Meckel

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Meckels diverticulum presenting as small bowel
obstruction

• ??????? Dr. ???

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Clinical Course

• At ward
• NG coffee-ground with bile contain (160ml)
• Low urine output with dropping BP 86/42 despite
  NS challenge
• Use three combined antibiotics (Ampicillin, GM,
  Metronidazole)
• Follow Abdominal echo persistent bowel
  distension, bowel wall thickening, no target
  sign, increase ascites amount
• Consult Pediatric surgeon suggest operation
• Sent to OR 12 hours later

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OP Findings and pathological report

• Dilated distal half of small bowel
• Meckels diverticulum ( 5 x 3 x 1 cm ) which was
  30cm away from ileocecal valve with fecal
  obstruction 5cm in length
• Resection 15cm of ileum, Clear ascites 100ml
• Diverticulum lined by small intestine mucosa with
  focal lymphocyte infiltration.
• The muscular wall of diverticulum is thin.
• No ectopic gastric or pancreatic tissue
• Surrounding ileal mucosa is unremarkable

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Discussion

• Intestinal obstruction
• Meckels diverticulum

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Cause of gastrointestinal obstructionsmall
intestine Nelson 17th

• Congenital
• Duodenal atresia
• Annular pancreas
• Malrotation / volvulus
• Malrotation / Ladd bands
• Ileal atresia
• Meconium ileus
• Meckels diverticulum with volvulus or
  intussusception
• Inguinal hernia
• Intestinal duplication

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Cause of gastrointestinal obstructionsmall
intestine Nelson 17th

• Acquired
• Postsurgical adhesions
• Crohns disease
• Intussusception
• Distal ileal obstruction syndrome ( cystic
  fibrosis )
• Duodenal hematoma
• Superior mesenteric artery syndrome

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Differentiation between simple and strangulating
obstruction

• Signs of shock, acidosis, and peritonitis, and
  abdominal wall often doughy and erythematous
• Fever, feculent vomiting, absent bowel sound,
  localized abdominal tenderness, and leukocytosis

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Meckels diverticulum
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Meckels diverticulum

• Lifetime complication around 4 including
  perforation, obstruction, inflammation,
  hemorrhage, herniation, neoplasm, umbilical
  fistula, ulceration
• Half of them occur before 2 years old
• Longer ( 4 cm ), broad base ( 2 cm )

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Obstruction in Meckels diverticulum

• Meckels diverticulum may be associated with
  partial or complete bowel obstruction.
• Act as a lead point of an intussusception ( more
  common in older male children )
• Intraperitoneal bands connecting residual
  omphalomesenteric duct remnants to the ileum and
  umbilicus
• 
  Nelson 17th edition

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Meckels diverticulum causing intestinal
obstruction The
American journal of gastroenterology December 2001

• 31 y/o man with recurrent vomiting and abdominal
  pain
• The apex of the Meckels diverticulum adhesion to
  the mesentery, making an obstructing fold in the
  adjacent small bowel
• Bowel loops proximal to the obstruction were
  dilated, adhesive band was lysed, unfolding the
  bowel and diverticulectomy was performed

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10 different ways for Meckels diverticulum can
cause bowel obstruction

1. Intussusception
2. Fibrous band persisting between the MD and the
   umbilicus causing a volvulus
3. Internal hernia caused by a loop of bowel trapped
   between the mesentery and the mesodiverticular
   band, mechanically compress the ileum
4. Litters hernia where MD obstructed in an
   external hernia
5. MD causing inflammatory reaction and adhesion
   with surrounding bowel cause obstruction

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10 different ways for Meckels diverticulum can
cause bowel obstruction

• 6. Obstruction of the neck of MD enlargement and
  compress the bowel lumen
• 7. Obstruction by a large enterolith in the MD
• 8. Torsion of MD on its own axis
• 9. Extrusion of the ileum through a persistent
  omphalomesenteric duct out of the abdomen
• 10. True knot involving MD and another hollow
  viscus

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Thank you for attention