Meckel’s diverticulum: new solutions for an old problem?

Abstract

Meckel's diverticulum (MD) is the most commonly encountered true diverticulum in the small bowel. Although overall a rare cause of gastrointestinal bleeding, it remains an important differential in a child/young adult presenting with lower gastrointestinal bleeding. We present two MD cases, one associated with brisk bleeding resulting in haemodynamic instability and the other in insidious blood loss causing symptoms of chronic iron deficiency. These cases illustrate the heterogeneous nature of the clinical picture associated with Meckel's diverticulae, a condition most gastroenterological and surgical units will encounter. We subsequently discuss the diagnostic and management dilemma Meckel's diverticulae pose and appraise the latest evidence and management strategies in this regard. CASE HISTORIESA 21-year-old previously well man presented with a 24 h history of melaena and pre-syncope. He was haemodynamically stable on admission with the clinical examination revealing conjunctival pallor and melaena on digital rectal examination. The patient specifically denied taking any medication including nonsteroidal anti-inflammatory drugs.Admission haemoglobin was documented as 11.3 g/dL. Admission blood tests including a coagulation profile were within normal limits. Emergent oesophagogastroduodenoscopy was normal.The patient continued to bleed overnight passing fresh melaena, eventually developing hypovolaemic shock. Four units of packed red blood cells and intravenous fluids were administered; both CT angiography and colonoscopy were non-diagnostic at this point. A Meckel's diverticulum (MD) was suspected and a diagnostic radionuclide SPECT/CT (single photon emission CT/CT) using technetium-99 m pertechnetate was performed ( figure 1). This is a relatively new type of imaging procedure where the patient undergoes a CT scan and an isotope scan on the same gantry without moving between scans. This allowed the functional abnormality seen on the isotope study to be precisely localised using the CT anatomy. A MD was thus diagnosed. The patient underwent a limited small bowel (3 cm) surgical resection (excised bowel-figure 2), made a good recovery and was discharged 2 days later.The second case involves a 17-year-old boy who presented to our emergency department with symptoms of extreme fatigability, exertional dyspnoea and malaise. Initially insidious, these symptoms had markedly worsened in the 2 weeks prior to admission. Admission observations were normal but admission haemoglobin was documented at 6.6 g/dL (microcytic, hypochromic), with a marked hypoferritinaemia (ferritin 3 mg/L); the remaining blood tests (including a coeliac screen) were normal. Nothing significant was noted in the past medical, family or drug history. The patient denied alcohol consumption. Clinical examination revealed conjunctival pallor and digital rectal examination ruled out melaena or fresh rectal bleeding.The patient was transfused due to symptomatic anaemia and a CT scan of the chest, abdomen and pelvis was conducted. This was norm...