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Gastrointestinal bleeding in a young male

Published:January 13, 2020DOI:https://doi.org/10.1016/j.ejim.2019.12.020

      1. Case description

      A previously healthy 17-year-old male was admitted for pain in the right lower quadrant of the abdomen and emission of blood with stools. Abdominal angio-CT (computed tomography) was negative for active bleeding sources, esophagogastroduodenoscopy showed grade B esophagitis, two colonoscopies could not identify the source of hemorrhage. Bleeding continued during observation; hemoglobin dropped from 13 g/dl at admission at 10 g/dl at 48 h. Capsule endoscopy identified bleeding from the distal ileus. Technetium (Tc) 99-m pertechnetate scintigraphy demonstrated gastric and right lower quadrant enhanced uptake (Fig. 1A). A laparoscopic intervention removed the cause of bleeding (Fig. 1B).
      Fig 1
      Fig. 1(A) Technetium (Tc) 99-m pertechnetate scintigraphy demonstrated gastric and right lower quadrant enhanced uptake (arrow). (B) Surgical specimen.

      2. What is the diagnosis?

      2.1 Diagnosis

      Scintigraphy was suggestive for Meckel diverticulum (MD) (indicated with arrow in Fig. 1A). Laparoscopy confirmed the diagnosis after identifying a 4 cm length diverticulum proximal to the ileocecal valve (Fig. 1B; opened gross specimen of MD; arrow indicates intestinal mucosa, arrowhead indicates gastric mucosa).
      MD is the most common congenital anomaly of the small bowel, due to an incomplete omphalomesenteric duct obliteration: it can be found in 2–4% of general population, with male prevalence, although symptomatic cases are 4–16% [
      • Hansen C.C.
      • Søreide K.
      Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century.
      ]. The diverticulum is usually 5 cm long (0,4 – 11 cm) and localize 60 cm (7–200 cm) proximal to the ileocecal valve [
      • Hansen C.C.
      • Søreide K.
      Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century.
      ]. Histologic examination can reveal gastric or pancreatic ectopic tissue [
      • Hansen C.C.
      • Søreide K.
      Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century.
      ].
      The majority of symptomatic cases occurs in children under 10 years of age, being rare in adults [
      • Hansen C.C.
      • Søreide K.
      Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century.
      ]. Clinical presentation is related to MD complications: diverticulitis, small-bowel obstruction, gastrointestinal bleeding [
      • Hansen C.C.
      • Søreide K.
      Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century.
      ].
      Abdominal CT is rarely diagnostic for MD. Capsule endoscopy is recommended for patients with overt gastrointestinal bleeding and negative endoscopy [
      • Chatterjee A.
      • Harmath C.
      • Vendrami C.L.
      • Hammond N.A.
      • Mittal P.
      • Salem R.
      • et al.
      Reminiscing on remnants: imaging of meckel diverticulum and its complications in adults.
      ]. Double-balloon endoscopy is an alternative technique that allows direct visualization of the diverticulum [
      • Chatterjee A.
      • Harmath C.
      • Vendrami C.L.
      • Hammond N.A.
      • Mittal P.
      • Salem R.
      • et al.
      Reminiscing on remnants: imaging of meckel diverticulum and its complications in adults.
      ].
      Nuclear scans with Technetium (Tc) 99-m pertechnetate may visualize the MD using the accumulation of the tracer in ectopic gastric tissues: specificity and sensibility are high in children, but lower in adults [
      • Irvine I.
      • Doherty A.
      • Hayes R.
      Bleeding meckel’s diverticulum: a study of the accuracy of pertechnetate scintigraphy as a diagnostic tool.
      ]. H2 antagonists can be used to increase the sensibility of the exam [
      • Irvine I.
      • Doherty A.
      • Hayes R.
      Bleeding meckel’s diverticulum: a study of the accuracy of pertechnetate scintigraphy as a diagnostic tool.
      ].
      Diverticulectomy is the recommended treatment of complicated cases of MD [
      • Hansen C.C.
      • Søreide K.
      Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century.
      ]. Management of uncomplicated MD is still controversial [
      • Hansen C.C.
      • Søreide K.
      Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century.
      ].

      References

        • Hansen C.C.
        • Søreide K.
        Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century.
        Medicine. 2018; 97: e12154
        • Chatterjee A.
        • Harmath C.
        • Vendrami C.L.
        • Hammond N.A.
        • Mittal P.
        • Salem R.
        • et al.
        Reminiscing on remnants: imaging of meckel diverticulum and its complications in adults.
        Am J Roentgenol. 2017; 209: W287-W296
        • Irvine I.
        • Doherty A.
        • Hayes R.
        Bleeding meckel’s diverticulum: a study of the accuracy of pertechnetate scintigraphy as a diagnostic tool.
        Eur J Radiol. 2017; 96: 27-30