Pediatric Meckel’s Diverticulum

00:02 Let’s shift gears a little bit and talk about another type of presentation.

00:06 Here’s a five-year-old girl who’s coming into the emergency department with bloody and occasionally melanotic stools.

00:12 Lab works shows that she’s got a little bit of an iron deficiency anemia.

00:17 She denies pain.

00:19 And according to mom, other than strange stools, she’s been relatively asymptomatic.

00:26 We like to think of the appendix as an outpouching of intestinal material around the cecum.

00:33 And in this case, this is another one that happens in only a smaller percentage of the population.

00:38 So this is going to be a Meckel’s diverticulum.

00:44 The Meckel’s diverticulum is a failed involution of the vitelline duct.

00:50 As you can see on the slide here, it’s generally an outpouching, a diverticulum, of the intestine that’s heading up towards the umbilicus.

01:01 This is the most common true diverticulum in humans.

01:05 And it’s the common congenital malformation of the GI tract.

01:13 So an important rule to remember is the rule of twos.

01:17 This is highly likely to show up on a multiple choice exam.

01:23 So Meckel’s diverticulums occur in 2% of the population.

01:29 They are two times as common in males than they are as females.

01:34 They are generally 2 inches long.

01:37 They generally occur 2 feet before the ileocecal valve.

01:43 And so if you can remember those rules of twos, you’ll be in good shape on the exam that you’re going to take.

01:50 Generally, these patients will present with bleeding from their Meckel’s and we’ll talk about why in a second.

01:56 But you’ll see that they’ll have melanotic or black stools.

02:00 They may have bloody stools or rectal bleeding.

02:04 But in general, they’ll be asymptomatic, they won’t have pain from this.

02:08 It will just be a brisk GI bleed.

02:12 Occasionally, they can develop bowel obstruction and occasionally, they may get some anemia as well.

02:19 Generally, it’s a slow bleed.

02:21 So they may have an iron deficiency anemia from simply not replacing their body iron stores as they’re making new blood to replace the old blood.

02:31 The bowel obstruction may be from something called an intussusception and we’ll learn about that in another talk but keep that in mind.

02:41 The way we test for a Meckel’s diverticulum is by using a radionucleotide scan, a technetium-99m pertechnetate scan.

02:53 And we’re going to look for gastric mucosa that is outside the stomach.

03:00 So you can see here that mucus cells have taken up the pertechnetate and they’ve done it as where the arrow shows on this slide at the level of a Meckel’s, which is outside the stomach, which is the large dark blob that you can see at the top of the slide.

03:19 70% of cases of a Meckel’s will be found this way.

03:25 But that means that 30% of cases of Meckel’s will not.

03:30 So if we suspected a Meckel’s that will not, we’ll look for other imaging modalities like ultrasound, MRI, and CAT scan like we did in the appendicitis.

03:41 How do we treat a Meckel’s? Simply just like we did in appendicitis, this requires a surgical excision.

03:51 So in summary, those are two common problems in children which are outpouchings or diverticuli of the intestinal wall that can cause problems in children.

04:03 Meckel’s is a painless bleed whereas the appendicitis is an acute infection.

04:08 Thanks for your attention.