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Meckel's diverticulum
MECKEL’S DIVERTICULUM HYMAN SNEIERSON, M.D. Binghamton, New York ECKEL’S diverticuIum as a chnical entity has been known since 1589 and it was not described adequately until 1809 by Meckel.9 According to Ladd and Gross7 a typica case arises from 35 cm to I M. above the ileocecal valve and must lie on the antimesenteric side of the intestine. Other diverticuli not conforming to the above are not true cases of MeckeI’s diverticuIum. The Iining of a MeckeI’s diverticulum which theoretically shouId be similar to that of the ileum actuaIly has aberrant but otherwise normal mucosa from other parts of the intestinal tract in a fairly Iarge percentage of cases (gastric, duodena1, coIonic and pancreatic). Malignancy, tubercuIosis, etc., may aIso occur.7 Gastric mucosa is especially important as the source of bleeding which is often the only presenting sign. As a result of the varying types of anomalies both in the size, shape and attachment of the diverticulum, as we11 as the aforementioned variations in the mucosa, the clinical signs may differ greatIy. The picture may be that of hemorrhage, inflammation and/or intestina1 obstruction. Symptoms referabIe to a Meckel’s diverticuIum may occur at any age. Cases have been reported varying from the age of five hours’ to seventy-seven years.” According to Ladd and Gross they are more apt to occur early in life (45 per cent being under two years) but this does not correspond to series in other hospitals. The sex incidence is usuahy reported as being twice as common in mares. The incidence of Meckel’s diverticuIum in a Iarge number of autopsies varied from .9 to 2.7 per cent.4 The percentage in operative reports, however, is naturahy much Iower since examination of the ileum is not indicated in many abdominal operations. June,
1930
CompIications in a Meckel’s -diverticuIum sufficient to cause troubIe are not common as is evident by the fact that in ro,ooo Iaparotomies 0nIy fifteen cases were reported in one series and onIy three in another of 14,000 .4 Reports on MeckeI’s diverticulum are usuaIIy of patients with compIications and are not a true indication of the percentage present in the body. Haber reports twenty-three patients over an eight-year period in a genera1 hospital. Ladd and Gross report seventy-three patients but do not give the exact number of years during which these were cohected. From the previousIy mentioned and similar reports it is evident that the average surgeon wiI1 see few of these unIess he carefuliy examines the termina1 iIeum in each case. The cIinica1 signs and symptoms are not pathognomonic of MeckeI’s diverticulum with the exception of hemorrhage which, in the absence of other causes, may Iead to the correct diagnosis. Since the presence of heterotopic tissue varies from 16 to 30 per cent and not a11 of these contain gastric mucosa, it is evident that most patients wiI1 not be diagnosed. The most common complicatrons are in Aammation and obstruction. The inff ammation may vary from a simpIe catarrhal type to an acute perforation with peritonitis. The obstruction may be due to a fibrotic band, to voIvuIus or to intussusception, of which the MeckeI’s diverticuIum is the starting point. Intussusception is particuIarIy prone in a diverticutum which is short and broad and therefore tends to become inverted.7 From this it is evident that the diagnosis wiI1 as a ruIe be made only at operation. In twenty years of experience on a surgica1 service we have been struck by the eagerness and frequency with which our 765
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house staff has made a primary diagnosis of Meckel’s diverticulum, often overIooking the more obvious and correct one, usuahy appendicitis. The operation at which a Meckel’s diverticuIum is found is generaIIy for some inflammatory process, usuaIIy diagnosed appendicitis, or for intestina1 obstruction of varying degrees. Thus the correct treatment is accorded the patient because of symptoms of abdomina1 pathoIogic disorder without indication of the true cause. AnaIysis of a11 cases in ten and a haIf years (January, 1936, to July, 1947) in the Binghamton City HospitaI (500 beds) reveaIed onIy two cases in which a preoperative diagnosis of MeckeI’s diverticulum was made. In one of these, reported in the obstruction group, recurring attacks of pain of an indeterminate nature caused the surgeon to mention the diagnosis. The presence of a Meckel’s diverticuIum, however, pIayed IittIe or no part in the pathoIogic disorder tound and, therefore, the correct diagnosis was not important. The first patient, a maIe aged twentytwo, (admitted October 27, 1946, discharged November IO, 1946) had a history of recurring attacks of right sided pain with passing of blood by rectum during some of these attacks since the age of seven. The attacks occurred about every six months for several years and then once every one or two years. About five months prior to this admission he had been hospitaIized for an attack of abdomina1 pain accompanied by persistent vomiting which was relieved by the use of a Miller-Abbott tube. No bIood was passed at this time. He had had a compIete work-up, incIuding gaIIbIadder, gastrointestina1 and renaI studies during the various admissions with negative findings. This admission was for miId constant soreness in the right side onIy. There was no nausea, vomiting or bIood in the stoo1. His temperature was normaI. BIood studies were compIeteIy normaI. Examination showed no cause for pain. The diagnosis of MeckeI’s diverticuIum was made by us entireIy on the history and was substantiated at operation.
DiverticuIum The diverticuIum was about 2 cm. in diameter and adherent to the posterior peritoneum. MicroscopicaIIy, it was Iined with gastric mucosa which expIained the recurrent bouts of bIeeding. The persistent pain and symptoms of obstruction can onIy be expIained on the basis of torsion about that part of the iIeum which was fixed. In this patient the correct diagnosis wouId have obviated a great deal of suffering as we11 as expense. This was the onIy instance in ten years in our hospita1 and in twenty years in our persona1 experience with MeckeI’s diverticuIum in which the correct diagnosis was necessary for adequate treatment. We next questioned the frequency of MeckeI’s diverticulum in cases of indeterminate abdomina1 pain with negative clinica findings from a diagnostic viewpoint. Two such cases were present in our series. In one, a maIe aged forty-nine, (admitted February 6, 1940, discharged March I I, 1940) admission was for possibIe gastrointestina1 malignancy. He had muItipIe compIaints such as constipation, crampy feeling in the abdomen, pain in the epigastrum after meals, etc., for a period of years. PhysicaI and Iaboratory examinations were normaI. An expIoratory Iaparotomy was done which reveaIed a small Meckel’s diverticulum as the only possible cause for his compIaints. It was removed as we11 as a normal appendix. The microscopic report of the MeckeI’s diverticuIum showed normal iIea1 mucosa. This patient has been comparativeIy we11 since then. We cannot see any direct connection between the MeckeI’s diverticuIum and either the symptoms or the reIief obtained aside from the psychic one. The second patient, a female aged twenty-four, (admitted May 27, 194 I, discharged June 8, 1941) was admitted with generaIized pain in the abdomen and nausea of two weeks’ duration. She was pregnant three months. At operation a shaIIow diverticuIum with a base 2 cm. Iong was found and removed as we11 as a normal appendix. No acute pathoIogic disorder was present microscopicaIIy. Here American
Journal of Surgery
Sneierson-Meckel’s again the connection between the symptoms and the pathoIogic condition found is very questionabIe. We cannot see any Iogical connection between the presence of an uncomplicated Meckel’s diverticulum and abdomina1 pain or vague gastrointestinal symptoms. The diagnosis if made wouId add IittIe to the treatment except to crystalhze the desire for expIoration. Another question was whether an inactive but potentiaIIy pathoIogic condition of a MeckeI’s diverticuIum couId cause troubIe as a result of other intestina1 or abdomina1 causes such as iIeus (postoperative), inflammation or from any other factors. Our series presents two cases in this category. The first patient, maIe aged tweIve, (admitted May 22, 1938, discharged June I, 1938) was admitted for pain in the abdomen and symptoms suggesting an acute obstruction. An appenditeal abscess had been drained four months previousIy. At operation extensive adhesions of the omentum to the oId operative scar were found. In the region of the right kidney there was a thick fibrotic band extending from the base of the diverticulum to the peritoneum in the upper Iumbar region and under this a Ioop of ileum was caught resuIting in the obstruction. The band was cut and the diverticuIum was removed. The appendix was aIso removed and the adhesions noted before were cut. The MeckeI’s diverticuIum showed a Iining identical with stomach mucosa. The band without a doubt was present prior to the drainage operation. Thus it must be inferred that something had changed in the area fohowing this procedure aIlowing the iIeum to become obstructed. The aberrant stomach tissue caused no symptoms and cannot in any way have contributed to the obstruction. In view of the deIayed obstruction an acute infIammatory process couId have initiated the changes. The second patient, a maIe aged fifty-one (admitted October I 7, 1939, discharged June,
1950
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December I 6, 1939), had had a choIecystectomy. The procedure was difhcuIt and postoperative convaIescence was stormy. A severe iIeus developed which responed to the MiIler-Abbott tube but which recurred upon its remova1. A diagnosis of intestina1 obstruction due to adhesions was made and expIoration was done on the tweIfth postoperative day. A Meckel’s diverticuIum about 235 cm. in diameter and 3 cm. long was found from which a fibrous band Ied to the cecum just below the iIeoceca1 junction. Under this band was a Ioop of bowel about 32 cm. long which was pinched off forming a typica cIosed Ioop of the termina1 iIeum. The appendix was normaI. Here again the primary Meckel’s diverticulum and band had been present prior to the initial surgery. The iIeus had caused enlargement of the bowel which ordinariry might slip in and out of the opening under the band. The resuIting obstruction was reIieved by the MiIIer-Abbott tube. Why this recurred after each drainage cannot be stated. It may be that the Ioop once caught was never compIeteIy decompressed enough to aIIow it to sIip out. The previousIy described cases demonstrate cIearIy that bands from any cause are potentia1 causes of obstruction. However, in the absence of such signs we cannot see how the presence of a Meckel’s diverticuIum with a band can be suspected. Also, we cannot see that it matters whether the band causing the obstruction is from a diverticulum or from any other organ or cause. A third question was whether Meckel’s diverticulum is as common a cause of obstruction as one would infer from the Iiterature.4 Besides the aforementioned, four other cases causing obstructive symptoms were encountered. The first patient, a female (admitted January 29, aged thirty-nine, 1945, died February 19, 1945) had a history of a similar attack three years before admission. She had a typica history of intermittent, severe abdomina1 cramps increasing in severity over a four-day period and
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accompanied by nausea, vomiting and distention. There had been no previous operations. She was treated with several intestinal drainages by a Miller-Abbott tube with relief each time foIIowed by recurring symptoms necessitating its reinsertion. On the tweIfth day after admission she went into shock. An emergency operation demonstrated a complete severance of the iIeum with severa perforations on the antimesenteric area in the proxima1 portion. The exact pathoIogic disorder was not determined but the surgeon believed it to have been secondary to a MeckeI’s diverticuIum with constriction of the bowe1. This patient beIonged to a cult which did not believe in surgery and refused operation until it was too late. No autopsy couId be obtained. The diagnosis of MeckeI’s diverticuium was unimportant in this case. Intestinal obstruction is an adequate diagnosis for warranting surgery. The second patient, a femaIe, aged thirty-four, (admitted February 28, 1943, discharged March 20, 1943) had a history of attacks of abdominal pain suggesting regional ileitis. At operation an acute catarrha1 appendicitis was found. The terminal ileum was thickened and there was a MeckeI’s diverticulum about 12 cm. above the ileocecal valve. This and the appendix were removed and an ileotransverse coIostomy with exclusion of terminal ileum was performed. The microscopic report showed no evidence of iIeitis and no aberrant tissue in the Meckel’s diverticuIum. The Meckel’s diverticulum obviously pIayed no part in the pathoIogic disorder found at operation. Why an acute inffammation of the appendix shouId have been found with such a history and with no acute symptoms is a question. A follow-up of four years shows apparent compIete relief. It may we11 have been an earIy ileitis; but since there was no specimen of the terminal ileum removed, it cannot be proven. The third patient, a female aged thirtysix, (admitted January 26, 194-0, dis-
Diverticulum charged February g, 1940) was admitted with a temperature of IO 1“~. compIaining of pain in the left upper quadrant with vomiting of twenty-four hours’ duration and a history of irreguIar bowe1 habits for the past week. At operation a MeckeI’s diverticuIum was found 60 cm. from the ileocecal junction. It was 235 cm. in diameter and 13 cm. Iong with the tip adherent to the mesentery forming a Ioop or band with the terminal 60 cm. of iIeum strangulated beneath it. The MeckeI’s diverticulum was removed and showed a catarrha1 diverticuIitis. The appendix was not removed. The fourth patient, a male aged twentyfive, (admitted May 2, 1936, discharged 1936) was operated upon for May 25, chronic appendicitis. At operation obstruction of the termina1 iIeum due to an adherent, strangulating type of Meckel’s diverticulum was found. The microscopic report was an acute catarrhal diverticulitis. Again, the presence of an acute condition in a patient with a chronic compIaint is hard to explain. There is no question of the partial obstruction but it is hard to infer a recurring inflammatory process. ProbabIe aggravation of the existing symptoms caused the patient to seek surgica1 rehef. The question whether Ieaving a Meckel’s diverticulum behind carries with it any morbidity or mortaIity was next investigated. In generaI, it is evidently true that such is not the case. In our smaI1 series two such cases were encountered. The first patient, a femaIe aged sixteen, (admitted JuIy IO, rgq.0, discharged August 3, 1940) had a history of intermittent attacks of right sided pain fohowing an appendectomy four years previousIy. The pain had been severe and constant for severa days prior to admission. At operation a MeckeI’s diverticuIum was found about 60 cm. above the ileoceca1 junction. It had a broad base and tip. Some omenta1 adhesions were bound to the oId operative scar. No bowel was invoIved in these The pathologic report was adhesions. American
Journal
of Surgery
Sneierson-Meckel’s chronic inflammation in a Meckel’s diverticulum. The role played by the Meckel’s diverticulum is subject to question but the patient has been well to date. The appendix had been removed with a diagnosis of acute appendicitis but a carcinoid of the tip with onIy moderate chronic inff ammation was found microscopicaIIy. The second patient, a female aged thirtysix, (admitted March 8, 1937, discharged March 29, 1937) had had an appendectomy twelve years before admission. Her chief complaint was of pain in the operative area of five weeks’ duration aggravated by being on her feet. She had been having such attacks off and on for five years but with increasing frequency in the Iast year. At operation dense adhesions to the old operative scar were found and a MeckeI’s diverticuhrm 3 35 cm. long and 135 cm. in diameter at the base was found about 50 cm. from the cecum. The adhesions were released and the diverticulum removed. No record of the appendectomy operation was nvaiIable. The cause of the pain is questionabIe. No aberrant tissue was present in the diverticulum and there were no indications of obstruction. The report was “chronic catarrhal diverticulitis in lumen and acute inAammation in serosa and subserosa.” It is diffrcuIt to accept a recurring inffammatory process of this sort as an active cause in a patient with such a Iong history. The roIe of adhesions without obstruction as a cause of pain is also a debatable one. However, the patient has been relieved of her symptoms to a great extent. The report of two cases cannot be taken as a reason for removing a11 Meckel’s diverticuli when found. A negative reason for so doing lies in the fact that no increase in the morbidity or mortality occurred when this was done (5 patients out of twenty-four). Also, our patients cannot be the only ones with recurring symptoms after appendectomy in whom subsequent exploration demonstrates the presence of a MeckeI’s diverticulum. contraIn this respect, the somewhat June,
1950
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dictory statements of two authorities are of interest. Mayo and Remington8 state, “ If a norma appearing MeckeI’s diverticuIum is found which is smaI1, is unattached to the abdomina1 waII or to other organs, and has an adequate Iumen, it should not be removed.” Ladd and Gross7 state, “A diverticuIum which has not given rise to symptoms but which is discovered during the course of a Iaparotomy for some other Iesion should be excised if the condition of the patient is satisfactory.” The latter beIieve that a MeckeI’s diverticulum is a potentia1 source of future trouble. Our findings Iead us to side with Ladd and Gross. The next question was the frequency of acute inflammation in a Meckel’s diverticuIum. Six cases were reported cIinicaIIy as acute diverticulitis. Of these only three showed advanced inflammatory pathologic disorders microscopicaIIy. Two of them were classed as acute suppurative diverticulitis and one showed a total hemorrhagic infarction of the diverticuIum. The convaIescence in one of these patients was stormy as obstruction occurred following a primary resection necessitating further surgery. Th e other three patients showed a chronic inflammatory condition pathoIogicaIIy. AI1 these patients were operated upon with the diagnosis of acute appendicitis. Five other patients were operated upon with the diagnosis of chronic appendicitis. COMMENTS
We have carefuhy anaIyzed twenty-four cases of MeckeI’s diverticuhrm occurring in a genera1 hospita1 with 500 beds. During this period, approximately I I ,000 abdominal patients were operated upon which corresponds in general with the incidence found elsewhere. Our age incidence corresponded with that usually found in the Iiterature being between the ages of three and fifty-seven. The usual male-female ratio was reversed, however, in that there were ten maIes and
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fourteen femaIes. The diverticuhrm was removed in a11 but one case when it was inverted. The appendix was aIso removed in a11 but two cases both of these being acute intestina1 obstructions. The most common causes of troubIe were inflammation (six out of nineteen primary operations or 31.4 per cent) and obstruction (six out of nineteen cases or 31.5 per eent). Of the obstructive patients peritonitis deveIoped in one with a fata outcome. Five cases were in patients in whom the surgery was for some pelvic pathoIogic condition and the MeckeI’s diverticuIum was an incidental finding. Two operations were for pain foIIowing previous appendectomy. Four other cases were cIassed as chronic recurrent appendicitis. There was one additiona case so diagnosed which is inchrded in the six obstruction cases. The correct diagnosis was made in onIy one case. Analysis of this series as a whole is enIightening. The correct treatment was carried out in eighteen of the nineteen primary cases without regard to the correct diagnosis. The indications were for surgica1 intervention and a knowIedge that a diverticuhrm was present wouId not have inffuenced the treatment. In onIy one case, a typica one of bIeeding with symptoms which are pathognomonic of a MeckeI’s diverticuIum, was a correct diagnosis necessary before proper treatment couId be rendered. This demonstrates that MeckeI’s diverticulum is an important clinica entity in the morbidity and mortahty of abdominal surgery and warrants the attention given it. However, it aiso substantiates our premise that the diagnosis of MeckeI’s diverticulum will be made most commonly in the course of an abdomina1 exploration for an inAammatory process, usuaIly appendicitis or for intestina1 obstruction, and that stress shouId be Iaid upon this fact in teaching. Unless there is bIeeding or unIess x-ray studies show its presence, the diagnosis per se wiI1 not be made. WhiIe the
Diverticulum preoperative knowIedge of the presence of a MeckeI’s diverticuIum may be a diagnostic triumph, in actuaI practice the abiIity to recognize an acute abdomen is the important thing. SUMMARY I. A brief resume of the present knowledge of Meckel’s diverticuIum has been presented and twenty-four additional cases added to the Iiterature. 2. The thesis that these patients wiI1 rareIy be diagnosed preoperativeIy has been proven and the fact that these will aImost invariably be found at operation for an acute abdomen, usuaIIy appendicitis or intestinal obstruction, has been demonstrated. 3. Stress shouId be Iaid upon this fact in order that the young surgeon aIways examines the terminal ileum for a Meckel’s diverticuIum in a11 cases of abdomina1 pain or obstruction in which the presenting pathologic condition does not compIeteIy answer the cIinica1 picture. REFERENCES I. AREY, LESLIE R. Developmental Anatomy. 5th ed., Philadelphia, 1946. W. B. Saunders Co. 2. CHRISTIE, A. Meckel’s diverticuIum; pathoIogic study of sixty-three cases. Am. J. Dis. Cbild., 42: 544-553. 1931. 3. GRAY, 1-I. Anatomy of the Human Body. 24th ed. PhiIadeIphia, 1942. Lea & Febiger. 4. HABER, J. J. MeckeI’s diverticuIum; review of literature and anaIytica1 study of twenty-three cases with particuIar reference to bowe1 obstruction. Am. J. Swg., 73: 468-486, 1947. 5. HALLENDORF,L. C. and LOVELACE,W. R. Aberrant gastric mucosa and pancreatic tissue in a bleeding Meckel’s diverticuIum; report of a case. Proc. Staff Meet., Mayo C/in., 22: 53-55, 1947, 6. KI-~TLE, C. F., JENKINS, H. P. and DRAGSTEDT,L. R. Patent omphalomesenteric duct and its reIation to the diverticulum of Meckel. Arch. Surg., 54: 10-36 1947. 7. LADD, W. E. and GROSS, R. E. AbdominaI Surgery in Infancy and Childhood. Philadelphia, 1941. W. B. Saunders Co. 8. MAYO, C. W. and REMINGTON,J. H. Acute surgical conditions of the abdomen; congenital lesions. Am. J. .Surg.,.77: 841-859, 1946. 9. MECKEL, J. F. Uber die Divertike am Darmkanal. Arch. f. d. Pbysiol., 9: 421, 1809. IO. WANGENSTEEN, OWEN H. IntestinaI Obstructions. 2nd ed. Springfield, III., 1942.Charles C. Thomas.
American
Journal of Surgery
1930
CompIications in a Meckel’s -diverticuIum sufficient to cause troubIe are not common as is evident by the fact that in ro,ooo Iaparotomies 0nIy fifteen cases were reported in one series and onIy three in another of 14,000 .4 Reports on MeckeI’s diverticulum are usuaIIy of patients with compIications and are not a true indication of the percentage present in the body. Haber reports twenty-three patients over an eight-year period in a genera1 hospital. Ladd and Gross report seventy-three patients but do not give the exact number of years during which these were cohected. From the previousIy mentioned and similar reports it is evident that the average surgeon wiI1 see few of these unIess he carefuliy examines the termina1 iIeum in each case. The cIinica1 signs and symptoms are not pathognomonic of MeckeI’s diverticulum with the exception of hemorrhage which, in the absence of other causes, may Iead to the correct diagnosis. Since the presence of heterotopic tissue varies from 16 to 30 per cent and not a11 of these contain gastric mucosa, it is evident that most patients wiI1 not be diagnosed. The most common complicatrons are in Aammation and obstruction. The inff ammation may vary from a simpIe catarrhal type to an acute perforation with peritonitis. The obstruction may be due to a fibrotic band, to voIvuIus or to intussusception, of which the MeckeI’s diverticuIum is the starting point. Intussusception is particuIarIy prone in a diverticutum which is short and broad and therefore tends to become inverted.7 From this it is evident that the diagnosis wiI1 as a ruIe be made only at operation. In twenty years of experience on a surgica1 service we have been struck by the eagerness and frequency with which our 765
766
Sneierson-MeckeI’s
house staff has made a primary diagnosis of Meckel’s diverticulum, often overIooking the more obvious and correct one, usuahy appendicitis. The operation at which a Meckel’s diverticuIum is found is generaIIy for some inflammatory process, usuaIIy diagnosed appendicitis, or for intestina1 obstruction of varying degrees. Thus the correct treatment is accorded the patient because of symptoms of abdomina1 pathoIogic disorder without indication of the true cause. AnaIysis of a11 cases in ten and a haIf years (January, 1936, to July, 1947) in the Binghamton City HospitaI (500 beds) reveaIed onIy two cases in which a preoperative diagnosis of MeckeI’s diverticulum was made. In one of these, reported in the obstruction group, recurring attacks of pain of an indeterminate nature caused the surgeon to mention the diagnosis. The presence of a Meckel’s diverticuIum, however, pIayed IittIe or no part in the pathoIogic disorder tound and, therefore, the correct diagnosis was not important. The first patient, a maIe aged twentytwo, (admitted October 27, 1946, discharged November IO, 1946) had a history of recurring attacks of right sided pain with passing of blood by rectum during some of these attacks since the age of seven. The attacks occurred about every six months for several years and then once every one or two years. About five months prior to this admission he had been hospitaIized for an attack of abdomina1 pain accompanied by persistent vomiting which was relieved by the use of a Miller-Abbott tube. No bIood was passed at this time. He had had a compIete work-up, incIuding gaIIbIadder, gastrointestina1 and renaI studies during the various admissions with negative findings. This admission was for miId constant soreness in the right side onIy. There was no nausea, vomiting or bIood in the stoo1. His temperature was normaI. BIood studies were compIeteIy normaI. Examination showed no cause for pain. The diagnosis of MeckeI’s diverticuIum was made by us entireIy on the history and was substantiated at operation.
DiverticuIum The diverticuIum was about 2 cm. in diameter and adherent to the posterior peritoneum. MicroscopicaIIy, it was Iined with gastric mucosa which expIained the recurrent bouts of bIeeding. The persistent pain and symptoms of obstruction can onIy be expIained on the basis of torsion about that part of the iIeum which was fixed. In this patient the correct diagnosis wouId have obviated a great deal of suffering as we11 as expense. This was the onIy instance in ten years in our hospita1 and in twenty years in our persona1 experience with MeckeI’s diverticuIum in which the correct diagnosis was necessary for adequate treatment. We next questioned the frequency of MeckeI’s diverticulum in cases of indeterminate abdomina1 pain with negative clinica findings from a diagnostic viewpoint. Two such cases were present in our series. In one, a maIe aged forty-nine, (admitted February 6, 1940, discharged March I I, 1940) admission was for possibIe gastrointestina1 malignancy. He had muItipIe compIaints such as constipation, crampy feeling in the abdomen, pain in the epigastrum after meals, etc., for a period of years. PhysicaI and Iaboratory examinations were normaI. An expIoratory Iaparotomy was done which reveaIed a small Meckel’s diverticulum as the only possible cause for his compIaints. It was removed as we11 as a normal appendix. The microscopic report of the MeckeI’s diverticuIum showed normal iIea1 mucosa. This patient has been comparativeIy we11 since then. We cannot see any direct connection between the MeckeI’s diverticuIum and either the symptoms or the reIief obtained aside from the psychic one. The second patient, a female aged twenty-four, (admitted May 27, 194 I, discharged June 8, 1941) was admitted with generaIized pain in the abdomen and nausea of two weeks’ duration. She was pregnant three months. At operation a shaIIow diverticuIum with a base 2 cm. Iong was found and removed as we11 as a normal appendix. No acute pathoIogic disorder was present microscopicaIIy. Here American
Journal of Surgery
Sneierson-Meckel’s again the connection between the symptoms and the pathoIogic condition found is very questionabIe. We cannot see any Iogical connection between the presence of an uncomplicated Meckel’s diverticulum and abdomina1 pain or vague gastrointestinal symptoms. The diagnosis if made wouId add IittIe to the treatment except to crystalhze the desire for expIoration. Another question was whether an inactive but potentiaIIy pathoIogic condition of a MeckeI’s diverticuIum couId cause troubIe as a result of other intestina1 or abdomina1 causes such as iIeus (postoperative), inflammation or from any other factors. Our series presents two cases in this category. The first patient, maIe aged tweIve, (admitted May 22, 1938, discharged June I, 1938) was admitted for pain in the abdomen and symptoms suggesting an acute obstruction. An appenditeal abscess had been drained four months previousIy. At operation extensive adhesions of the omentum to the oId operative scar were found. In the region of the right kidney there was a thick fibrotic band extending from the base of the diverticulum to the peritoneum in the upper Iumbar region and under this a Ioop of ileum was caught resuIting in the obstruction. The band was cut and the diverticuIum was removed. The appendix was aIso removed and the adhesions noted before were cut. The MeckeI’s diverticuIum showed a Iining identical with stomach mucosa. The band without a doubt was present prior to the drainage operation. Thus it must be inferred that something had changed in the area fohowing this procedure aIlowing the iIeum to become obstructed. The aberrant stomach tissue caused no symptoms and cannot in any way have contributed to the obstruction. In view of the deIayed obstruction an acute infIammatory process couId have initiated the changes. The second patient, a maIe aged fifty-one (admitted October I 7, 1939, discharged June,
1950
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December I 6, 1939), had had a choIecystectomy. The procedure was difhcuIt and postoperative convaIescence was stormy. A severe iIeus developed which responed to the MiIler-Abbott tube but which recurred upon its remova1. A diagnosis of intestina1 obstruction due to adhesions was made and expIoration was done on the tweIfth postoperative day. A Meckel’s diverticuIum about 235 cm. in diameter and 3 cm. long was found from which a fibrous band Ied to the cecum just below the iIeoceca1 junction. Under this band was a Ioop of bowel about 32 cm. long which was pinched off forming a typica cIosed Ioop of the termina1 iIeum. The appendix was normaI. Here again the primary Meckel’s diverticulum and band had been present prior to the initial surgery. The iIeus had caused enlargement of the bowel which ordinariry might slip in and out of the opening under the band. The resuIting obstruction was reIieved by the MiIIer-Abbott tube. Why this recurred after each drainage cannot be stated. It may be that the Ioop once caught was never compIeteIy decompressed enough to aIIow it to sIip out. The previousIy described cases demonstrate cIearIy that bands from any cause are potentia1 causes of obstruction. However, in the absence of such signs we cannot see how the presence of a Meckel’s diverticuIum with a band can be suspected. Also, we cannot see that it matters whether the band causing the obstruction is from a diverticulum or from any other organ or cause. A third question was whether Meckel’s diverticulum is as common a cause of obstruction as one would infer from the Iiterature.4 Besides the aforementioned, four other cases causing obstructive symptoms were encountered. The first patient, a female (admitted January 29, aged thirty-nine, 1945, died February 19, 1945) had a history of a similar attack three years before admission. She had a typica history of intermittent, severe abdomina1 cramps increasing in severity over a four-day period and
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accompanied by nausea, vomiting and distention. There had been no previous operations. She was treated with several intestinal drainages by a Miller-Abbott tube with relief each time foIIowed by recurring symptoms necessitating its reinsertion. On the tweIfth day after admission she went into shock. An emergency operation demonstrated a complete severance of the iIeum with severa perforations on the antimesenteric area in the proxima1 portion. The exact pathoIogic disorder was not determined but the surgeon believed it to have been secondary to a MeckeI’s diverticuIum with constriction of the bowe1. This patient beIonged to a cult which did not believe in surgery and refused operation until it was too late. No autopsy couId be obtained. The diagnosis of MeckeI’s diverticuium was unimportant in this case. Intestinal obstruction is an adequate diagnosis for warranting surgery. The second patient, a femaIe, aged thirty-four, (admitted February 28, 1943, discharged March 20, 1943) had a history of attacks of abdominal pain suggesting regional ileitis. At operation an acute catarrha1 appendicitis was found. The terminal ileum was thickened and there was a MeckeI’s diverticulum about 12 cm. above the ileocecal valve. This and the appendix were removed and an ileotransverse coIostomy with exclusion of terminal ileum was performed. The microscopic report showed no evidence of iIeitis and no aberrant tissue in the Meckel’s diverticuIum. The Meckel’s diverticulum obviously pIayed no part in the pathoIogic disorder found at operation. Why an acute inffammation of the appendix shouId have been found with such a history and with no acute symptoms is a question. A follow-up of four years shows apparent compIete relief. It may we11 have been an earIy ileitis; but since there was no specimen of the terminal ileum removed, it cannot be proven. The third patient, a female aged thirtysix, (admitted January 26, 194-0, dis-
Diverticulum charged February g, 1940) was admitted with a temperature of IO 1“~. compIaining of pain in the left upper quadrant with vomiting of twenty-four hours’ duration and a history of irreguIar bowe1 habits for the past week. At operation a MeckeI’s diverticuIum was found 60 cm. from the ileocecal junction. It was 235 cm. in diameter and 13 cm. Iong with the tip adherent to the mesentery forming a Ioop or band with the terminal 60 cm. of iIeum strangulated beneath it. The MeckeI’s diverticulum was removed and showed a catarrha1 diverticuIitis. The appendix was not removed. The fourth patient, a male aged twentyfive, (admitted May 2, 1936, discharged 1936) was operated upon for May 25, chronic appendicitis. At operation obstruction of the termina1 iIeum due to an adherent, strangulating type of Meckel’s diverticulum was found. The microscopic report was an acute catarrhal diverticulitis. Again, the presence of an acute condition in a patient with a chronic compIaint is hard to explain. There is no question of the partial obstruction but it is hard to infer a recurring inflammatory process. ProbabIe aggravation of the existing symptoms caused the patient to seek surgica1 rehef. The question whether Ieaving a Meckel’s diverticulum behind carries with it any morbidity or mortaIity was next investigated. In generaI, it is evidently true that such is not the case. In our smaI1 series two such cases were encountered. The first patient, a femaIe aged sixteen, (admitted JuIy IO, rgq.0, discharged August 3, 1940) had a history of intermittent attacks of right sided pain fohowing an appendectomy four years previousIy. The pain had been severe and constant for severa days prior to admission. At operation a MeckeI’s diverticuIum was found about 60 cm. above the ileoceca1 junction. It had a broad base and tip. Some omenta1 adhesions were bound to the oId operative scar. No bowel was invoIved in these The pathologic report was adhesions. American
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of Surgery
Sneierson-Meckel’s chronic inflammation in a Meckel’s diverticulum. The role played by the Meckel’s diverticulum is subject to question but the patient has been well to date. The appendix had been removed with a diagnosis of acute appendicitis but a carcinoid of the tip with onIy moderate chronic inff ammation was found microscopicaIIy. The second patient, a female aged thirtysix, (admitted March 8, 1937, discharged March 29, 1937) had had an appendectomy twelve years before admission. Her chief complaint was of pain in the operative area of five weeks’ duration aggravated by being on her feet. She had been having such attacks off and on for five years but with increasing frequency in the Iast year. At operation dense adhesions to the old operative scar were found and a MeckeI’s diverticuhrm 3 35 cm. long and 135 cm. in diameter at the base was found about 50 cm. from the cecum. The adhesions were released and the diverticulum removed. No record of the appendectomy operation was nvaiIable. The cause of the pain is questionabIe. No aberrant tissue was present in the diverticulum and there were no indications of obstruction. The report was “chronic catarrhal diverticulitis in lumen and acute inAammation in serosa and subserosa.” It is diffrcuIt to accept a recurring inffammatory process of this sort as an active cause in a patient with such a Iong history. The roIe of adhesions without obstruction as a cause of pain is also a debatable one. However, the patient has been relieved of her symptoms to a great extent. The report of two cases cannot be taken as a reason for removing a11 Meckel’s diverticuli when found. A negative reason for so doing lies in the fact that no increase in the morbidity or mortality occurred when this was done (5 patients out of twenty-four). Also, our patients cannot be the only ones with recurring symptoms after appendectomy in whom subsequent exploration demonstrates the presence of a MeckeI’s diverticulum. contraIn this respect, the somewhat June,
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dictory statements of two authorities are of interest. Mayo and Remington8 state, “ If a norma appearing MeckeI’s diverticuIum is found which is smaI1, is unattached to the abdomina1 waII or to other organs, and has an adequate Iumen, it should not be removed.” Ladd and Gross7 state, “A diverticuIum which has not given rise to symptoms but which is discovered during the course of a Iaparotomy for some other Iesion should be excised if the condition of the patient is satisfactory.” The latter beIieve that a MeckeI’s diverticulum is a potentia1 source of future trouble. Our findings Iead us to side with Ladd and Gross. The next question was the frequency of acute inflammation in a Meckel’s diverticuIum. Six cases were reported cIinicaIIy as acute diverticulitis. Of these only three showed advanced inflammatory pathologic disorders microscopicaIIy. Two of them were classed as acute suppurative diverticulitis and one showed a total hemorrhagic infarction of the diverticuIum. The convaIescence in one of these patients was stormy as obstruction occurred following a primary resection necessitating further surgery. Th e other three patients showed a chronic inflammatory condition pathoIogicaIIy. AI1 these patients were operated upon with the diagnosis of acute appendicitis. Five other patients were operated upon with the diagnosis of chronic appendicitis. COMMENTS
We have carefuhy anaIyzed twenty-four cases of MeckeI’s diverticuhrm occurring in a genera1 hospita1 with 500 beds. During this period, approximately I I ,000 abdominal patients were operated upon which corresponds in general with the incidence found elsewhere. Our age incidence corresponded with that usually found in the Iiterature being between the ages of three and fifty-seven. The usual male-female ratio was reversed, however, in that there were ten maIes and
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fourteen femaIes. The diverticuhrm was removed in a11 but one case when it was inverted. The appendix was aIso removed in a11 but two cases both of these being acute intestina1 obstructions. The most common causes of troubIe were inflammation (six out of nineteen primary operations or 31.4 per cent) and obstruction (six out of nineteen cases or 31.5 per eent). Of the obstructive patients peritonitis deveIoped in one with a fata outcome. Five cases were in patients in whom the surgery was for some pelvic pathoIogic condition and the MeckeI’s diverticuIum was an incidental finding. Two operations were for pain foIIowing previous appendectomy. Four other cases were cIassed as chronic recurrent appendicitis. There was one additiona case so diagnosed which is inchrded in the six obstruction cases. The correct diagnosis was made in onIy one case. Analysis of this series as a whole is enIightening. The correct treatment was carried out in eighteen of the nineteen primary cases without regard to the correct diagnosis. The indications were for surgica1 intervention and a knowIedge that a diverticuhrm was present wouId not have inffuenced the treatment. In onIy one case, a typica one of bIeeding with symptoms which are pathognomonic of a MeckeI’s diverticuIum, was a correct diagnosis necessary before proper treatment couId be rendered. This demonstrates that MeckeI’s diverticulum is an important clinica entity in the morbidity and mortahty of abdominal surgery and warrants the attention given it. However, it aiso substantiates our premise that the diagnosis of MeckeI’s diverticulum will be made most commonly in the course of an abdomina1 exploration for an inAammatory process, usuaIly appendicitis or for intestina1 obstruction, and that stress shouId be Iaid upon this fact in teaching. Unless there is bIeeding or unIess x-ray studies show its presence, the diagnosis per se wiI1 not be made. WhiIe the
Diverticulum preoperative knowIedge of the presence of a MeckeI’s diverticuIum may be a diagnostic triumph, in actuaI practice the abiIity to recognize an acute abdomen is the important thing. SUMMARY I. A brief resume of the present knowledge of Meckel’s diverticuIum has been presented and twenty-four additional cases added to the Iiterature. 2. The thesis that these patients wiI1 rareIy be diagnosed preoperativeIy has been proven and the fact that these will aImost invariably be found at operation for an acute abdomen, usuaIIy appendicitis or intestinal obstruction, has been demonstrated. 3. Stress shouId be Iaid upon this fact in order that the young surgeon aIways examines the terminal ileum for a Meckel’s diverticuIum in a11 cases of abdomina1 pain or obstruction in which the presenting pathologic condition does not compIeteIy answer the cIinica1 picture. REFERENCES I. AREY, LESLIE R. Developmental Anatomy. 5th ed., Philadelphia, 1946. W. B. Saunders Co. 2. CHRISTIE, A. Meckel’s diverticuIum; pathoIogic study of sixty-three cases. Am. J. Dis. Cbild., 42: 544-553. 1931. 3. GRAY, 1-I. Anatomy of the Human Body. 24th ed. PhiIadeIphia, 1942. Lea & Febiger. 4. HABER, J. J. MeckeI’s diverticuIum; review of literature and anaIytica1 study of twenty-three cases with particuIar reference to bowe1 obstruction. Am. J. Swg., 73: 468-486, 1947. 5. HALLENDORF,L. C. and LOVELACE,W. R. Aberrant gastric mucosa and pancreatic tissue in a bleeding Meckel’s diverticuIum; report of a case. Proc. Staff Meet., Mayo C/in., 22: 53-55, 1947, 6. KI-~TLE, C. F., JENKINS, H. P. and DRAGSTEDT,L. R. Patent omphalomesenteric duct and its reIation to the diverticulum of Meckel. Arch. Surg., 54: 10-36 1947. 7. LADD, W. E. and GROSS, R. E. AbdominaI Surgery in Infancy and Childhood. Philadelphia, 1941. W. B. Saunders Co. 8. MAYO, C. W. and REMINGTON,J. H. Acute surgical conditions of the abdomen; congenital lesions. Am. J. .Surg.,.77: 841-859, 1946. 9. MECKEL, J. F. Uber die Divertike am Darmkanal. Arch. f. d. Pbysiol., 9: 421, 1809. IO. WANGENSTEEN, OWEN H. IntestinaI Obstructions. 2nd ed. Springfield, III., 1942.Charles C. Thomas.
American
Journal of Surgery