an infant with melena as the result of peptic uIceration. This may, perhaps, indicate some Iaxity in the study of chiIdren with recurrent attacks of abdomina1 pain. We believe that any chiId with frequent attacks of abdomina1 pain which have never been so severe as to bring him to operation shouId be studied for melena. Any patient whose operative findings fai1 to substantiate the preoperative cIinica1 impressions shouId be considered as a prospective victum of MeckeI’s diverticuIum. SUMMARY
Fifty cases of MeckeI’s diverticuIum are presented and anaIyzed. The Iiterature is
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AUGUST,
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consuIted for comparison of this series with the series of other authors. The embryoIogic background is brieffy given. The authors’ experience in dealing with these patients is summarized and suggestions are made for improvement in diagnosis and treatment. REFERENCES I. Cabot
Case 21441. UIcer of Meckel’s diverticuIum. New England J. Med., 213: 878-880, 1935. 2. Cabot Case 22101. Meckel’s diverticulum. New England J. Med., 214: 481-484, 1936. 3. Cabot Case 26052. Meckel’s diverticuIum with intestinal obstruction. New England J. Med., 222: 195-197, 1940. 4. CONRAD, H. A. Meckel’s Surg., 3: 267-274, 1941.
diverticuIum,
5. FRENCH, RALPH W. Meckel’s diverticulum. dale Hosp. Bull., Dec., 1931.
Am.
J.
Trues-
6. GOODMAN, B. A. Meckel’s diverticuIum, its incidence and significance in routine operations on the abdomen. Arch. Surg., 36: 144, 1938. 7. GREENBLATT, R. B., PUND, E. R. and CHANEY, R. H. MeckeI’s diverticuIum, and anaIysis of eight&n cases with reports of one tumor. Am. J. Surg., 3 I : 285-293, I 936. 8.
H. N. Intussusception due to invaginated MeckeI’s diverticulum, report of two cases with a study of 160 cases collected from the literature. Ann. Surg., 98: 1070-1099, 1933.
HARKINS,
9. PFAHLER, G. E. The roentgenological diagnosis of MeckeI’s diverticuIum. Surg., Gynec. u Oh., 109: 929334, 1934. IO. STEWART, G. A. The significance of Meckel’s diverticurum in the surgical abdomen. Rev. Gostroenterol., 7: 310-312, 1940. I I.
THOMPSON,
J. E. Meckel’s diverticulum.
Ann. Surg.,
55: 44-55. 1937. 12. WORMACK, N. A. and SIEGERT, R. B. SurgicaI aspects of lesions of MeckeI’s diverticulum. Ann. Swg., 58: 221-236, 1938.
MIGLIACCIO, M.D. AND CHARLES BEGG,
M.D.
Providence, Rhode Island
T
HIS review covers the experience of the Rhode IsIand HospitaI with MeckeI’s diverticuhrm and its comphcations during a tweIve-year period beginning January I, 1935 and ending purpose of December 3 I, 1946. The the review is twofoId: First, severa of the cases are of unusua1 interest; second, the review as a whoIe provides a means of seIfanaIysis and seIf-criticism. It is our opinion that the Rhode IsIand HospitaI represents an average, genera1 hospita1 in a non-teaching center. For this reason our reffections, concIusions and experiences may benefit or at Ieast interest simiIar institutions. HISTORIC
AND
EMBRYOLOGIC
BACKGROUND
This aspect of the subject has been adequateIy treated in many pubIications.‘,2,3 The embryoIogic facts of pertinent interest may be briefly summarized: The omphaIomesenteric duct, which connects the yoIk sac with the intestine, begins to be obIiterated in about the fifth week of feta1 Iife. ObIiteration is compIete at about the seventh week. Various degrees of faiIure of obIiteration Iead to various disease entities. First, if the entire duct remains patent, a feca1 fistuIa opening at the umbiIicus resuIts. Second, when the d&a1 end faiIs to cIose, intestina1 mucosa is seen at the umbiIicus where the secretions of the gIanduIar eIements form a discharge. Third, a retention cyst is formed if the mid-section persists. Fourth, persistence of the proxima1 end may be seen as an outpouching of the intestina1 tract usuaIIy of the termina1 iIeum. This is what is commonIy referred to as MeckeI’s diverticuIum. It differs from other diverticuIa in that it contains a11 the Iayers of the muscuIaris of the intestina1 waI1. OccasionaIIy associated with it is persistence of a fibrous staIk connecting its tip with the
inner aspect of the anterior abdomina1 waI1 in the region of the umbiIicus. This is the resuIt of incompIete regression of the omphaIomesenteric duct. The bIood suppIy of the diverticuIum usuaIIy comes from its mesentery, which arises from the mesentery of the bowe1, or it may come from the bowe1 waI1 itself in some instances. GENERAL
CONSIDERATIONS
Site of Diverticuhn. MeckeI’s diverticuIum may arise from any portion of the intestina1 tract aIthough the termina1 iIeum is the usua1 site; it may arise from any point in the circumference of the bowe1, incIuding that area between the Ieaves of the mesentery. The usua1 point of origin is the anti-mesenteric border. In this series the extremes were a diverticulum arising onIy $5 inch from the iIeoceca1 vaIve and one arising 2 feet proxima1 to the vaIve. Size. The size varies greatIy. The Iargest recorded in the Iiterature is 104 cm.4 aIthough an average diverticuIum is about the size of a thumb, no unusuaIIy Iarge diverticuIa were encountered in this series. Incidence and other Statistics. Figures derived from autopsy materia1 show an incidence ranging from I to 2..5 per cent of patients coming to autopsy.2’3*6 Various series show that the condition is more common in maIes than in femaIes, the ratio ranging from 2. I to 4.1.~ In the author’s series the ratio is three maIes to two femaIes. It is of interest to note the percentage of patients in whom MeckeI’s diverticuIum was discovered and which was responsibIe for the symptoms. This figure varies from 20 to 35 per cent in other series.415v7 In ours it is 42 per cent. The age incidence in this series paraIIeIs that of other series. A notabIe finding in
VOL. LXXVI,
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Begg-MeckeI’s
reIation to age incidence is that the percentage of patients showing a pathoIogic condition of the diverticuIum is higher in the first two decades. Twenty-two of our cases occurred. in the first two decades; fifteen of these, or 68 per cent showed AGE
Age
INCIDENCE
NO.
(Years)
Less than z
5’ 8
2-10
I I-20 r-30 31-40 4’-$0 5 1-60 Over 60 2
TotaIs
pathoIogic 32 per cent, in patients pathoIogic
No. Showing Pathologic Changes
: 4 5
9 ‘3 7 3 5 o
0
I 2 0
-
-
50
21
changes, whereas only nine, or of twenty-eight cases occurring after the second decade showed changes. CLASSIFICATION
GreenbIatt’s cIassifications of disorders of the omphaIomesenteric duct is one of the most adequate and incIusive. We have modified it to a certain extent by removing the heterotopic cases from the tumor group and cIassifying them as a separate group in which we incIude cases of peptic uIcer which Greenblatt has cIassified separateIy. The revised cIassification foIIows : I. Obstructive Group.. (a) Intussusception........................ (b) VoIvulus.. (c) Bands and adhesions.. (d) Contents of hernia.. 2. Diverticulitis Group.. (a) Simple acute inflammation. (b) Acute with perforation and gangrene. (c) Chronic inff ammation. 3. Ejeterotopic Group. . . (a) Gastric mucosa.. (I) with uker and hemorrhage. (2) with ulcer and perforation. (3) with ulceration.. (4) without ulceration.. (b) Other tissues (I) pancreas. . . (2) duodenum.. (3) colon..
II 2
4
3
2 3 3 o
I IO 7 I 4
o 2 2
o I
DiverticuIum
A n&can Journalof Surgery
4. UmbilicaI Group.. (a) Fecal fistula.. (b) Umbilical adenoma.. J. Tumor Group.. (a) Mahgnant. (b) Benign.. 1 6. Incidental Group..
I 89
o o
o o o o 29
Figures in the right hand coIumn show the number of cases in this series faIIing into each group. One of our own cases remains uncIassified. None of the cases in our series feI1 into groups 4 and 5 or into 2(b). Obstructive Group. EIeven of our cases are incIuded in this group. (TabIe I.) There were two cases of intussusception (cases 6 and 23). In both cases invaginated MeckeIs’ diverticuIum was the Ieading point of the intussusception. It is interesting that each of these diverticula contained a sizeable noduIe of pancreatic tissue and these were the onIy cases in which pancreatic tissue was found. It seems possibIe that peristaItic movements of the diverticuIum in attempting to expeI its contents or an intrinsic mass couId be responsibIe for invagination. Such a chain of events is suggested by Atwood in a recent paper.g Hunt and BonesteeI Iist four such cases in their compiIation.” Ladd and GrosslO report that of 372 cases of intussusception occurring in chiIdren fourteen were associated with MeckeI’s diverticuIum. Another case of intussusception occurred in this series but there was no evidence that the diverticuIum in this case was more than an incidenta finding. There were four cases of voIvuIus (Cases I, 15, 20 and 33). In the Iast three a stalk was present running from the tip of the diverticuIum to the inner surface of the abdomina1 waI1 in the region of the umbiIicus about which Ioops of smal1 bowe1 had become twisted. Figure I shows the diverticuIum and staIk in Case 20. In case 15 the entire smaI1 intestine was twisted about the band. In Case I the voIvuIus invoIved a two-foot Ioop of termina1 iIeum. In the mid-point of this Ioop was an inflamed MeckeI’s diverticuIum but it cannot be ascertained from the operative
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DiverticuIum
FIG. I. Meckel’s diverticulum can be seen attached to the under surface of the umbiIicus; x, umbilicus; A, B and c, Meckel’s diverticuIum; X-Y, ileum.
note whether or not the diverticuIum was an integra1 part of the disorder. (Figs. 2, 3 and 4.) Disturbances as the resuIt of bands and adhesions are iIIustrated by Cases 8, 24 and 25. Case 8 is of interest in that the patient showed signs of obstruction eight days after the remova of an acute appendix and operation showed a MeckeI’s diverticuIum Iooped over the iIeum and compressing it. Two other points of obstruction, the resuIt of adhesions, were freed and the diverticuIum was Ieft in pIace because of the patient’s poor condition. Three months Iater the patient returned to the hospita1 compIaining of frequent crampy periumbiIica1 pains with nausea and vomiting. An operation reveaIed distention above the point of origin of the diverticuIum. Adhesions so distorted and kinked the iIeum that obstruction had resuIted. Resection of the Ioop bearing the diverticuIum was then carried out. In the other two cases the position of the diverticuIum so roIIed and kinked the iIeum that there was narrowing of the Iumen at the point of origin with symptoms of intermittent partia1 obstruction. In three cases a MeckeI’s diverticuIum was found in a hernia. In one case it was an incidenta finding but in Case 5 the pa-
tient had symptoms consistent with stranguIation and a Iarge, infarcted Meckel’s diverticuIum was the soIe content of the hernia1 sac. In Case 43 an omphaIoceIe was noted at birth and an operation carried out before the chiid was four hours oId. It was found that adhesion of a MeckeI’s diverticuIum to the waI1 of the cord prevented retraction of a Ioop of the iIeum. The diverticuIum was removed and the bowe1 restored. Group. MeckeI’s divertiDiverticulitis cuIum is subject -to inffammatory changes in much the same manner as the appendix but with this difference: The Iumen and ostium of the diverticuIum is usuaIIy greater than that of the appendix and obstructive types of inffammation are Iess frequent. Cases 16, 22 and 28 represent acute inffammation. Each had an abrupt, progressive history indistinguishabIe from appendicitis. One man had previousIy had his appendix removed and the diagnosis of acute diverticuIitis of MeckeI’s diverticuIum was made preoperativeIy. Chronic diverticuIitis as a diagnosis is about as unsatisfactory as the diagnosis of chronic Case 27 showed pathoIogic appendicitis. changes consistent with this diagnosis. The patient had had the history and physica signs usuaIIy associated with acute appen-
VOL. LXXVI.
MigIiaccio,
No. 1
Begg-MeckeI’s TABLE
Case No.
OBSTRUCTIVE
-
Type of Adhesions
Age
Symptoms
1[r tussusception
23
1[ntussusception
I5
5
VoIvulus
IO
20
v01vu1us
29
33
v01vu1us
9
8
Bands and adhesions
19
24
Bands and adhesions
26
25
Bands and adhesions
27
01f
54
Contents 01f omphalocele
hr:.
Contents hernia
43
-
GROUP
Operative Findings
?eriumbiIical 1Right lower pain with nausea L quadrant and vomiting spasm and tenderness
lleo-iIea1 intussusception with Meckel’s Ieading
v’omiting 24 hr.
lleocolic intussusception with MeckeI’s leading v01vu1us of 2 ft. Ioop of iIeum with gangrene
1Melenae, visible peristalsis
mo.
22
5
I9 I
PathoIogic Findings
RX.
‘_
1VolvuIus
I
A mericanJournalof Surgery
I
Signs
~~ 8
DiverticuIum
-
*ower abdomina1 cramps with nausea and vom iting 24 hr. Periumbilical cramps with vomiting 2 days
Right lower quadrant spasm and tenderness Right lower quadrant and periumbiIica1 tenderness and spasm ,Generalized spasm and tenderness; absent arisstaIsis
PeriumbiIicaI cramps and vomiting 24 hr.; attack 3 yr. before Periumbilical pain and vomiting; 2 previous attacks PeriumbilicaI pain and vomiting 4 days; 2 previous operations Episodes of right lower quadrant pain and nausea I mo. Episodes of epigastric pain, obstipation and nausea 5 yr.
Right Iower quadrant spasm and tenderness Negative
Right lower quadrant tenderness and spasm Tenderness and spasm to right of umbiIicus
Incarcerated hernia
IrreducibIe tender mass; inguina1 region
Omphalocele noted at birth
OmphaIoceIe noted at birth
-
Venous infarcLoop with tion; pancreatic c MeckeI’s diverticutissue Ium resected MeckeI’s Venous infarction; pancreatis c diverticuIum retissue sected Venous infarcLoop resected tion
Entire smaI1 bow,el formed volvulus about staIk of Meckel’
.Tissue Iost
Meckel’s diverticulum resected
VolvuIus of terminal ileum about MeckeI’s and its staIk
inff amAcute mation of Meckel’s diver ticulum
Meckel’s diverticulum resected
IIeum twisted about band running from Meek el’s to umbilicus Bowel at base of MeckeI’s kinked and rolled on mesentery; lumen small Tip of MeckeI’: heId down by fibrous band am ileum kinked Arose from latera aspect of ileum: iIeum kinked and Iumen nar. rowed
Chronic inflam- Meckel’s diverticumation of Ium reMeckeI’s diver ticuIum sected Peridiverticuliti s Loop with Meckel’s of Meckel’s didiverticuverticuIum Ium resected Meckel’s diver- Meckel’s diverticuticuIum lum resected MeckeI’s MeckeI’s diver. diverticuticuIum lum and loop of iIeum resected infarc :- Meckel’s Red swolIen Venous Meckel’s sole tion of Meckel’ 2 diverticucontents of her, Ium rediverticuIum niae sac sected Meckel’s adher. Tissue Iost Meckel’s ent to waI1 01 diverticusac, preventec Ium reretraction of sected ileum -
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DiverticuIum
AUGUST,
1948
2 3 FIG. 2. A plain film of the abdomen showing the presence of dilated loops of sma11 intestine which Ied to the making of serial studies of the small intestine. FIG. 3. Meckel’s diverticulum is present at the constricted area. The roentgenologist beIieved that this represented a retroperitoneal tumor which was encroaching on the Iumen of the termina1 ileum. Note the dilatation of the proximal loop.
TABLE
-
T
Operative Findings
PathoIogic Findings
Red, angry Meckel’s diverticuIum 4.2 cm by 1.2 cm.
Acute inflammation
Spasm and tenderness in right Iower quadrant; tender on right on recta1 examination
InfIamed diverticuIum Meckel’s 435 inches long
Acute inflammation
Spasm and tenderness in right Iower quadrant
InAamed Meckel’s diverticulum I .T cm long
Acute inflammation
MeckeI’s diverticuIum resected
Chronic tion
Meckel’s diverticuIum resected
Case No.
Age
Symptoms
16
$2
No history recorded
No history
22
41
28
9
Previous appendectomy; severe right Iower quadrant pain with nausea and vomiting 24 hr. abdomina1 Upper pain shifting to right lower quadrant 24 hr
Signs
recorded
Chronic 27
II
DIVERTICULITIS SimpIc Acute InA ammation
16
Right lower quadrant pain with nausea and vomiting 12 hr.
_1
RX.
Meckel’s diverticuIum resected Meckel’s diverticuIum resected
Inflammation
Spasm and tender- Large Meckel’s diness in right Iower verticulum packed quadrant; tender on with feces right on rectal examination
inff amma-
VOL. LXXVI.
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Migliaccio,
Begg-Meckel’s
dicitis. A MeckeI’s diverticuIum was found to be soIidIy packed with hard feca1 material. (TabIe II.) Heterotopic Group. Gastric mucosa, jejuna1, duodena1 or coIonic mucosa and pancreatic tissue may be found in MeckeI’s
DiverticuIum
A mericanJournalof Surgery 193
53 per cent; 74 per cent of these patients were under the age of fifteen. No statistics are to be found which iIIustrate the percentage of those patients having gastric mucosa in a diverticuIum who aIso have peptic uIceration. In addition to hemor-
FIG. 4. A, Meckel’s diverticulum hanging free in abdomina1 cavity; B, Meckel’s diverticuIum falling from the site of origin of its mesentery; note obstruction; c, Meckel’s diverticulum falling toward side of origin of its mescntery; no obstruction.
diverticuIum. Gastric mucosa is by far the most frequentIy found of those mentioned and is the onIy type consistently associated with symptoms. It is present in 16 per cent of a11 cases with MeckeI’s diverticuIum according to Schaetz.2 In children heterotopic gastric mucosa in the most frequent cause of symptoms; uIcer is the most frequent complication resuIting from this disorder. Cobb2 has reported a series of I IO cases showing uIceration in MeckeI’s diverticuIum associated with the presence of gastric mucosa. The uIcer usuaIIy occurred in the immediateIy adjacent iIea1 mucosa, that is, near the base of the diverticuIum. In Cobb’s series hemorrhage occurred in 72 per cent and perforation in
rhage and uIceration a third compIication is reported by Waugh et aI.12 These authors describe two patients in whom the scarring, resuIting from the uIceration, so reduced the Iumen of the adjacent bowe1 that obstruction resuIted. The mechanism of uIceration is discussed by Cobb2 and may be briefly summarized: Acid secretion of the gastric mucosa of the diverticuIum paraIIeIs that of the stomach; it, therefore, occurs at a time when the ileum Iacks the protection of neutraIizing food and secretions. Thus favorabIe conditions are found for uIceration. Acute perforation, comparabIe to that which occurs in the stomach, is found in
I94
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Begg-Meckel’s TABLE
Diverticuhm
III
HETEROTOPIC Case No.
Age
Symptoms
Operative Findings
Signs
Pathologic Findings
RX
_ Gastric 48
8 mo.
Anemia and z eoisodes of melena I
6
Right lower quadrant pain with vomiting, I day
3’
17
46
9
Crampy right lower quadrant pain spreading through abdomen 2 days, vomiting GeneraIized abdom inal pain with vomiting 12 hr.
49
24
Upper abdomina1 cramps 8 days; right lower quadrant pain, 20 hr.; no nausea, vomiting
I MeckeI’s
diverticuIum 1.7 by 1.6 cm.
Mucosa
10
17
21
I Ulcer
on oroxima1 edge of gastric mucosa Iining diverticulum
I Meckel’s diverticulum resected
with Ulcer and Perforation
Spasm and tenderFree fluid perforation ness in right lower of Meckel’s diverquadrant; tender or ticulum right on rectal examination Generalized spasm Free fluid; perforate< ulcer of MeckeI’s; and tenderness; recstaIk ran to umbiltal tenderness icus GeneraIized spasm and tenderness
Generalized spasm and right lower quadrant tendernes:
Gastric 14
with UIcer and Hemorrhage
I Pallor
Gastric 2
Mucosa
Mucosa
Perforation at tip of Meckel’s diverticuIum; free fluid in abdomen Free fluid in abdomen; perforation at base of Meckel’s diverticulum
without
Meckel’s diverticuIum lined with gastric mucosa; perforated uIcer near base MeckeI’s diverticuIum Iined with gastric mucosa; perforated uIcer near base MeckeI’s diverticuIum lined with gastric mucosa; ulcer at tip Gastric mucosa presuIcer perforent; ated at junction prox. and mid. +$
Meckel’s diverticuIum resected Meckel’s diverticuIum resected Meckel’s diverticulum resected MeckeI’s diverticulum resected
UIceration
Periumbilical pain with vomiting 48 hr.
Right Iower quadrant spasm and tenderness
Appendix acuteIy inAamed; Meckle’s diverticuIum present
Hirsutism
Hirsutism
Meckel’s diverticuIum found durexpl. Iaporotomy for casue of hirsutism
Acute appendicitis; MeckeI’s diverticuIum contained gastric mucosa in diverticulum of its own Gastric mucosa found in tip of MeckeI’s diverticulum
Meckle’s diverticuIum resected
Meckel’s diverticuIum resected
Pancreas 6
23
I5
5 mo.
Periumbilical with nausea vomiting
Vomiting,
pain and
24 hr.
Right Iower quadrant spasm and tenderness
IIeo-ilea intussusception with MeckeI’s diverticuIum Ieading
Venous Infarction; pancreatic tissue
MeIena, visibIe Peristalsis
IIeocoIic intussusception with Meckel’s diverticulum Ieadine:
Venous infarction; pancreatic tissue
Loop with MeckeI’s diverticuIum resected Meckel’s diverticuIum resected
CoIon Meckel’s
diverticu-
) ,!;~c;~~nccefrom
Meckel’s
( f;zhnt:ozth
diverticuco-
Meckel’s
( 5$x-
VOL. LXXVI, No. z
MigIiaccio,
Begg-MeckeI’s
MeckeI’s diverticuIum usuaIIy in the growing chiId under eighteen. Perforation in the older age group is rare. Gastric mucosa was present in seven of our cases and possibIy in an eighth. (TabIe III.) In Cases 14 and 17 there was no associated uIceration; in both of these cases the diverticuIum had given no symptoms and was an incidenta finding. One patient, Case 48, had uIceration with bIeeding and no perforation. This patient was an infant who was studied because of a severe bIood-Ioss type of anemia. The condition was suspected and proved at operation. Four cases and possibIy a fifth had gastric mucosa and peptic uIceration with perforation. These Cases are 2, 31, 46, 4g and 50. The Iast case cannot be incIuded StatisticaIIy, for the poor condition of the patient precIuded remova of the diverticuIum. A perforated uIcer was present, but the type of mucosa Iining the diverticuIum wiI1 not be known unti1 a second operation is performed for the remova1 of the diverticuIum. In none of the cases of perforation was there any cIue as to the origin of the perforation preoperativeIy. The patients presented themseIves with signs of perforation of a hoIIow viscus but with no signs which wouId IocaIize the site of the perforation. NoduIes of pancreatic tissue were present in MeckeI’s diverticuIum in our Cases 6 and 23; In both of these cases intussusception had occurred, with an invaginated diverticuIum as the Ieading point. A casua1 reIationship is suggested but cannot be proved. CoIon mucosa was present in the diverticuIum in Case 32. In this instance the finding of MeckeI’s diverticuIum was incidenta to other conditions and had no reIation to the patient’s illness. DIAGNOSIS
The diagnosis is rareIy made preoperativeIy with any degree of certainty. Symptoms are as varied as the compIications and are, in fact, the symptoms of the compIications. Patients in whom obstruction
DiverticuIum
A me&an Journal of Surgery 195
is the manifestation cannot be differentiated from those with obstruction due to other causes, nor can patients in whom perforation occurs be separated symptomaticaIIy from those with perforation of other hoIIow viscera. An exception might be made in the Iatter instance. Perforation of a MeckeI’s diverticulum has usuaIIy a Iess abrupt onset than perforation of a gastric or duodena1 uIceration and is Iess IikeIy to show the presence of air beneath the diaphragm. However, it cannot be distinguished from appendicea1 perforation unIess the appendix has been removed previousIy. In chiIdren peptic uIceration of Meckel’s diverticuIum is an important cause of intestina1 bIeeding, and such a diagnosis shouId be entertained in every case. X-ray has IittIe to offer diagnosticaIIy. According to PfahIer,13 the diagnosis was not made by x-ray prior to 1934. However, since the advent of seria1 studies of the smaI1 bowe1, the roentgenoIogists have on rare occasions been abIe to show the presence of residua1 barium in MeckeI’s diverticuIum. The cases in this series were reviewed with the intention of discovering any symptoms and signs which wouId Iead one to suspect a diagnosis of Meckel’s diverticuIum. No specific diagnostic criteria were found. TREATMENT
The treatment of choice is resection; an attempt should be made to take as wide a base as possibIe in an effort to remove a11 heterotopic tissue. This form of treatment was carried out in thirty-eight of our cases. In four cases the diverticuIum was invaginated by simpIe purse-string sutures. Two criticisms of this procedure may be made: First, it creates a poIypoid mass which may be the Ieading point of an intussusception aIthough no such cases have been reported; second, it may Ieave heterotopic tissue. In eight of our cases the diverticuIum was not removed. In four of these the process was extremeIy smaI1; the serious condition of the remaining .four
196
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patients precluded any more manipuIation than was absoIuteIy necessary. CONCLUSION
It has been the authors’ experience that the incidence of MeckeI’s diverticuIum has shown an increase paraIIeIing the diIigence with which it is sought. We note that the incidence in our series in which MeckeI’s diverticuIum actuaIIy caused the patient’s iIIness is considerabIy higher than the incidence in simiIar series. Perhaps the structure must IiteraIIy cry for attention before we seek it. More carefu1 search at operation may perhaps increase our percentage of “ incidental” Meckel’s diverticuIum but at the same time prevent future iIIness. The authors were surprised to discover that onIy one case in their series was an infant with melena as the result of peptic uIceration. This may, perhaps, indicate some Iaxity in the study of chiIdren with recurrent attacks of abdomina1 pain. We believe that any chiId with frequent attacks of abdomina1 pain which have never been so severe as to bring him to operation shouId be studied for melena. Any patient whose operative findings fai1 to substantiate the preoperative cIinica1 impressions shouId be considered as a prospective victum of MeckeI’s diverticuIum. SUMMARY
Fifty cases of MeckeI’s diverticuIum are presented and anaIyzed. The Iiterature is
DiverticuIum
AUGUST,
1948
consuIted for comparison of this series with the series of other authors. The embryoIogic background is brieffy given. The authors’ experience in dealing with these patients is summarized and suggestions are made for improvement in diagnosis and treatment. REFERENCES I. Cabot
Case 21441. UIcer of Meckel’s diverticuIum. New England J. Med., 213: 878-880, 1935. 2. Cabot Case 22101. Meckel’s diverticulum. New England J. Med., 214: 481-484, 1936. 3. Cabot Case 26052. Meckel’s diverticuIum with intestinal obstruction. New England J. Med., 222: 195-197, 1940. 4. CONRAD, H. A. Meckel’s Surg., 3: 267-274, 1941.
diverticuIum,
5. FRENCH, RALPH W. Meckel’s diverticulum. dale Hosp. Bull., Dec., 1931.
Am.
J.
Trues-
6. GOODMAN, B. A. Meckel’s diverticuIum, its incidence and significance in routine operations on the abdomen. Arch. Surg., 36: 144, 1938. 7. GREENBLATT, R. B., PUND, E. R. and CHANEY, R. H. MeckeI’s diverticuIum, and anaIysis of eight&n cases with reports of one tumor. Am. J. Surg., 3 I : 285-293, I 936. 8.
H. N. Intussusception due to invaginated MeckeI’s diverticulum, report of two cases with a study of 160 cases collected from the literature. Ann. Surg., 98: 1070-1099, 1933.
HARKINS,
9. PFAHLER, G. E. The roentgenological diagnosis of MeckeI’s diverticuIum. Surg., Gynec. u Oh., 109: 929334, 1934. IO. STEWART, G. A. The significance of Meckel’s diverticurum in the surgical abdomen. Rev. Gostroenterol., 7: 310-312, 1940. I I.
THOMPSON,
J. E. Meckel’s diverticulum.
Ann. Surg.,
55: 44-55. 1937. 12. WORMACK, N. A. and SIEGERT, R. B. SurgicaI aspects of lesions of MeckeI’s diverticulum. Ann. Swg., 58: 221-236, 1938.