Bleeding postoperatively from a Meckel diverticulum, secondary to NSAIDs: a cautionary note

Abstract

A Meckel diverticulum is a well-recognized source of intestinal bleeding in children. A Meckel diverticulum occurs in about 2% of the population and haemorrhage is the presenting feature in approximately onethird of children with a symptomatic lesion. Almost all such cases have ectopic gastric mucosa in the diverticulum and the ulceration occurs in the adjacent ileal mucosa [1]. Normally the episode of bleeding has no demonstratable triggering factor. It is well known that non-steroidal anti-inflammatory drugs (NSAIDs) can cause erosions in gastric mucosa in the stomach. We would like to report a case of a child who bled from ulceration in the gastric mucosa in a Meckel diverticulum while on a non-steroidal anti-inflammatory drug.A previously fit and healthy 6-year-old boy underwent an umbilical herniorraphy and right hydrocele correction as a day procedure. He was discharged home with paracetamol and Ibuprofen. Postoperatively the boy took two tablets of 200 mg Ibuprofen at an interval of 8 h apart. He was presented on third postoperative day with four episodes of dark tarry stools which progressed to bright red blood per rectum. On presentation he was pale, although haemodynamically stable. His haemoglobin was 8.5 g/dl and he had a normal coagulation profile. A 99Tc Meckel's scan was organized which was positive for functional gastric mucosa. The patient underwent a mini-laparotomy through the umbilical hernia repair site and a Meckel diverticulum was resected. The patient made an uneventful recovery. The histology confirmed the presence of ulcerated gastric mucosa in the Meckel diverticulum.Non-steroidal anti-inflammatory drugs induce their gastric mucosal injury by inhibition of endogenous prostaglandin synthesis. This in turn leads to decrease in epithelial mucus, secretion of bicarbonate, mucosal blood flow, epithelial proliferation and mucosal resistance to injury. The impairment in mucosal resistance permits injury by endogenous factors, including pepsin, acid and bile salts, as well as by exogenous factors such as NSAIDs [2]. A similar case of a 27-year-old man with bleeding from ulceration in the ectopic gastric mucosa of a Meckel diverticulum while taking a NSAID has been reported [3]. A study of adult population which analysed surgical specimens of Meckel diverticulum, found 10 out of 58 specimens had heterotrophic gastric mucosa. Four out of ten with heterotropic gastric mucosa had acute intestinal haemorrhage, and a history of previous oral administration of NSAIDs was positive in three [4].Although rare it should be remembered a shortterm use of NSAIDs even in small amounts can play a major role in causing acute bleeding from a Meckel diverticulum.

The truth behind the "rule of twos" the Meckel diverticulum revised

“…stemming from an adhesion after diverticulitis [32,34] or from a mesodiverticular band [35,36]; or iii) incarceration of a Littre hernia [37]; iv) pathologic intussusception. Hemorrhage is rare after the age of two but the MD remains the most common source of bleeding from the small intestine through all ages [38]. Thus, a ''rule of three'' would better apply to the symptom triad of the MD: hemorrhage, inflammation, and intestinal obstruction.…”

“…A pathogenetic role of Helicobacter pylori was often suspected but has not been proven so far [23,24,44]; and the contribution non-steroidal anti-inflammatory drugs (alone or in combination with anticoagulants or platelet aggregation inhibitors) is unclear, especially when concomitant acid-suppressing drugs are applied [45][46][47]. H2-receptor blockers for their part are certainly effective on ectopic parietal cells because they can be used, similar to pentagastrin [48], to enhance the sensitivity of ''Meckel'' scans [21].…”

NSAID-Associated Perforation of a Meckel’s Diverticulum: A Case Report

“…Mathur et al described the first case of NSAID-associated GI bleeding from Meckel’s diverticulum in an adult [4]. Khosa et al described a similar case of NSAID-associated bleeding in a 6-year-old boy [8]. …”