Meckel's diverticulum medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Initially, the medical management of a symptomatic case of Meckel's diverticulum is directed toward management of clinical manifestations of complications. Intravenous lines for fluid and electrolyte therapy, nasogastric decompression for patients with symptoms and signs of intestinal obstruction, proton-pump inhibitors and Aluminum hydroxide for patients with gastrointestinal bleeding are preferred. The process of initial resuscitation in patients with lower gastrointestinal bleeding due to Meckel's diverticulum) is similar to the steps followed in any case of lower GI bleeding.

Medical Therapy

• Initial medical management of symptomatic Meckel's diverticulum is directed toward management of clinical manifestations of complicated cases of Meckel's diverticulum associated with:
  • Hemorrhage
  • Perforation of the bowel
  • Diverticulitis
  • Small bowel obstruction
  • Ulceration
  • Intussusception
  • Peritonitis
• In order to manage complications, treatment administered is as follows:
• Intravenous lines for:
  • Fluid therapy
  • Electrolyte therapy
• Nasogastric decompression for patients with symptoms and signs of intestinal obstruction
• For patients with gastrointestinal bleeding:
  • Proton-pump inhibitor therapy
  • Aluminum hydroxide

Initial Resuscitation in patients with lower gastrointestinal bleed due to Meckel's diverticula

The process of initial resuscitation in patients with lower gastrointestinal bleeding due to any pathology (including Meckel's diverticulum) is similar and includes the steps enlisted below.

Initial Evaluation

• In patients with acute lower gastrointestinal bleeding who are unstable, rapid assessment and resuscitation should be initiated even before diagnostic evaluation.
• The initial steps in the management of a patient with lower gastrointestinal bleeding are to assess the severity of bleeding, and then institute fluid and other measures of resuscitation as needed.
• Once hemodynamic stability is achieved, nasogastric lavage should be performed to rule out an upper GI source.
• Equilibration between the intravascular and extravascular volumes cannot be achieved until 24 to 72 hours after bleeding has occurred.

Role of Nasogastric tube (NGT)

• Nasogastric tube (NGT) lavage is recommended in all patients with lower gastrointestinal bleeding, once the patient is stabilized.
• A carefully placed nasogastric tube (NGT) with irrigation and aspiration of bile is necessary to ensure sampling of duodenal contents.
• If there is a bloody NGT aspirate, then an esophagogastroduodenoscopy (EGD) is warranted (11 to 15% of cases of “negative” NGT aspirates are due to upper GI bleeding).
• Obtaining clear fluid favors a lower GI source of bleeding.

Workup and Initial Management
Initial Evaluation	Airway, Breathing, Circulation
Supportive Therapy	Ensure patent and protected airway Intubate if needed Consider mechanical ventilation 2 large-bore, peripheral intravenous lines Can consider large-bore central venous catheter or intraosseous line if rapid transfusion is needed
Blood transfusion	Resuscitate with 1:1:1 of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets Consider massive transfusion protocol Target hemoglobin=7 mg/dL Consider Sengstaken-Blakemore tube for control of immediately life-threatening upper GI bleeding

Assessment of severity of bleeding

Bleeding severity	Vital signs	Blood loss
Minor	Normal	<10%
Moderate	Postural hypotension	10-20%
Severe	Shock	>25%

Fluid resuscitation

• Two large caliber (16-gauge) peripheral catheters or a central venous line should be inserted in patients who are hemodynamically unstable.
• The rate of fluid resuscitation is proportional to the severity of bleeding with the goal of restoring and maintaining the patient’s blood pressure.
• Infusion of 500 mL of normal saline or lactated Ringer's solution over 30 minutes is the preferred treatment for patients with active bleeding before blood type matching and blood transfusion.
• Intensive monitoring with a pulmonary artery catheter is recommended to monitor the response of initial resuscitation efforts and any complications of fluid overload.
• If the blood pressure fails to respond to initial resuscitation, the rate of fluid administration should be increased and urgent intervention (eg, angiography) should be considered.

Blood transfusion

• Patients with severe bleeding need to be transfused.
• Fresh frozen plasma, platelets, or both should be given to patients with coagulopathy who are actively bleeding and to those who have received more than 10 units of packed erythrocytes.

Indications for transfusion
Age	Target Hematocrit
Elderly patient ( >45)	30%
Younger patient (<45)	25%
Patients with portal hypertension	28%

Triage and consultations

• Visible rectal bleeding warrants an immediate evaluation in all cases. The timing and setting of the evaluation depends upon the severity of bleeding and the patient comorbidities.
• A gastroenterology consultation should be obtained early in the hospital course of patients with acute lower GI bleeding.

Evaluation setting	Patient catagories
ICU	Patients with high-risk features
Outpatient	Patients with low-risk features†
Regular Ward	Most other patients can be admitted to a regular medical ward♦
†: Low-risk features include a young, otherwise healthy patient with minor, self-limited rectal bleeding suspected to be from an anal source) ♦: Requires continuous electrocardiogram monitoring and pulse oximetry.

Risk stratification

• Clinical features can predict the risk of complications in patients with presumed acute lower GI bleeding. These features may also be used to categorize patients as either low or high risk.
• The presence of more number of high-risk features directly correlate with the likelihood of a poor outcome.

High-risk features

Hemodynamic instability (hypotension, tachycardia, orthostasis, syncope) Persistent bleeding Significant comorbidities Advanced age Bleeding that occurs in a patient who is hospitalized for another reason A prior history of bleeding from diverticulosis or angiodysplasia Current aspirin use Prolonged prothrombin time A non-tender abdomen Anemia An elevated blood urea nitrogen level An abnormal white blood cell count

Medical Therapy

Pharmacotherapy is only used as an adjuvant therapy for patients with lower GI bleed due to Meckel's diverticulum. Epinephrine is used alone or in conjunction with other surgical techniques. Local injection of epinephrine stops bleeding by both pressure tamponade and the vasoconstrictor effect. In patients with re-bleeding, surgery should be considered.

Dosage

• Preferred regimen (1): Local injection of 1:10,000 to 20,000 solution (Intra-arterial epinephrine infusions begin at a rate of 0.2 U/min. If the bleeding persists, the rate of the infusion is increased to 0.4-0.6 U/min).
• Note:- The bleeding stops in about 91% of patients receiving intra-arterial epinephrine but recurs in up to 50% of patients when the infusion is stopped.

Major contraindications

• Closed-angle glaucoma
• Labor
• Shock
• Sulphur hypersensitivity
• CAD, PAD

Complications

During vasopressin infusion, patients must be monitored for:

• Recurrent hemorrhage
• Myocardial ischemia (Nitroglycerine drip can be used to overcome cardiac complications)
• Arrhythmias
• Hypertension
• Volume overload with hyponatremia