Meckel's diverticulum natural history, complications and prognosis: Difference between revisions
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==Overview== | ==Overview== | ||
Meckel's diverticulum is mostly seen in male children (mostly <2 years of age). One fourth of untreated cases of Meckel's diverticulum may develop complications such as [[Bowel obstruction|intestinal obstruction]], [[Bleeding|hemorrhage]], [[diverticulitis]], bowel [[ischemia]], and [[necrosis]]. [[Bleeding|Hemorrhage]] is the most common complication in patients with [[Meckel's diverticulum]]. [[Bleeding]] in patients may be minimal, recurrent or massive and [[shock]]-producing. The rate of [[bleeding]] is assessed based on quantity of [[blood]] lost in the [[Human feces|stools]], appearance of the material passing through the [[rectum]] and [[Hemodynamics|hemodynamic]] state of the patient. Depending on the extent of the [[symptom]] progression at the time of diagnosis, the [[prognosis]] may vary. However, the [[prognosis]] is generally regarded as excellent in cases where [[symptomatic]] Meckel's diverticulum is treated in a timely manner. Complete [[Healing|recovery]] may be expected with [[surgery]] in majority of the cases. | |||
==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
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** Brisk [[Bleeding|hemorrhage]] may present as bright red blood in the [[Human feces|stools]] | ** Brisk [[Bleeding|hemorrhage]] may present as bright red blood in the [[Human feces|stools]] | ||
** Minor [[Upper gastrointestinal bleeding|upper GI]] [[bleeding]], associated with delayed [[Intestine|intestinal]] transit causing alteration of [[blood]] may present as [[Melena|tarry stools]] | ** Minor [[Upper gastrointestinal bleeding|upper GI]] [[bleeding]], associated with delayed [[Intestine|intestinal]] transit causing alteration of [[blood]] may present as [[Melena|tarry stools]] | ||
** [[Intussusception]] may present as currant jelly [[Human feces|stools]] with copious amounts of [[mucus]] due to bowel ischemia | ** [[Intussusception]] may present as currant jelly [[Human feces|stools]] with copious amounts of [[mucus]] due to [[Intestine|bowel]] [[ischemia]] | ||
** [[Fissure]]-in-ano may present with [[blood]]-streaked [[Human feces|stools]] | ** [[Fissure]]-in-ano may present with [[blood]]-streaked [[Human feces|stools]] | ||
* [[Ectopia|Ectopic]] [[gastric mucosa]] is found in about half of all cases of [[Meckel's diverticulum|Meckel's diverticula]]; and three fourths of all the cases of [[bleeding]] [[Meckel's diverticulum|Meckel's diverticulae]]. | * [[Ectopia|Ectopic]] [[gastric mucosa]] is found in about half of all cases of [[Meckel's diverticulum|Meckel's diverticula]]; and three fourths of all the cases of [[bleeding]] [[Meckel's diverticulum|Meckel's diverticulae]]. | ||
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** Littre hernia: The incarceration of a [[Meckel's diverticulum]] in an [[inguinal hernia]] is called a Littré hernia. | ** Littre hernia: The incarceration of a [[Meckel's diverticulum]] in an [[inguinal hernia]] is called a Littré hernia. | ||
==== Diverticulitis ==== | ==== Diverticulitis ==== | ||
* | *Occurs in approximately 10-20% of patients with symptomatic [[Meckel's diverticulum]] | ||
* | *Seen in the elderly population | ||
* Presentation: | * Presentation: | ||
** | ** Intermittent, crampy [[abdominal pain]] | ||
** [[ | ** [[Tenderness]] in the periumbilical area | ||
* Mechanism: | * Mechanism: | ||
| Line 106: | Line 98: | ||
*** Secondary [[infection]] | *** Secondary [[infection]] | ||
*** [[Adhesion (medicine)|Adhesions]] may develop due to [[diverticular]] [[inflammation]] causing [[Symptom|symptoms]] of [[Bowel obstruction|intestinal obstruction]] | *** [[Adhesion (medicine)|Adhesions]] may develop due to [[diverticular]] [[inflammation]] causing [[Symptom|symptoms]] of [[Bowel obstruction|intestinal obstruction]] | ||
*** [[Peritonitis]]: [[perforation]] of the [[Inflammation|inflamed]] [[diverticulum]] may lead to inflammation of the peritoneum, which is a thin tissue that lines the inside of the abdomen. | *** [[Peritonitis]]: [[perforation]] of the [[Inflammation|inflamed]] [[diverticulum]] may lead to [[inflammation]] of the [[peritoneum]], which is a thin [[Tissue (biology)|tissue]] that lines the inside of the [[abdomen]]. | ||
==== Umbilical anomalies ==== | ==== Umbilical anomalies ==== | ||
| Line 123: | Line 115: | ||
*** [[Sinus]] healing | *** [[Sinus]] healing | ||
*** On examination, [[Gastrointestinal tract|intestinal mucosa]] may be identified over the [[skin]] | *** On examination, [[Gastrointestinal tract|intestinal mucosa]] may be identified over the [[skin]] | ||
*** [[Cannula|Cannulation]] and [[Injection (medicine)|injection]] with radiographic contrast may help in the delineation of the entire [[tract]] and aids in surgery | *** [[Cannula|Cannulation]] and [[Injection (medicine)|injection]] with [[Contrast|radiographic contrast]] may help in the delineation of the entire [[tract]] and aids in surgery | ||
** Treatment: | ** Treatment: | ||
*** [[Surgery]] | *** [[Surgery]] | ||
*** Exploratory laparotomy | *** Exploratory [[laparotomy]] | ||
*** In case a fibrous band is found at [[laparotomy]], it should be excised because of the risk of [[volvulus]] and internal [[Hernia|herniation]]. | *** In case a fibrous band is found at [[laparotomy]], it should be excised because of the risk of [[volvulus]] and internal [[Hernia|herniation]]. | ||
[[Neoplasm]] | [[Neoplasm]] | ||
* [[Neoplasm|Neoplasms]] are found in approximately 4-5% of complicated [[Meckel's diverticulum]] cases. | * [[Neoplasm|Neoplasms]] are found in approximately 4-5% of complicated [[Meckel's diverticulum]] cases. | ||
* Types of tumors:<ref name="pmid17373755">{{cite journal |vauthors=Karadeniz Cakmak G, Emre AU, Tascilar O, Bektaş S, Uçan BH, Irkorucu O, Karakaya K, Ustundag Y, Comert M |title=Lipoma within inverted Meckel's diverticulum as a cause of recurrent partial intestinal obstruction and hemorrhage: a case report and review of literature |journal=World J. Gastroenterol. |volume=13 |issue=7 |pages=1141–3 |year=2007 |pmid=17373755 |pmc=4146883 |doi= |url=}}</ref><ref name="pmid21135700">{{cite journal |vauthors=Thirunavukarasu P, Sathaiah M, Sukumar S, Bartels CJ, Zeh H, Lee KK, Bartlett DL |title=Meckel's diverticulum--a high-risk region for malignancy in the ileum. Insights from a population-based epidemiological study and implications in surgical management |journal=Ann. Surg. |volume=253 |issue=2 |pages=223–30 |year=2011 |pmid=21135700 |pmc=4129548 |doi=10.1097/SLA.0b013e3181ef488d |url=}}</ref> | * Types of [[Tumor|tumors]]:<ref name="pmid17373755">{{cite journal |vauthors=Karadeniz Cakmak G, Emre AU, Tascilar O, Bektaş S, Uçan BH, Irkorucu O, Karakaya K, Ustundag Y, Comert M |title=Lipoma within inverted Meckel's diverticulum as a cause of recurrent partial intestinal obstruction and hemorrhage: a case report and review of literature |journal=World J. Gastroenterol. |volume=13 |issue=7 |pages=1141–3 |year=2007 |pmid=17373755 |pmc=4146883 |doi= |url=}}</ref><ref name="pmid21135700">{{cite journal |vauthors=Thirunavukarasu P, Sathaiah M, Sukumar S, Bartels CJ, Zeh H, Lee KK, Bartlett DL |title=Meckel's diverticulum--a high-risk region for malignancy in the ileum. Insights from a population-based epidemiological study and implications in surgical management |journal=Ann. Surg. |volume=253 |issue=2 |pages=223–30 |year=2011 |pmid=21135700 |pmc=4129548 |doi=10.1097/SLA.0b013e3181ef488d |url=}}</ref> | ||
** [[Leiomyoma]] is the one that is most frequently found | ** [[Leiomyoma]] is the one that is most frequently found | ||
** [[Leiomyosarcoma]] | ** [[Leiomyosarcoma]] | ||
| Line 156: | Line 148: | ||
*Complete [[Healing|recovery]] may be expected with [[surgery]].<ref name="pmid20871204">{{cite journal |vauthors=Yagnik VD, Yagnik BD |title=Asymptomatic Meckel's diverticulum in adults: is diverticulectomy indicated? |journal=Saudi J Gastroenterol |volume=16 |issue=4 |pages=306 |year=2010 |pmid=20871204 |pmc=2995107 |doi=10.4103/1319-3767.70626 |url=}}</ref> | *Complete [[Healing|recovery]] may be expected with [[surgery]].<ref name="pmid20871204">{{cite journal |vauthors=Yagnik VD, Yagnik BD |title=Asymptomatic Meckel's diverticulum in adults: is diverticulectomy indicated? |journal=Saudi J Gastroenterol |volume=16 |issue=4 |pages=306 |year=2010 |pmid=20871204 |pmc=2995107 |doi=10.4103/1319-3767.70626 |url=}}</ref> | ||
*The risk of developing complications in the postoperative period is 2-7%, the most common complication being [[bowel obstruction]].<ref name="pmid18216533">{{cite journal |vauthors=Zani A, Eaton S, Rees CM, Pierro A |title=Incidentally detected Meckel diverticulum: to resect or not to resect? |journal=Ann. Surg. |volume=247 |issue=2 |pages=276–81 |year=2008 |pmid=18216533 |doi=10.1097/SLA.0b013e31815aaaf8 |url=}}</ref> | *The risk of developing complications in the postoperative period is 2-7%, the most common complication being [[bowel obstruction]].<ref name="pmid18216533">{{cite journal |vauthors=Zani A, Eaton S, Rees CM, Pierro A |title=Incidentally detected Meckel diverticulum: to resect or not to resect? |journal=Ann. Surg. |volume=247 |issue=2 |pages=276–81 |year=2008 |pmid=18216533 |doi=10.1097/SLA.0b013e31815aaaf8 |url=}}</ref> | ||
*The risk of developing complications such as [[perforation]], | *The risk of developing complications such as [[perforation]], [[inflammation]], [[bleeding]] and [[obstruction]] in asymptomatic patients with Meckel's diverticulum is 4-6.4%.<ref name="pmid7944666">{{cite journal |vauthors=Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ |title=Surgical management of Meckel's diverticulum. An epidemiologic, population-based study |journal=Ann. Surg. |volume=220 |issue=4 |pages=564–8; discussion 568–9 |year=1994 |pmid=7944666 |pmc=1234434 |doi= |url=}}</ref> | ||
==References== | ==References== | ||
Revision as of 20:22, 27 December 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Meckel's diverticulum is mostly seen in male children (mostly <2 years of age). One fourth of untreated cases of Meckel's diverticulum may develop complications such as intestinal obstruction, hemorrhage, diverticulitis, bowel ischemia, and necrosis. Hemorrhage is the most common complication in patients with Meckel's diverticulum. Bleeding in patients may be minimal, recurrent or massive and shock-producing. The rate of bleeding is assessed based on quantity of blood lost in the stools, appearance of the material passing through the rectum and hemodynamic state of the patient. Depending on the extent of the symptom progression at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as excellent in cases where symptomatic Meckel's diverticulum is treated in a timely manner. Complete recovery may be expected with surgery in majority of the cases.
Natural History, Complications, and Prognosis
Natural History
- The symptoms of Meckel's diverticulum usually develop in children, and start with painless lower gastrointestinal bleeding.[1]
- If left untreated, 25% of patients with Meckel's diverticulum may progress to develop hemorrhage, ulceration, bowel perforation, diverticulitis, peritonitis and small bowel obstruction.[2]
Complications
- Common complications of Meckel's diverticulum include:[2][3]
Hemorrhage
- Most common complication in patients with Meckel diverticulum
- Accounts for one fourth of all complications
- More commonly seen in:
- Children younger than 2 years
- Male sex
- Presentation:
- Patients present with the following symptoms:
- Passage of bright red blood in the stools
- May or may not be associated with:
- Abdominal pain (usually painless)
- Weakness
- Anemia
- Bleeding may be:
- Minimal
- Recurrent
- Massive, shock-producing
- Assessment of the rate of bleeding may be done on the basis of the following:
- Quantity of blood lost in the stools
- Appearance of the material passing through the rectum
- Hemodynamic state
- Characteristics of hemorrhage based on the appearance of stools include the following:
- Brisk hemorrhage: bright red blood in the stools
- Minor upper GI bleeding, associated with delayed intestinal transit causing alteration of blood: Tarry stools
- Intussusception: Currant jelly stools with copious amounts of mucus due to bowel ischemia
- Fissure-in-ano: Blood-streaked stools
- The gastric mucosa found in the diverticulum may form a chronic ulcer and may also damage the adjacent ileal mucosa because of acid production. Ectopic gastric mucosa is found in about 50% of all Meckel's diverticula; and three fourths of bleeding Meckel's diverticula.
- Perforation may occur, and the patient then presents with an acute abdomen, often associated with air under the diaphragm, best visualized on an erect chest radiograph.
- Patients present with the following symptoms:
- Characteristics of hemorrhage based on the appearance of stools include the following:
- Brisk hemorrhage may present as bright red blood in the stools
- Minor upper GI bleeding, associated with delayed intestinal transit causing alteration of blood may present as tarry stools
- Intussusception may present as currant jelly stools with copious amounts of mucus due to bowel ischemia
- Fissure-in-ano may present with blood-streaked stools
- Ectopic gastric mucosa is found in about half of all cases of Meckel's diverticula; and three fourths of all the cases of bleeding Meckel's diverticulae.
- Panendoscopy may help detect GI bleeds from the two most common sites:
- Upper GI tract
- Colorectal region
Perforation
- Perforation may present as:
Intestinal obstruction
- Presentation:
- In case of intussusception, patient may also present with:
- Radiography of the abdomen may indicate:
- Ileus
- Stepladder air-fluid levels, as seen in dynamic intestinal obstruction
- Observed in one fourth of patients with symptomatic Meckel's diverticulum
- Various mechanisms of intestinal obstruction occur with Meckel's diverticulum:
- Volvulus: The omphalomesenteric duct may be attached to the wall of the abdomen by a fibrotic band, and volvulus of the small bowel around the band may occur.
- Intussusception: An intussusception is a blockage in the intestines caused by folding of the intestines. The lead point of the intussusception may be:
- Diverticulum
- Tumor arising in the wall of the diverticulum
- Littre hernia: The incarceration of a Meckel's diverticulum in an inguinal hernia is called a Littré hernia.
Diverticulitis
- Occurs in approximately 10-20% of patients with symptomatic Meckel's diverticulum
- Seen in the elderly population
- Presentation:
- Intermittent, crampy abdominal pain
- Tenderness in the periumbilical area
- Mechanism:
- Stasis in the diverticulum, particularly in one with a narrow neck leads to:
- Inflammation
- Secondary infection
- Adhesions may develop due to diverticular inflammation causing symptoms of intestinal obstruction
- Peritonitis: perforation of the inflamed diverticulum may lead to inflammation of the peritoneum, which is a thin tissue that lines the inside of the abdomen.
- Stasis in the diverticulum, particularly in one with a narrow neck leads to:
Umbilical anomalies
- Occurs in up to 10% of patients and consist of the following:
- Cysts
- Sinuses
- Fistulas
- Fibrous bands between the umbilicus and the diverticulum
- Presentation:
- Chronic discharging umbilical sinus superimposed by:
- Infection
- Excoriation of periumbilical skin
- Patient may have a history of:
- Abdominal-wall abscess formation
- Recurrent infection
- Sinus healing
- On examination, intestinal mucosa may be identified over the skin
- Cannulation and injection with radiographic contrast may help in the delineation of the entire tract and aids in surgery
- Treatment:
- Surgery
- Exploratory laparotomy
- In case a fibrous band is found at laparotomy, it should be excised because of the risk of volvulus and internal herniation.
- Chronic discharging umbilical sinus superimposed by:
- Neoplasms are found in approximately 4-5% of complicated Meckel's diverticulum cases.
- Types of tumors:[4][5]
- Leiomyoma is the one that is most frequently found
- Leiomyosarcoma
- Fibroma
- Ectopic gastric adenocarcinoma
- Lipoma
- Gastrinomas
- Angioma
- Carcinoid tumor
Other complications
- Other complications in Meckel's diverticulum include:
- Vesicodiverticular fistulas
- Phytobezoar formation
- Stone formation
- Diverticulum within a Meckel's diverticulum: formation of 'daughter" diverticula
- Complications occur frequently in:
- Children
- Infants
- Males
Prognosis
Prognosis of patients with Meckel's diverticulum is as follows: [6]
- Depending on the extent of the symptom progression at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as excellent in cases where symptomatic Meckel's diverticulum is treated in a timely manner.
- Complete recovery may be expected with surgery.[7]
- The risk of developing complications in the postoperative period is 2-7%, the most common complication being bowel obstruction.[8]
- The risk of developing complications such as perforation, inflammation, bleeding and obstruction in asymptomatic patients with Meckel's diverticulum is 4-6.4%.[3]
References
- ↑ "Meckel's Diverticulum | Cleveland Clinic".
- ↑ 2.0 2.1 Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, Mew D (2006). "Complications of Meckel's diverticula in adults". Can J Surg. 49 (5): 353–7. PMC 3207587. PMID 17152574.
- ↑ 3.0 3.1 Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ (1994). "Surgical management of Meckel's diverticulum. An epidemiologic, population-based study". Ann. Surg. 220 (4): 564–8, discussion 568–9. PMC 1234434. PMID 7944666.
- ↑ Karadeniz Cakmak G, Emre AU, Tascilar O, Bektaş S, Uçan BH, Irkorucu O, Karakaya K, Ustundag Y, Comert M (2007). "Lipoma within inverted Meckel's diverticulum as a cause of recurrent partial intestinal obstruction and hemorrhage: a case report and review of literature". World J. Gastroenterol. 13 (7): 1141–3. PMC 4146883. PMID 17373755.
- ↑ Thirunavukarasu P, Sathaiah M, Sukumar S, Bartels CJ, Zeh H, Lee KK, Bartlett DL (2011). "Meckel's diverticulum--a high-risk region for malignancy in the ileum. Insights from a population-based epidemiological study and implications in surgical management". Ann. Surg. 253 (2): 223–30. doi:10.1097/SLA.0b013e3181ef488d. PMC 4129548. PMID 21135700.
- ↑ "Meckel diverticulum Prognosis - Epocrates Online".
- ↑ Yagnik VD, Yagnik BD (2010). "Asymptomatic Meckel's diverticulum in adults: is diverticulectomy indicated?". Saudi J Gastroenterol. 16 (4): 306. doi:10.4103/1319-3767.70626. PMC 2995107. PMID 20871204.
- ↑ Zani A, Eaton S, Rees CM, Pierro A (2008). "Incidentally detected Meckel diverticulum: to resect or not to resect?". Ann. Surg. 247 (2): 276–81. doi:10.1097/SLA.0b013e31815aaaf8. PMID 18216533.