Slides - Pilgrims Hospital

Who was Hilidanus
A. Adegbesan,
Case 1
• 68 year old lady admitted with a 2 day history of
diffuse abdominal pain and vomiting.
• Acute onset intermittent sharp epigastric pain,
rated 7/10 with no aggravating or relieving
• Bowel motion and flatus last passed 3 day
• Poor appetite.
• No recent alcohol ingestion as per patient.
Case History
• Past Medical History:
Hiatus hernia
Chronic Kidney Disease
• Past Surgical History
– Hysterectomy
– Cholecystectomy
– Appendectomy
Case History
• Family History
– Nil significant
• Social History
– Ex smoker
• ROS:
– Nil significant
On Examination
• Vital Signs:
BP 111/74
HR 92
Temp 36.2
RR 16
O2 SATS 100% on RA
• Abdomen was not distended. Tenderness in
epigastrium with mild guarding. No rebound.
Bowel sounds exaggerated. Hernial orifices
were intact.
• WCC 7.4; Hb 13.3; Plts 433; CRP 17
• Urea 42; Na 125; K 7.4; Creat 609 (baseline
• ABG: pH 7.38, pCO2 4.57, pO2 12.4, HCO3 20
• Amylase 160
• ECG: NSR; tachycardic; tented T waves
• CXR: no free air under diaphragm.
• PFA: prominent small bowel loops
• Initially admitted medically with
– Acute on chronic renal failure
– Dehydration
• Upon surgical review:
– Features of small bowel obstruction for
conservative management.
• Day 1 post admission:
– Abdomen now distended, non tender, BS
present. PFA showed progression - ? small
bowel obstruction 2o to adhesions.
• Day 2 post admission:
– Medical review re: acute renal failure, hyperkalaemia
and hyponatraemia.
– Surgical team review
– To continue conservative management
– NG tube and urinary catheter placed
• Day 5 post admission:
– Renal failure indices resolved
– Abdominal distension still persistent
– Obstipated
– PFA showed increasing bowel dilatation
– NG tube active
– Proceeded to laparotomy
Operative findings
• Small bowel volvolus with fulcrum around
meckel’s diverticulum adherent to pelvic
• Merckel’s diverticulum and adjacent small
bowel were resected and sent for
• Side to side anastomosis
Post Operative
• The post operative period was uneventful.
• Histology
– Gastric body type mucosa
– No helicobacter pylori
– No evidence of malignancy
Case 2
• 31 year old gentleman admitted with:
– 1/7 history of sudden onset non-radiating
colicky lower abdominal pain.
– No associated nausea, vomiting or altered
bowel habit.
– No previous medical/surgical hx.
– ROS – nil significant
On Examination
• Vital Signs:
BP 115/68
HR 93
O2 SATS 99% on RA
Apyrexial 36.2oC
• On examination:
• Tenderness and guarding in lower abdomen
• Reduced bowel sounds.
• Urinalysis
• Bloods
– WCC 13.4 (neuts 10.58), Hb 13.4, CRP 49, Amylase
– Sickle cell screen negative
– No air under the diaphragm
– Bowel gas pattern normal. No bowel distension or
obstruction. No free air.
• CT Abdomen/Pelvis
– Minor stranding of fat around a loop of small
bowel in right lower quadrant (differential
included inflammatory change around a
meckel’s diverticulum)
– Small nodes in the adjacent mesentery.
– No evidence of large colonic diverticulitis and
normal appearance of the appendix.
CT Abdo/Pelvis
• On admission:
– IV fluids, co-amoxiclav and analgesia
• Day 2 post admission:
– Proceeded to Laparoscopy:
• Operative findings:
– Perforated merckel’s diverticulum which was resected at its
base using Endo GIA and sent for histology
– Appendix long and injected but not acutely inflamed - most
likely not the cause of his symptoms but removed.
Histological Findings
• Ectopic gastric tissue at the fundus of the
meckel’s diverticulum.
• The excised edge was free of ectopic
gastric tissue
• A true congenital diverticulum, a congenital
bulge in the small intestine.
• It is a vestigial remnant of the
omphalomesenteric duct
• is the most frequent malformation of the
gastrointestinal tract
• It was first described by Fabricius Hildanus,
German surgeon, in 1598
• Johann Friedrich Meckel, described the
embryological origin of this type of diverticulum
in 1809
• It is a vestigial remnant of the
omphalomesenteric (vitellointestinal) duct
• Human embryos initially have convex umbilical
loops of primitive gut that communicate freely
with the yolk sac through the
omphalomesenteric (vitellointestinal) duct
• As development proceeds, the duct normally
becomes occluded and disappears entirely by
weeks 8-10 of gestation
• Results from the failure of the vitelline duct to
obliterate during the fifth week of fetal
• The following anomalies are caused by the persistence
of the omphalomesenteric (vitellointestinal) duct
• Autopsy records show an incidence of
about 2% in the general population.
• For asymptomatic diverticula there is no
gender predominance,.
• For symptomatic diverticula some studies
give a 3:1 male to female ratio, while
others have detected little difference.
• The risk of complications ranges from 425% in various studies.
Anatomic Considerations
• Meckel's diverticulum is located in the
distal ileum, on its antimesenteric border.
usually within about 60-100 cm of the
ileocecal valve
• It can also be present as an indirect
hernia, typically on the right side, where it
is known as a "Hernia of Littre."
Anatomic consideration
Topography of abdomen
Anatomic Considerations
A memory aid is the rule of 2's:
2% (of the population)
2 feet (from the ileocecal valve)
2 inches (in length)
2% are symptomatic
2 types of common ectopic tissue (gastric 80% ,
pancreatic, colonic and other tissues 20%),
• The most common age at clinical presentation is
2, and
• males are 2 times as likely
Clinical features
Asymptomatic in majority of cases
Painless rectal bleeding,
Intestinal obstruction,
Volvulus and Intussusception.
Meckel's diverticulitis may present with all the
features of acute appendicitis.
• Epigastric pain & Bloating
• Neoplasm - lipoma, leiomyoma, neurofibroma
and angioma, leiomyosarcoma and carcinoid,
which represent about 80% & adenocarcinoma
and metastatic lesions
• A technetium-99m (99mTc) pertechnetate scan
is commonly used to diagnose Meckel's
diverticulum – Gastric tissue.
• Abd CT
• Barium studies to out rule enterocolitis and
• Laparoscopy
• A bleeding scan.
• Selective arteriography
• Wireless capsule endoscopy
• Abd USS
• Surgical for symptomatic Merckel’s diverticulum
• Incidental Meckel’s diverticulum in asymptomatic
patients remains controversial – Narrow vs wide
• Excision is carried out by performing a wedge
resection of adjacent ileum and anastomosis
• a primitive persistent right vitelline artery
originating from the mesentery has been found
during operation - Bleeding
• Heterotropic gastric mucosa 62%
• pancreatic tissue 6%,
• Both pancreatic tissue and gastric mucosa
were found in 5%,
• Jejunal mucosa was found in 2%,
• Brunner tissue was found in 2%, and
• Both gastric and duodenal mucosa were
found in 2%
Take home message
• Meckel's diverticulum is the most common
congenital abnormality of the
gastrointestinal tract.
• it is often difficult to diagnose
• It may remain asymptomatic
• it may mimic disorders such as Crohn's
disease, appendicitis, peptic ulcer disease,
obstruction and bleeding.
Thank you
• Who should take credit for this clinical
• Fabricius Hildanus,, in 1598
• Johann Friedrich Meckel, 1809