Meckel’s Diverticulum with Gastrointestinal Bleeding: Role of Computed Tomography in Diagnosis

Abstract

Case Presentation and EvolutionA 26-year-old white male with a prior history of a benign cardiac arrhythmia and seasonal allergies presented with gastrointestinal bleeding and anemia. Two months prior to admission, he was seen in an urgent care clinic with intermittent, crampy left lower quadrant abdominal pain, worse 15-60 min after eating, and associated with alternating constipation and diarrhea. During that visit, a comprehensive metabolic panel, complete blood cell count and right upper quadrant ultrasound were normal. The patient was given the diagnosis of ''vigorous gastrocolic reflex'' and was successfully treated with MiralaxÒ.The patient remained in excellent health until 1 day prior to admission when he began to experience diffuse, infraumbilical, intense pain estimated to be six out of ten in severity, and an urge to defecate. While on the commode, he had an episode of transient pre-syncope. Two large, liquid maroon-colored stools and continuous bowel urgency prompted him to come to the emergency department.He denied any prior history of gastrointestinal bleeding, use of non-steroidal anti-inflammatory drugs, aspirin, alcohol or recreational drugs. He reported nausea but not vomiting and had no change in appetite or weight loss. His family history was negative for gastrointestinal malignancy. He was employed as a lawyer and had smoked one pack of cigarettes per day for 10 years.In the emergency department, his temperature was 36.2°C, pulse 67, blood pressure 97/60 mmHg, respiratory rate 20, and oxygen saturation 99% on room air. He was thin and well appearing, anicteric and slightly pale. There were no stigmata of chronic liver disease. Lungs were clear to auscultation bilaterally. Heart exhibited a regular rate and rhythm, without murmurs, rubs or gallops. His abdomen was soft, nontender and not distended; there was no organomegaly or palpable masses. Rectal examination revealed normal anal tone, no masses and liquid maroon stool.Two large bore intravenous catheters were placed, a 1-L saline bolus was given, and a nasogastric tube was placed without return of blood or bile. Laboratory tests showed white blood cell count 7,900/mm 3 , hematocrit 36.8%, platelet count 123,000/mm 3 , sodium 137 mmol/L, cloride 103 mmol/L, carbon dioxide 29 mmol/L, blood urea nitrogen 22 mg/dL, and creatinine 1.0 mg/dL. Liver function tests were normal. He was admitted to the general medical service, kept fasting with an active blood bank sample, and stool studies were sent to rule out infectious colitis. A pantoprazole drip was empirically initiated. A colonoscopy was performed the following day after bowel preparation, and blood was seen throughout the colon and terminal ileum.Twenty-four hours later, in the setting of continuous rectal bleeding, his hematocrit dropped to 24.2%. After a total of six units of packed red blood cells throughout the ensuing day, his hematocrit was 27%. In order to localize the source of bleeding, a computed tomography (CT) scan was performed using an angiography protocol. The CT revealed ac...

Computed tomography of complicated Meckel’s diverticulum in adults: a pictorial review

“…When active extravasation of contrast occurs in the terminal ileal loops, without underlying anomalies seen on CT, the diagnosis of bleeding Meckel’s diverticulum is most likely [24]. The differential diagnosis of an active hemorrhage in the terminal ileum takes into consideration bleeding from ruptured aneurysm of the ileocolic artery [25] or bleeding from vasculitis or angiodysplasia; the differential diagnosis also includes hemorrhage associated with an underlying small bowel tumor [26].…”

CT Detection of Symptomatic and Asymptomatic Meckel Diverticulum

“…The major reason for this limitation is that the adjacent small bowel is difficult to separate from a Meckel diverticulum [6]. With the improving spatial resolution and MPR and 3D capabilities of CT, the role of CT in the evaluation of intraabdominal conditions and diseases has increased and an increasing number of reports about the use of CT for the diagnosis of symptomatic Meckel diverticula have been published [7,11,[16][17][18][19][20][21][22][23].…”

“…There are reported cases of Meckel diverticulum causing gastrointestinal hemorrhage detected on CT, including cases with occult gastrointestinal hemorrhage using the CT enteroclysis technique [18,22], and cases of actively bleeding Meckel diverticulum with active contrast extravasation using the CT angiographic technique [17,21]. CT angiography typically detects active bleeding when the bleeding exceeds 0.3-0.5 mL/min, a rate that is slightly lower than the threshold assigned to catheter angiography (0.5 mL/min) and is higher than that of scintigraphy with 99m Tc-pertechnetate-labeled RBCs (0.1 mL/min) [25][26][27].…”

An elusive cause of black stool

“…The new technique of thin slice, highly sensitive, multidetector computed tomography scanning may be useful in the diagnosis of bleeding Meckel's diverticulum and its role will probably be investigated in the next few years. 4 However, the most widely used and well established diagnostic tool is radionuclide imaging using 99m Tc pertechnetate, a "Meckel's scan." 99m Tc pertechnetate is taken up and secreted by the tubular glands of the gastric mucosa.…”

“…Intestinal obstruction is another common complication, which can occur when the diverticulum serves as a lead point for herniation, intussusception, or volvulus. 4 Patients with Meckel's diverticulitis can present with symptoms and signs that mimic appendicitis. 7 Rarely tumours can be found within a Meckel's diverticulum (incidence of 0.5-3.2%).…”