A three-and-a-half-year-old boy is brought in because he passed about a teacup amount of fresh blood during a bowel movement. The color of the blood is pale, indicating significant blood loss. Normally, when children are brought in with complaints of bloody stools, common conditions like anal fissures or rectal polyps are considered, but they don’t typically cause such excessive bleeding. Moreover, if there were a tear or fissure, one would expect symptoms like pain and constipation. After a quick examination, no definitive signs are found. I stabilize his general condition and diagnose Meckel’s diverticulum bleeding with a scintigraphy test. Then, I perform a laparoscopy to remove the diverticulum, and he is discharged.
In the Pediatric Surgeon’s journal, I will discuss one of the reasons for gastrointestinal bleeding in children, Meckel’s Diverticulum. Enjoy!
In our last journal, I talked about a rare cause of umbilical discharge, urachus remnants, and the conditions they may cause. Some people criticized me for discussing such rare cases, but my goal is not to increase my subscriber count by covering popular topics. As pediatric surgeons, it is in our nature to deal with rare and obscure conditions that most people have never heard of. There is already a wealth of information available on common problems. If even one person finds this video useful, then it has fulfilled its purpose.
Now, let me explain what Meckel’s Diverticulum is. As I mentioned in the previous video, while discussing urachus remnants, I promised to talk about the situations that can arise when the connection between the intestines and the umbilical cord doesn’t completely disappear before birth. Normally, this connection vanishes around the 5th or 6th week of gestation. However, if it persists, it can cause problems, either as a fully open channel between the intestines and the umbilicus, closed at both ends, forming a cystic structure, or as a sinus with an opening at the umbilicus. In some cases, it can evolve into Meckel’s Diverticulum, a protrusion or outpouching in the small intestine.
Let me delve into some details.
In medical school, we used to memorize the “rule of twos” for Meckel’s Diverticulum. It occurs in about two percent of the population, is twice as common in boys compared to girls, is typically located about two feet (approximately 60 cm) from the end of the small intestine, and is usually around two inches (approximately 5 cm) in length. About two percent of cases may present problems around the age of two. Diverticula that cause bleeding contain two distinct types of tissue – resembling the lining of the stomach and the lining of the intestine.
So, this structure can be present in about two percent of the population, but it doesn’t always cause issues. While Meckel’s Diverticulum is generally clinically silent, it can cause headaches, especially in children, due to the bleeding caused by the presence of gastric mucosa. Unlike bleeding from anal fissures, there is no pain in the rectum, and blood might not be accompanied by stool during bowel movements. Instead, there can be a significant amount of bleeding. In some cases, it can become infected, causing abdominal pain similar to appendicitis. It can also cause intestinal obstructions by getting twisted around the intestines due to the remaining band of tissue between the diverticulum and the umbilicus. Occasionally, when telescoping into the intestines, it can cause intestinal blockages. Although very rare, around two percent, it can lead to the development of tumors, usually benign ones. Sometimes, this diverticulum can enter an existing hernia and cause problems. I once wrote a medical article about a Meckel’s Diverticulum trapped in an inguinal hernia, which we call a Littre hernia.
Anyway, let’s not get off track.
So, if a child is experiencing fresh blood from the anus without any abdominal pain, or if there are recurring intestinal obstructions at an unexpected age, or if they have symptoms resembling appendicitis even after their appendix has been removed, we consider the possibility of Meckel’s Diverticulum.
How do we make the diagnosis?
If the problem is bleeding, it means there is gastric mucosa present. We can visualize gastric mucosa by performing a Meckel scan, which involves using a nuclear substance directly attached to the stomach mucosa to detect any presence of gastric tissue outside the stomach. It can catch Meckel’s Diverticulum with about 85-90 percent sensitivity, and if it detects it, it is about 95 percent accurate. There is a five percent chance of false positives, especially if other conditions like duplication cysts or inflammatory bowel disease are present. Another diagnostic method is angiography, where we visualize the blood vessels, and if there is a separate vessel supplying the diverticulum, it can indicate its presence. In young adults, it can also be diagnosed through double-balloon or capsule endoscopy techniques. If our diagnostic methods are inconclusive but we highly suspect Meckel’s Diverticulum, surgery may be considered both as a diagnostic and therapeutic option.
The treatment, as you can guess, is surgical.
Do we perform surgery on all cases? For example, if Meckel’s Diverticulum is suspected by chance during another surgery?
If it is asymptomatic, we don’t do anything.
So, what do we do if we come across Meckel’s Diverticulum during surgery for another reason? If it is a child, it is recommended to remove it. In young adults, if it is longer than 2 cm, it is usually removed. If it’s an incidental finding in people over 50, and the Meckel’s Diverticulum looks normal and isn’t causing any issues, we leave it untouched.
Usually, we remove either just the Meckel’s Diverticulum itself or the entire segment of the intestine from which the diverticulum arises, depending on the appropriateness. The surgical technique is left to the surgeon’s discretion.
Let’s wrap up this presentation without dragging it on. Please click if you want to watch the the video, subscribe, and follow me on Instagram.
Stay happy!”
Prof. Dr. Egemen Eroğlu
June 2023