The trouble with investigating anaemia in young adults: bleeding from a giant Meckel's diverticulum without ectopic gastric mucosa

Abstract

A 21-year-old man collapsed with anaemia (haemoglobin < 6 g/dl). He underwent immediate oesophagogastroduodenoscopy and colonoscopy which were both normal. The bleeding stopped spontaneously and, following a blood transfusion, he made a rapid recovery. His repeat blood tests showed a haemoglobin of 11.6 g/dl, mean corpuscular volume (MCV) 74 fl, platelet count 398 x 10 9 /l, ferritin 37 ng/ml and normal clotting. A barium study demonstrated a large saccular viscus in the pelvis containing food debris but it was not possible to determine whether these areas were diverticula or saccular parts of the bowel. A computed tomography (CT) scan of the abdomen revealed a large gas and debris-filled structure in the pelvis. Again, it was not possible to determine from which loop of bowel it arose but there was the suggestion of a vitelline artery supplying it. An isotope Meckel's scan using 99m-technetium pertechnatate was performed and this showed normal uptake by the gastric mucosa and normal passage of tracer distally from the stomach. However, there was no uptake seen in right iliac fossa to suggest a Meckel's diverticulum. The area that corresponded to the abnormal viscus was represented by a photopaenic area with no isotope activity within it.Soon after, he was admitted to hospital as an emergency with massive rectal haemorrhage. He underwent laparotomy when a giant Meckel's diverticulum was found. The middle of the diverticulum measured 8 cm in diameter and, on slicing, revealed the presence of a large blood clotThe trouble with investigating anaemia in young adults: bleeding from a giant Meckel's diverticulum without ectopic gastric mucosa S TANG, A ZAIDI Department of Surgery, St Helier Hospital, Carshalton, Surrey, UKABSTRACT Giant Meckel's diverticulum is rare and usually presents in childhood with haemorrhage or bowel obstruction. Bleeding results from the presence of ectopic gastric mucosa causing peptic ulceration of adjacent mucosa. We discuss the case of a 21-year-old man with a giant Meckel's diverticulum who presented with rectal bleeding. A Meckel's scan was negative and histology following surgical excision ruled out the presence of ectopic gastric mucosa. There was however evidence of chronic inflammation and small bowel mucosal ulceration. We hypothesize that this arose from ischaemia and pressure necrosis because of the large size of the diverticulum and chronic distension by food debris. This case highlights the difficulties in investigating anaemia in young adults despite modern imaging techniques.

Giant Meckel’s Diverticulum as a Cause of Post-traumatic Hemoperitoneum in a 25-Year-Old Male: An Extremely Rare Phenomenon

“…We refrained from performing CT Abdomen due to the clear free fluid in the abdominopelvic cavity and the deteriorating hemodynamic parameters of our patient. Existing English scientific literature shows various radiographic signs in patients with GMD, like the triradiate fold pattern, whirlpool sign, mucosal triangular plateau, opacification, and gastric rugal pattern [3,[6][7][8].…”

“…Less than 0.5% of vitelline anomalies can be classified formally as Giant Meckel's Diverticula (GMD). Of the cases, 80% are asymptomatic, and the lifetime risk of developing a complication is 6.4% [ 6 ]. GMD has further classified into type 1 elongated and type 2 ovoid forms, depending on their gross morphology.…”

“…GMD has further classified into type 1 elongated and type 2 ovoid forms, depending on their gross morphology. Some authors reserve the term 'giant' for type 2 diverticula [ 6 ].…”

“…A similar study seeking the cause of anemia in a young male published in England highlights that 99m technetium-pertechnetate is highly reserved for the affected pediatric population. At the same time, computerized tomography (CT) scan is advocated for young adults [ 6 ]. The former has a higher sensitivity (85-90%) in the pediatric population than in adult (60%) patients [ 5 ].…”

“…We excised the 35cm long GMD and sutured the defect in the small bowel with Vicryl 3/0. Such lengthy MD has yet to be reported in English scientific literature [ 1 , 3 , 4 , 6 - 8 ].…”