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Successful Endoscopic Resection of Inverted Meckel's Diverticulum by Double-Balloon Enteroscopy
Electronic Image of the Month Successful Endoscopic Resection of Inverted Meckel’s Diverticulum by Double-Balloon Enteroscopy MASASHI FUKUSHIMA,* YOSHIFUMI SUGA,‡ and CHIHARU KAWANAMI§ *Department of Gastroenterology, Kobe City Medical Center General Hospital, Kobe, Hyogo; ‡Department of Gastroenterology, Shinko Hospital, Kobe, Hyogo; and §Department of Gastroenterology, Otsu Red Cross Hospital, Otsu, Shiga, Japan
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58-year-old woman was referred for a 1-month history of melena in September 2007. Physical examination was unremarkable with the exception of pale conjunctiva. Laboratory tests showed a hemoglobin level of 5.7 g/dL (normal range, 11–15 g/dL). Esophagogastroduodenoscopy was carried out, but no bleeding lesion was identified. Colonoscopy showed blood clots in the terminal ileum but no bleeding lesion in the terminal ileum or colon. Abdominal computed tomography revealed a long, pedunculated, polypoid lesion with fat density in the ileum. This patient was presented to our hospital for close examination and treatment of the small intestinal lesion. We diagnosed this polypoid lesion as an ileal lipoma by using abdominal computed tomography, and retrograde double-balloon enteroscopy (DBE) was performed for the purpose of endoscopic resection in October 2007. DBE showed a pedunculated polyp with ulceration in the distal ileum (Figure A); it almost filled the lumen. Endoscopic snare resection was carried out, and the resection site was closed with 3 clips to prevent hemorrhage or perforation (Figures B and C, Supplementary Video). Histologic findings identified a 60 ⫻ 25 ⫻ 20-mm inverted Meckel’s diverticulum with ectopic pancreatic tissue. The postpolypectomy course was uneventful. The patient was discharged in good condition 15 days after endoscopic resection. Meckel’s diverticulum is generally asymptomatic, but some patients present with painless gastrointestinal bleeding. How inversion of Meckel’s diverticulum occurs is unclear. It has been suggested that abnormal peristaltic movement caused by ulceration or ectopic tissue at the bottom of Meckel’s diverticulum may cause it to invert.1
Endoscopic observation of Meckel’s diverticulum is important, and DBE is highly effective. However, diagnosis of inverted Meckel’s diverticulum is difficult, especially in adults. When a pedunculated polyp in the distal ileum is observed, inverted Meckel’s diverticulum should be included as a differential diagnosis. The surface pattern of inverted Meckel’s diverticulum, which is normal intestinal mucosa, may contribute to the diagnosis. In the present case, we were able to perform endoscopic resection by using DBE, whereas one case of iatrogenic perforation caused by endoscopic resection of inverted Meckel’s diverticulum has been reported.2 We consider that complications were avoided in our case because the resection site was closed by clips.
References 1. Blakeborough A, McWilliams RG, Raja U, et al. Pseudolipoma of inverted Meckel’s diverticulum: clinical, radiological and pathological correlation. Eur Radiol 1997;7:900 –904. 2. Huang TY, Liu YC, Lee HS, et al. Inverted Meckel’s diverticulum mimicking an ulcerated pedunculated polyp: detection by singleballoon enteroscopy. Endoscopy 2011;43:E244 –E245.
Conflicts of interest The authors disclose no conflicts. © 2013 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2012.09.023
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2013;11:e35
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58-year-old woman was referred for a 1-month history of melena in September 2007. Physical examination was unremarkable with the exception of pale conjunctiva. Laboratory tests showed a hemoglobin level of 5.7 g/dL (normal range, 11–15 g/dL). Esophagogastroduodenoscopy was carried out, but no bleeding lesion was identified. Colonoscopy showed blood clots in the terminal ileum but no bleeding lesion in the terminal ileum or colon. Abdominal computed tomography revealed a long, pedunculated, polypoid lesion with fat density in the ileum. This patient was presented to our hospital for close examination and treatment of the small intestinal lesion. We diagnosed this polypoid lesion as an ileal lipoma by using abdominal computed tomography, and retrograde double-balloon enteroscopy (DBE) was performed for the purpose of endoscopic resection in October 2007. DBE showed a pedunculated polyp with ulceration in the distal ileum (Figure A); it almost filled the lumen. Endoscopic snare resection was carried out, and the resection site was closed with 3 clips to prevent hemorrhage or perforation (Figures B and C, Supplementary Video). Histologic findings identified a 60 ⫻ 25 ⫻ 20-mm inverted Meckel’s diverticulum with ectopic pancreatic tissue. The postpolypectomy course was uneventful. The patient was discharged in good condition 15 days after endoscopic resection. Meckel’s diverticulum is generally asymptomatic, but some patients present with painless gastrointestinal bleeding. How inversion of Meckel’s diverticulum occurs is unclear. It has been suggested that abnormal peristaltic movement caused by ulceration or ectopic tissue at the bottom of Meckel’s diverticulum may cause it to invert.1
Endoscopic observation of Meckel’s diverticulum is important, and DBE is highly effective. However, diagnosis of inverted Meckel’s diverticulum is difficult, especially in adults. When a pedunculated polyp in the distal ileum is observed, inverted Meckel’s diverticulum should be included as a differential diagnosis. The surface pattern of inverted Meckel’s diverticulum, which is normal intestinal mucosa, may contribute to the diagnosis. In the present case, we were able to perform endoscopic resection by using DBE, whereas one case of iatrogenic perforation caused by endoscopic resection of inverted Meckel’s diverticulum has been reported.2 We consider that complications were avoided in our case because the resection site was closed by clips.
References 1. Blakeborough A, McWilliams RG, Raja U, et al. Pseudolipoma of inverted Meckel’s diverticulum: clinical, radiological and pathological correlation. Eur Radiol 1997;7:900 –904. 2. Huang TY, Liu YC, Lee HS, et al. Inverted Meckel’s diverticulum mimicking an ulcerated pedunculated polyp: detection by singleballoon enteroscopy. Endoscopy 2011;43:E244 –E245.
Conflicts of interest The authors disclose no conflicts. © 2013 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2012.09.023
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2013;11:e35