Meckel's diverticulum natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Intestinal torsions around the intestinal stalk may also occur, leading to obstruction, ischemia, and necrosis. If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

OR

Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

OR

Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

Natural History, Complications, and Prognosis

Natural History

• The symptoms of (disease name) usually develop in the first/ second/ third decade of life, and start with symptoms such as ___.
• The symptoms of (disease name) typically develop ___ years after exposure to ___.
• If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

Complications

• Common complications of Meckel's diverticulum include:
  • Hemorrhage
  • Perforation of the bowel
  • Diverticulitis
  • Small bowel obstruction
  • Ulceration
  • Intussusception
  • Peritonitis

Hemorrhage

• Most common complication in patients with Meckel diverticulum
• Accounts for one fourth of all complications
• More commonly seen in:
  • Children younger than 2 years
  • Male sex

• Presentation:
  • Patients present with the following symptoms:
    • Passage of bright red blood in the stools
    • May or may not be associated with:
      • Abdominal pain (usually painless)
      • Weakness
      • Anemia
    • Bleeding may be:
      • Minimal
      • Recurrent
      • Massive, shock-producing
    • Assessment of the rate of bleeding may be done on the basis of the following:
      • Quantity of blood lost in the stools
      • Appearance of the material passing through the rectum
      • Hemodynamic state
    • Characteristics of hemorrhage based on the appearance of stools include the following:
      • Brisk hemorrhage: bright red blood in the stools
      • Minor upper GI bleeding, associated with delayed intestinal transit causing alteration of blood: Tarry stools
      • Intussusception: Currant jelly stools with copious amounts of mucus due to bowel ischemia
      • Fissure-in-ano: Blood-streaked stools
    • The gastric mucosa found in the diverticulum may form a chronic ulcer and may also damage the adjacent ileal mucosa because of acid production. Ectopic gastric mucosa is found in about 50% of all Meckel's diverticula; and three fourths of bleeding Meckel's diverticula.
    • Perforation may occur, and the patient then presents with an acute abdomen, often associated with air under the diaphragm, best visualized on an erect chest radiograph.

• Characteristics of hemorrhage based on the appearance of stools include the following:
  • Brisk hemorrhage may present as bright red blood in the stools
  • Minor upper GI bleeding, associated with delayed intestinal transit causing alteration of blood may present as tarry stools
  • Intussusception may present as currant jelly stools with copious amounts of mucus due to bowel ischemia
  • Fissure-in-ano may present with blood-streaked stools
• Ectopic gastric mucosa is found in about half of all cases of Meckel's diverticula; and three fourths of all the cases of bleeding Meckel's diverticulae.
• Panendoscopy may help detect GI bleeds from the two most common sites:
  • Upper GI tract
  • Colorectal region

Perforation

• Perforation may present as:
  • Acute abdomen
  • Erect CXR: Air under the diaphragm

Intestinal obstruction

• Presentation:
  • Abdominal pain
  • Vomiting
  • Obstipation
• In case of intussusception, patient may also present with:
  • palpable lump in the lower abdomen
  • currant jelly stools
• Radiography of the abdomen may indicate:
  • Ileus
  • Stepladder air-fluid levels, as seen in dynamic intestinal obstruction
• Observed in one fourth of patients with symptomatic Meckel's diverticulum
• Various mechanisms of intestinal obstruction occur with Meckel's diverticulum:
  • Volvulus: The omphalomesenteric duct may be attached to the wall of the abdomen by a fibrotic band, and volvulus of the small bowel around the band may occur.
  • Intussusception: An intussusception is a blockage in the intestines caused by folding of the intestines. The lead point of the intussusception may be:
    • Diverticulum
    • Tumor arising in the wall of the diverticulum
  • Littre hernia: The incarceration of a Meckel's diverticulum in an inguinal hernia is called a Littré hernia.

Diverticulitis

• occurs in approximately 10-20% of patients with symptomatic Meckel's diverticulum

• seen in the elderly population
• Presentation:
  • intermittent, crampy abdominal pain
  • tenderness in the periumbilical area

• Mechanism:
  • Stasis in the diverticulum, particularly in one with a narrow neck leads to:
    • Inflammation
    • Secondary infection
    • Adhesions may develop due to diverticular inflammation causing symptoms of intestinal obstruction
    • Peritonitis: perforation of the inflamed diverticulum may lead to inflammation of the peritoneum, which is a thin tissue that lines the inside of the abdomen. 

Umbilical anomalies

These occur in up to 10% of patients and consist of fistulas, sinuses, cysts, and fibrous bands between the diverticulum and the umbilicus. A patient may present with a chronic discharging umbilical sinus superimposed by infection or excoriation of periumbilical skin. There may be a history of recurrent infection, sinus healing, or abdominal-wall abscess formation. When a fistula is present, intestinal mucosa may be identified on the skin. Cannulation and injection with radiographic contrast help to delineate the entire tract and aid in planning a surgical approach for cure. A discharging sinus should be approached surgically with a view toward correction. Exploratory laparotomy may be required. When found at laparotomy, a fibrous band should be excised because of the risk of internal herniation and volvulus.

Neoplasm

This is the pathology least commonly associated with Meckel diverticulum and is reported in approximately 4-5% of complicated Meckel diverticulum cases. Of the various types of tumors reported, leiomyoma is the one that is most frequently found, followed by leiomyosarcoma, carcinoid tumor, and fibroma. One case of ectopic gastric adenocarcinoma has been reported. Lipoma and angioma have also been found. [4, 5]

Other complications

Other reported complications in Meckel diverticulum are vesicodiverticular fistulas, "daughter" diverticula (formation of a diverticulum within a Meckel diverticulum), and formation of stones and phytobezoar in the Meckel diverticulum. Children and infants are at the highest risk for complications, and for some reason, complications occur more often in males than females. Due to this, males are more frequently diagnosed with Meckel’s Diverticulum than females.

The possible complications with Meckel’s Diverticulum include:

A blockage in the intestines caused by folding of the intestines (intussusception)

Abnormal and excessive bleeding arising within the diverticulum

Injury to the diverticulum may result in perforation of the bowel wall

Inflammation of the peritoneum, which is a thin tissue that lines the inside of the abdomen

Rarely, tumors can occur within a Meckel’s Diverticulum. The most common tumor includes carcinoid tumors and gastrinomas. These tumors arise from abnormal collection of neuroendocrine cells or gastrin hormone producing cells

Prognosis

Prognosis of patients with Meckel's diverticulum is as follows:

• Depending on the extent of the symptom progression at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as excellent in cases where symptomatic Meckel's diverticulum is treated in a timely manner.
• Complete recovery may be expected with surgery.
• The risk of developing complications in the postoperative period is 2-7%, the most common complication being bowel obstruction.
• The risk of developing complications such as perforation, inflammation, bleeding and obstruction in asymptomatic patients with Meckel diverticulum is 4-6.4%.