Dr.Subbulakshmi.P.S, Dr.Bhanu Vikraman Pillai, Dr.Jayakumar.C
AIMS, Kochi
Four year old male child presented to paediatric ER with the complaints of passing black tarry stools intermittently for past one week with no history of abdominal pain, loose stools, vomiting, fever or rash.
No History bleeding from any other sites
No history of taking iron preparations
Differentials:
● Infectious colitis
● Inflammatory bowel disease
● Meckels diverticulum
● Henoch scholein purpura
● Hemolytic uremic syndrome
Vitals were stable and growth parameters were appropriate for age.
On examination pallor was noted and there was no evidence of icterus/cyanosis/clubbing/lymphadenopathy/edema or bleeding tendency in the skin .Systemic examination were within normal limits.
Picture – BLACK TARRY STOOLS
Labs:
Total Count:8.04, Differentials HB7.6gm%N56,L37,M0,E0.4 ,Platelets: 301
LFT/RFT/S.Electrolytes were within normal limits
Peripheral smear was not done
In view of low Hb, the child was given PRBC transfusion. As the child didn’t have any other relevant symptoms, Meckels diverticulum was strongly suspected and further evaluated Tc99 schintigraphy (Meckels’s scan) which showed the presence of Ectopic mucosa in terminal ileum/proximal ascending colon further confirming Meckel’s.
Hence the child was planned for surgery and Meckel’s diverticulectomy was performed and biopsy done with the extracted tissue showed Meckel’s diverticulum with gastric heterotropia. Post operatively he was stable and discharged after a week of observation and advised for a regular follow-up.
Discussion:
Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract.
Meckel’s diverticulum is a true diverticulum that arises from the antimesenteric surface of the mid-to-distal ileum that results from incomplete obliteration of the vitelline duct.
Epidemiology – The rule of twos is the classic description of the essential features of Meckel’s diverticulum. Meckel’s diverticulum occurs in approximately 2 percent of the population with a male-to-female ratio of 2:1, is found approximately two feet from the ileocecal valve, and is approximately two inches long. Approximately 2 percent of patients develop a complication over their lifetime, typically before the age of two. Symptomatic Meckel’s diverticula most often contain two types of tissue: both native intestinal and heterotopic gastric mucosa.
Clinical presentations – Meckel’s diverticulum is often clinically silent; only 4 to 6 percent present with gastrointestinal bleeding or acute abdominal symptoms related to bowel obstruction, Meckel’s diverticulitis, or perforation. Between 25 and 50 percent of symptomatic patients present at less than 10 years of age
Diagnosis – Meckel’s diverticulum should be suspected in patients with the following clinical features :
● Children with painless lower gastrointestinal bleeding.
● Adults with gastrointestinal bleeding but negative upper endoscopy and colonoscopy
● Patients with features of appendicitis, particularly when the appendix has already been removed
● Children and adults with recurrent intussusception
A definitive diagnosis of Meckel’s diverticulum is generally made on imaging studies or surgical exploration.
Diagnostic evaluation – A suspicion for an intermittent bleeding Meckel’s diverticulum can be investigated with a Meckel’s scan, which identifies the presence of ectopic gastric mucosa within the diverticulum. A conventional or CT mesenteric arteriogram can be used to diagnose Meckel’s diverticulum with more brisk bleeding. Other abdominal symptoms are best investigated with a contrast-enhanced abdominopelvic CT scan.
When diagnosed, Meckel’s diverticulum can be surgically resected or observed.
Management of Meckel’s diverticulum is according to the clinical presentation:
● Symptomatic patients require surgical resection of the Meckel’s diverticulum.
● Asymptomatic patients with incidental, imaging-detected Meckel’s diverticulum do not require surgical resection. But this statement holds value for adults rather than in children.
● The management of asymptomatic patients with incidental, intraoperative finding of a Meckel’s diverticulum is controversial. Its decide based on the patient’s clinical status, their lifelong risk of Meckel’s-related complications, and anatomic features associated with developing symptoms.
Take home message- In children presenting with painless Gastrointestinal Bleeding, Meckels’ diverticulum should always be considered as a possibility. Also in children surgical resection of all incidentally found Meckel’s diverticulum during abdominal exploration because of higher risk of complications of Meckel’s diverticulum compared with adults