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Case 7

                                                                                         Contributors

                                           Dr.Ambika Sunil Gayad, Dr.S.K.Joshi

                                                                                Dr. Radha

Diagnosis

Meckel's Diverticulum with diverticulitis

Radiological Findings, Disease course, and Management

 

                        High Resolution Ultrasound Abdomen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

Findings

  • Well defined,non-compressible blind ending tubular structure with thickened hypoechoic walls and surrounding inflammatory changes in the umbilical region

  • Tubular structure closely abuts the small bowel loops with possible communication within it

                    

                 Meckel’s diverticulum scintigraphy 

    Findings did not suggest ectopic gastric mucosa                            

                 

                 Contrast Enhanced CT (CECT) of Abdomen                                                          

                                      

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

Findings

  • Blind-ending fluid filled tubular structure with enhancing walls in the abdominal cavity deep to the umbilicus, possibly arising from adjoining small bowel loop.

  • Wall to wall diameter 12 mm, Length approximately 2 cm.

  • Significant inflammatory changes noted in the adjacent fat

  • Abnormal SMA/SMV relationship noted with whirling of mesenteric vessels adjacent to the enhancing lesion described above,could represent adhesions.

  • DJ flexure is seen to the left of midline.

  • Appendix is visualized,appendicolith seen at the tip. No signs of inflammation noted.

Diagnosis

 Features suggest possiblity of Meckel’s diverticulitis

Course

    Laparoscopic  surgery was performed

    Operative findings:       

  • Meckel’s attached to the umbilicus.

  • Wedge excision of diverticulum done.

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Histopathology

  • Mucosa made of tall columnar cells and submucosa. Lamina propria show gastric type of glands with eosinophilic granular cytoplasm

  • Features consistent with Meckel’s diverticulum.

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Discussion

Meckel’s diverticulum

  • small bowel appendage

  • normal anatomic variant found in 0.3-3% of the population

  • True diverticulum, contains all layers of the small bowel

  • Called a "second appendix"

  • Embryologically, remnant of the omphalomesenteric duct

  • Failure of duct obliterration by 7weeks gestation results in        fistulas, enterocysts, adhesions, and Meckel’s diverticula

  • Mostly asymptomatic            

  • Complications include painless haemorrhage,Meckel’s diverticulitis

  • Diverticula may contain ectopic gastric mucosa which can secrete acid, thereby causing inflammation.

  • Inflammation could also be due to obstruction of the diverticular neck by an enterolith, faecolith, foreign body, or neoplasm leading to stasis and infection within the diverticulum 
     

Radiological Findings

 

Ultrasonography :

    May show a blind ending peristaltic loop connected to the small bowel.

 

Computed tomography 

 In presence of Meckel’s diverticulitis, diverticulum is seen as  

  • blind,antimesenteric,

  • 1-10 cm long tubular pouch attached to the ileum by its neck within 100 cm (medial) of the ileocaecal junction 

  • contains fluid or air

  • May remain attached to the umbilicus, distinguishing it from small bowel

  • Inflammatory changes: mural thickening with mesenteric fat stranding, presence of free fluid. Contrast enhancement. 

  • Absence of oral contrast in the diverticular lumen .

  • Appendix appears normal, excluding appendicitis 

 

​Scintigraphy

 99mTc-Na-pertechnetate scinigraphy

  • preferred modality

  • limited sensitivity

  • helpful in diagnosis of diverticula having ectopic gastric mucosa because pertechnetate is taken up by mucin secreting cells of gastric and ectopic gastric mucosa

 

Complications

  • Perforation and peritonitis

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Differential Diagnosis 

  • Intestinal duplication cyst

  • Mesenteric cyst

  • Appendicitis

  • Ileal diverticulitis

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References

 

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