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Meckel's diverticulum perforation with intraabdominal hemorrhage
Meckel’s Diverticulum Perforation With Intraabdominal Hemorrhage By Franc Jelenc, Mirko Strlicˇ, and Diana Gvardijancˇicˇ Ljubljana, Slovenia
Perforation of Meckel’s diverticulum in children is a rare and serious complication. The authors report a case of a 3-yearold boy with perforation and hemoperitoneum caused by Meckel’s diverticulum. Difficulty of preoperative diagnosis is discussed, indication for incidental diverticulotomy is established, and the literature is reviewed.
J Pediatr Surg 37:E18. Copyright 2002, Elsevier Science (USA). All rights reserved.
INDEX WORDS: Meckel’s diverticulum, perforation, hemoperitoneum.
M
ECKEL’S DIVERTICULUM, the result of incomplete obliteration of the omphalomesenteric (vitelline) duct, is the most common congenital abnormality of the small bowel.1 Ninety percent occur within the terminal 90 cm of ileum.2 Meckel’s diverticulum is a “true” diverticulum, therefore; it has all layers of the ileal wall, but in 30% to 40% of cases, ectopic tissue also is present.3 Highly variable incidences of ectopia in published series are caused by the high incidence of complications in ectopic tissue.4 Series of complicated diverticula, therefore, have a higher incidence of ectopic tissue than those that include asymptomatic cases. Gastric mucosa is the most common and clinically important of the ectopic tissues. It has the potential to induce peptic ulceration in the ileal mucosa with pain, inflammation, hemorrhage, or even perforation.5,6 The most common complication of the Meckel’s diverticulum in children is hemorrhage. However, diverticular perforation is a rare and serious complication.2 We therefore report the case of a 3-year-old boy with perforation and hematoperitoneum caused by Meckel’s diverticulum. CASE REPORT A 3-year-old boy was admitted to our department with signs and symptoms of acute abdomen. Three months before admission he had been admitted to another institution for abdominal colics. On admission, the abdomen was distended and diffusely tender. The child had fever up to 38.5°C. Laboratory values were all within the normal ranges except for the white blood cell (WBC) count, 13,500/
From the Department of Pediatric Surgery, Medical Center Ljubljana, Slovenia. Address reprint requests to Franc Jelenc, MD, PhD, Department of Pediatric Surgery, Medical Center Ljubljana, Zalosˇka 7, 1000 Ljubljana, Slovenia. Copyright 2002, Elsevier Science (USA). All rights reserved. 1531-5037/02/3706-0035$35.00/0 doi:10.1053/jpsu.2002.32929 18
Fig 1.
Meckel’s diverticulum with a perforation near the base.
mm3. The boy underwent surgery for suspected peritonitis through a median incision 2 hours after admission. Three hundred mililiters of free intraperitoneal blood was discovered. Exploratory laparotomy showed a Meckel’s diverticulum with a perforation near the base (Fig 1). The appendix appeared grossly normal. At operation, a partial resection of the ileum with Meckel’s diverticulum was performed. His initial hemoglobin subsequently dropped, requiring blood transfusion. Postoperative course was uneventful. After 1 week of hospitalization the boy was discharged in good condition. Histology findings of the resected Meckel’s diverticulum, which measured 3 ⫻ 2.5 cm showed inflammation and perforation in ectopic gastric mucosa near the base of diverticulum.
DISCUSSION
Although Meckel’s diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract, it Journal of Pediatric Surgery, Vol 37, No 6 (June), 2002: E18
MECKEL’S DIVERTICULUM AND HEMORRHAGE
19
often is difficult to diagnose. It may remain completely asymptomatic, or it may mimic such disorders as appendicitis, peptic ulcer disease, or Crohn’s disease. The diagnosis of Meckel’s diverticulum always should be considered in patients with unexplained abdominal pain, nausea and vomiting, or intestinal bleeding. The most useful method of diagnosis is with a technetium-99m pertechnetate scan, which is dependent on uptake of the isotope in ectopic tissue. Angiography performed for severe enigmatic gastrointestinal bleeding has led to the correct diagnosis when Meckel’s scans were negative.7 The most common complication of Meckel’s diverticulum is hemorrhage, which usually manifests itself in early infancy or childhood.8 Gastrointestinal bleeding is seen in aproximately 55% of patients with Meckel’s diverticulum.9 The most important cause of hemorrhage is ulceration of the small intestine caused by acid production in ectopic gastric mucosa, which is found in 30% to 40% of all Meckel’s diverticula. Perforation of the diverticulum usually is secondary to inflammatory diver-
ticulitis and gangrene, although peptic ulceration also can lead to perforation.10 Every symptomatic Meckel’s diverticulum should be resected. Although there is little morbidity after simple diverticulectomy, Williams2 considers this method to be inadequate and prefers partial resection of the ileum. Ileal resection is advisable for bleeding diverticula because ectopic tissue can reach beyond the base of the diverticulum, whereas signs of inflammation and the presence of ectopic tissue cannot be excluded during operation.10 To our knowledge, there have been only few reports of a hemoperitoneum resulting from a perforated Meckel’s diverticulum in the world literature.5,11-14 In the current case, hemoperitoneum resulted from peptic ulceration with hemorrhage and perforation. A perforated Meckel’s diverticulum should be included among the causes of hemoperitoneum, even if it is a rare complication. The diagnosis of Meckel’s diverticulum always should be considered in children with unexplained abdominal colics or pain.
REFERENCES 1. Dowse JLA: Meckel’s diverticulum. Br J Surg 48:392-399, 1961 2. Williams RS: Management of Meckel’s diverticulum. Br J Surg 68:477-480, 1981 3. Debartolo HM, Vanheerden JA: Meckel’s diverticulum. Ann Surg 180:30-33, 1976 4. Root GT, Baker CP: Complications associated with Meckel’s diverticulum. Am J Surg 114:285-288, 1967 5. Moses WR: Meckel’s diverticulum: Report of two unusual cases. N Engl J Med 237:118-121, 1947 6. Rohjan MS, Hejazi R: Incidence of Meckel’s diverticulum in 100 cadavers. Postgrad Med J 50:694-701, 1974 7. Martin JP, Connor PD, Charles K: Meckel’s diverticulum. Am Fam Physician 61:1037-1042, 2000 8. Farr CM, Iqbal R, Bezmalinovic Z, et al: Bleeding Meckel’s diverticulum in an adult. 11:208-210, 1989
9. Cullen JJ, Kelly KA, Moir CR, et al: Surgical management of Meckel’s diverticulum. An epidemiologic, population-based astudy. Ann Surg 220:564-569, 1994 10. Fa-Si-Oen PR, Roumen RMH, Croiset van Uchelen: Complications and management of Meckel’s diverticulum—A review. Eur J Surg 165.674-678, 1999 11. Manters E, Maderna C: Hemoperitoneum caused by perforation of Meckel’s diverticula. Minerva Chir 15:872-876, 1960 12. Frank G, Reichel K: Intraabdominale Blutung als seltene Komplikation eines Meckel’schen Divertikels. Chirurg 48:238-240, 1977 13. Kaukonen JP: Peptic ulcer perforation in Meckel’s diverticulum and intra-abdominal hemorrghage in pregnancy. Doudecim 98:207208, 1982 14. Fowler CL, Ohlms LA, Reid BS, et al: Hemoperitoneum from perforated Meckel’s diverticulum. J Pediatr Surg 23:982-983, 1988
Perforation of Meckel’s diverticulum in children is a rare and serious complication. The authors report a case of a 3-yearold boy with perforation and hemoperitoneum caused by Meckel’s diverticulum. Difficulty of preoperative diagnosis is discussed, indication for incidental diverticulotomy is established, and the literature is reviewed.
J Pediatr Surg 37:E18. Copyright 2002, Elsevier Science (USA). All rights reserved.
INDEX WORDS: Meckel’s diverticulum, perforation, hemoperitoneum.
M
ECKEL’S DIVERTICULUM, the result of incomplete obliteration of the omphalomesenteric (vitelline) duct, is the most common congenital abnormality of the small bowel.1 Ninety percent occur within the terminal 90 cm of ileum.2 Meckel’s diverticulum is a “true” diverticulum, therefore; it has all layers of the ileal wall, but in 30% to 40% of cases, ectopic tissue also is present.3 Highly variable incidences of ectopia in published series are caused by the high incidence of complications in ectopic tissue.4 Series of complicated diverticula, therefore, have a higher incidence of ectopic tissue than those that include asymptomatic cases. Gastric mucosa is the most common and clinically important of the ectopic tissues. It has the potential to induce peptic ulceration in the ileal mucosa with pain, inflammation, hemorrhage, or even perforation.5,6 The most common complication of the Meckel’s diverticulum in children is hemorrhage. However, diverticular perforation is a rare and serious complication.2 We therefore report the case of a 3-year-old boy with perforation and hematoperitoneum caused by Meckel’s diverticulum. CASE REPORT A 3-year-old boy was admitted to our department with signs and symptoms of acute abdomen. Three months before admission he had been admitted to another institution for abdominal colics. On admission, the abdomen was distended and diffusely tender. The child had fever up to 38.5°C. Laboratory values were all within the normal ranges except for the white blood cell (WBC) count, 13,500/
From the Department of Pediatric Surgery, Medical Center Ljubljana, Slovenia. Address reprint requests to Franc Jelenc, MD, PhD, Department of Pediatric Surgery, Medical Center Ljubljana, Zalosˇka 7, 1000 Ljubljana, Slovenia. Copyright 2002, Elsevier Science (USA). All rights reserved. 1531-5037/02/3706-0035$35.00/0 doi:10.1053/jpsu.2002.32929 18
Fig 1.
Meckel’s diverticulum with a perforation near the base.
mm3. The boy underwent surgery for suspected peritonitis through a median incision 2 hours after admission. Three hundred mililiters of free intraperitoneal blood was discovered. Exploratory laparotomy showed a Meckel’s diverticulum with a perforation near the base (Fig 1). The appendix appeared grossly normal. At operation, a partial resection of the ileum with Meckel’s diverticulum was performed. His initial hemoglobin subsequently dropped, requiring blood transfusion. Postoperative course was uneventful. After 1 week of hospitalization the boy was discharged in good condition. Histology findings of the resected Meckel’s diverticulum, which measured 3 ⫻ 2.5 cm showed inflammation and perforation in ectopic gastric mucosa near the base of diverticulum.
DISCUSSION
Although Meckel’s diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract, it Journal of Pediatric Surgery, Vol 37, No 6 (June), 2002: E18
MECKEL’S DIVERTICULUM AND HEMORRHAGE
19
often is difficult to diagnose. It may remain completely asymptomatic, or it may mimic such disorders as appendicitis, peptic ulcer disease, or Crohn’s disease. The diagnosis of Meckel’s diverticulum always should be considered in patients with unexplained abdominal pain, nausea and vomiting, or intestinal bleeding. The most useful method of diagnosis is with a technetium-99m pertechnetate scan, which is dependent on uptake of the isotope in ectopic tissue. Angiography performed for severe enigmatic gastrointestinal bleeding has led to the correct diagnosis when Meckel’s scans were negative.7 The most common complication of Meckel’s diverticulum is hemorrhage, which usually manifests itself in early infancy or childhood.8 Gastrointestinal bleeding is seen in aproximately 55% of patients with Meckel’s diverticulum.9 The most important cause of hemorrhage is ulceration of the small intestine caused by acid production in ectopic gastric mucosa, which is found in 30% to 40% of all Meckel’s diverticula. Perforation of the diverticulum usually is secondary to inflammatory diver-
ticulitis and gangrene, although peptic ulceration also can lead to perforation.10 Every symptomatic Meckel’s diverticulum should be resected. Although there is little morbidity after simple diverticulectomy, Williams2 considers this method to be inadequate and prefers partial resection of the ileum. Ileal resection is advisable for bleeding diverticula because ectopic tissue can reach beyond the base of the diverticulum, whereas signs of inflammation and the presence of ectopic tissue cannot be excluded during operation.10 To our knowledge, there have been only few reports of a hemoperitoneum resulting from a perforated Meckel’s diverticulum in the world literature.5,11-14 In the current case, hemoperitoneum resulted from peptic ulceration with hemorrhage and perforation. A perforated Meckel’s diverticulum should be included among the causes of hemoperitoneum, even if it is a rare complication. The diagnosis of Meckel’s diverticulum always should be considered in children with unexplained abdominal colics or pain.
REFERENCES 1. Dowse JLA: Meckel’s diverticulum. Br J Surg 48:392-399, 1961 2. Williams RS: Management of Meckel’s diverticulum. Br J Surg 68:477-480, 1981 3. Debartolo HM, Vanheerden JA: Meckel’s diverticulum. Ann Surg 180:30-33, 1976 4. Root GT, Baker CP: Complications associated with Meckel’s diverticulum. Am J Surg 114:285-288, 1967 5. Moses WR: Meckel’s diverticulum: Report of two unusual cases. N Engl J Med 237:118-121, 1947 6. Rohjan MS, Hejazi R: Incidence of Meckel’s diverticulum in 100 cadavers. Postgrad Med J 50:694-701, 1974 7. Martin JP, Connor PD, Charles K: Meckel’s diverticulum. Am Fam Physician 61:1037-1042, 2000 8. Farr CM, Iqbal R, Bezmalinovic Z, et al: Bleeding Meckel’s diverticulum in an adult. 11:208-210, 1989
9. Cullen JJ, Kelly KA, Moir CR, et al: Surgical management of Meckel’s diverticulum. An epidemiologic, population-based astudy. Ann Surg 220:564-569, 1994 10. Fa-Si-Oen PR, Roumen RMH, Croiset van Uchelen: Complications and management of Meckel’s diverticulum—A review. Eur J Surg 165.674-678, 1999 11. Manters E, Maderna C: Hemoperitoneum caused by perforation of Meckel’s diverticula. Minerva Chir 15:872-876, 1960 12. Frank G, Reichel K: Intraabdominale Blutung als seltene Komplikation eines Meckel’schen Divertikels. Chirurg 48:238-240, 1977 13. Kaukonen JP: Peptic ulcer perforation in Meckel’s diverticulum and intra-abdominal hemorrghage in pregnancy. Doudecim 98:207208, 1982 14. Fowler CL, Ohlms LA, Reid BS, et al: Hemoperitoneum from perforated Meckel’s diverticulum. J Pediatr Surg 23:982-983, 1988