Medical Journal of Dr. D.Y. Patil Vidyapeeth

CASE REPORT
Year
: 2012  |  Volume : 5  |  Issue : 1  |  Page : 54--59

Imaging findings in inflammed Meckel's diverticulum


Abhijeet Patil, Vilasoreshwar Kulkarni, Satish Naware 
 Department of Radio-Diagnosis, Padmashree Dr. D. Y. Patil Medical College, Pune, Maharashtra, India

Correspondence Address:
Abhijeet Patil
501, Vikas Paradise, LBS Road, Mulund (W), Mumbai - 400 080
India

Abstract

Meckel«SQ»s diverticulum is congenital abnormality of gastrointestinal tract. It is generally accepted that the radiological demonstration of a Meckel«SQ»s diverticulum is not practicable. But when there is associated complications with Meckel«SQ»s diverticulum it becomes relatively easy. Abdominal radiograph does not provide any information but USG and CT features are helpful in diagnosing however the single most accurate diagnostic test for a Meckel«SQ»s diverticulum is scintigraphy.



How to cite this article:
Patil A, Kulkarni V, Naware S. Imaging findings in inflammed Meckel's diverticulum.Med J DY Patil Univ 2012;5:54-59


How to cite this URL:
Patil A, Kulkarni V, Naware S. Imaging findings in inflammed Meckel's diverticulum. Med J DY Patil Univ [serial online] 2012 [cited 2021 Dec 6 ];5:54-59
Available from: https://www.mjdrdypu.org/text.asp?2012/5/1/54/97514


Full Text

 Introduction



Meckel's diverticulum is congenital abnormality of gastrointestinal tract. Theappearance on imaging is variable and non-specific. It is generally accepted that the radiological demonstration of a Meckel's diverticulum is not practicable. [1]



Caffey (1945) states that "It cannot be satisfactorily demonstrated Roentgen graphically."Potts (1948) wrote "Roentgen logic examination is valueless except in those very rare instances in which barium is given by mouth and by rare good fortune a film happened to be taken at the right time to show an accumulation in the diverticulum. I have never had the good fortune to see one demonstrated Roentgen graphically."

 Case Report



A 6-year-old boy presented with pain in periumbilical region of abdomen associated with 7-8 episodes of vomiting and constipation since 4 days. Intermittent fever was since 2 days. Per abdominal examination revealed guarding with right iliac fossa tenderness. On auscultation bowel sounds were absent.

Laboratory results showed raised leukocyte count and which was 13,000 and Hemoglobin was 12.5 gm/dl.

The plain abdominal radiograph [Figure 1] showed multiple loops filled with gas but non-specific diagnostic features with no obvious signs of intestinal obstruction.{Figure 1}

Abdominal ultra sonography was carried out on Siemen's Acuson X300 machine. It revealed abnormal hypoechoic cystic swelling seen superficially near anterior abdominal wall close to umbilicus [Figure 2]. It measures 3 × 2.5 cm in size with soft echoes within it. Pericystic lesion reveals fat stranding suggestive of chronic inflammation.{Figure 2}

This cystic structure is attached to small bowel loop which is dilated and shows no peristalsis [Figure 3]. Minimal free fluid is seen in the pelvis. Marked probe tenderness is noted in the cystic lesion.{Figure 3}

CT performed on GE duo FII scanner without oral and intravenous contrast. Abnormal cystic lesion noted in the right peri-umbilical region which is abutting the anterior abdominal wall merging with adjacent small bowel loop [Figure 4] and [Figure 5]. This loop contains fluid within it with stranding of mesenteric fat [Figure 6]. No pneumoperitoneum, no intestinal obstruction seen.{Figure 4}{Figure 5}{Figure 6}

An inflamed Meckel's diverticulum was excised at laparotomy [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], and [Figure 12].{Figure 7}{Figure 8}{Figure 9}{Figure 10}{Figure 11}{Figure 12}

 Discussion



Meckel's diverticulum is the consequences of incomplete regression of the omphalomesenteric duct. The omphalomesenteric duct in the embryo serves as a communication between the gut and the yolk sac. Obliteration of the duct occurs gradually between the fifth and seventh week, as placental nutrition becomes established. The duct may persist as a fistula between the small bowel and the abdominal wall [Figure 13]A, as a fibrous cord connecting the small bowel with the abdominal wall [Figure 13]B, as a Meckel's diverticulum [Figure 13]C, on as an umbilical sinus [Figure 13]D. Meckel's diverticulum opens into the anti-mesenteric side of the small intestine. This is a differential feature from duplications of small bowel which arise on the mesenteric side of the small intestine. [1] {Figure 13}

Clinical Presentation

Meckel's diverticulum can cause symptoms at any age; however, about 50% of the patients come to the hospital in the first 2 years of life. [2]

Complications of Meckel's diverticulum develop in approximately 2.5% of the cases and include inflammation, peptic ulceration with hemorrhage on perforation, intussusceptions, and volvulus about the fibrous cord. Neoplasia has also been reported. [3]

Patients with Meckel's diverticulum may have different symptoms. Gastrointestinal bleeding secondary to peptic ulceration is the most common. The bleeding is copious and usually not accompanied by abdominal pain. The stool may at first be dark or black, but subsequently is bright red. Abdominal pain is the second most common clinical presentation and may be secondary to Meckel's diverticulitis, sealed off perforation with abscess formation, on recurrent intussusceptions with spontaneous reductions [Table 1]. Small bowel obstruction is caused by intussusceptions, volvulus, mechanical obstruction about a persistent cord, or internal hernia through the mesentery of a Meckel's diverticulum. [4] Perforation of a diverticulum has also been reported following blunt abdominal trauma, on penetration of a foreign body-most commonly fish bones-through the wall of the diverticulum. [5]{Table 1}

Carcinoid tumors within a Meckel's diverticulum have been associated with the Carcinoid syndrome. [5]

Complications and Pathology [3]

Meckel's diverticulum assumes importance chiefly through its liability to various complications, and these have been described between the ages of 5 h and 77 years [Table 2].{Table 2}



Acute inflammation. This may lead to local abscess formation, gangrene, perforation and peritonitis.Acute intestinal obstruction may occur, following strangulation of the bowel by a fibrous or vascular cord from the sac to the umbilicus. Sometimes the tip of the sac is adherent to some other viscous and traps the intestines. If there is twisting of the bowel, volvulus may occur.Intussusception caused by an invaginated diverticulum is well recognized, and is said to cause between 2.5 to 5 per cent of all intussusceptions. This is said to be commoner in children between 3 and 12 years.Hemorrhage is a frequent finding; this is usually the result of a peptic ulcer, often chronic, in the secreting gastric mucosa, and a small eroded artery in this region.New growths are rare, but many different types are recognized. Of benign tumors, lipoma, myoma, neuroma, papilloma, Carcinoid tumor, leiomyoma and argentaffin tumors.Tuberculosis of a Meckel's diverticulum, with perforation and generalized peritonitis is recordedRegion ileitis affecting the diverticulum.In a review of foreign body perforations of the diverticulum, majority are caused by fish bones.Miscellaneous. Intra-uterine perforation into the bladder, forming a fistula. Perforation of a diverticulum, presenting as a unilateral hydrocele, acute diverticulitis with round worms in the peritoneal cavity , a Meckel's diverticuloappendiceal fistula and calcium carbonate faecoliths.

Imaging Diagnosis

Diagnosis of Meckel's diverticulum radiological may be difficult. [6]

Plain Abdominal Radiographs: Plain abdominal radiographs may reveal non-specific signs of intestinal obstruction. [6] Inflammation in a Meckel's diverticulum, unlike appendicitis, rarely produces gas and fluid levels in the caecum. A rare non-specific sign is the association of enteroliths within the diverticulum and air-fluid levels. [6]

Barium Studies: The conventional small-bowel series has often been considered unreliable for the detection of Meckel's diverticulum because the technique has some inherent limitations. The diverticulum can occasionally be diagnosed by reflux of barium during a colon enema; however, the colon barium enema is not used as a primary imaging method to make the diagnosis of Meckel's diverticulum. [7]

Enteroclysis: It is considered by some authors a better technique than the conventional barium follow-through studies in diagnosing small bowel disease and Meckel's diverticulum. [8] With this technique, it is possible to obtain consistent, moderate distension of bowel segments that are suspected to be abnormal. The confirmation of the Meckel's origin of the diverticulum rests on the visualization of its fold patterns, especially at the site of its attachment to the normal intestine. A "triradiate" fold pattern in which the loops are collapsed and a "mucosal triangular plateau" in which the loops are distended are the junction fold appearances that are considered characteristic. [7] A gastric rugal pattern may also be identified within the diverticulum. [7]

Sonography: Meckel's diverticulum can be identified on sonography in cases of complications. In cases of an obstructed and fluid-filled diverticulum, sonography may show a tubular over distended fluid structure connected to the umbilicus. [9]

CT: It is usually of little value in diagnosing Meckel's diverticulum because distinction between a diverticulum and intestinal loops is usually impossible. If the diverticulum is attached to the umbilicus, the diagnosis may be suspected on CT scans. [9],[10]

Nuclear Medicine: Radionuclide scans may provide a diagnosis of Meckel's diverticulum when uptake of radionuclide occurs in ectopic gastric mucosa or by identifying the site of gastrointestinal bleeding. 99 m Tc pertechnetate is preferentially taken up by the mucus-secreting cells of gastric mucosa and ectopic gastric tissue in the diverticulum. [11],[12]

Angiography: In patients with Meckel's diverticulum, arteriography is usually indicated when there is active bleeding in the gastrointestinal tract, or in episodes of self-limiting bleeding, after scintigraphy and Enteroclysis show normal findings. Bleeding at a rate of at least 0.5 ml/min is generally required in adults to demonstrate contrast extravasations; a greater rate of bleeding may be necessary to detect this finding in children. [13] The angiographic diagnosis is based on visualization of an anomalous artery feeding the diverticulum, the presence of dense capillary staining, and extravasations of contrast material in actively bleeding patients. Selective superior mesenteric arteriography can be done. The arterial, capillary, and venous phases and the mucosal blush must be accurately studied.

 Conclusion



Imaging-based diagnosis of Meckel's diverticulum is difficult. However, when there is associated complication, it becomes relatively easy. USG and CT are helpful in diagnosing however the single most accurate diagnostic test for a Meckel's diverticulum is scintigraphy with sodium 99 mTc pertechnetate which has the advantage of being noninvasive.

References

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