eISSN 1308-4038
International Journal of Anatomical Variations (2013) 6: 145–148
Case Report
Mesenteric Meckel’s diverticulum: a real variant
Published online September 11th, 2013 © http://www.ijav.org
Susanne G. CARPENTER
Ann E. McCULLOUGH [2]
Shabana PASHA [3]
Kristi L. HAROLD [1]
[1]
Departments of Surgery [1], Pathology [2], Gastroenterology
[3], Mayo Clinic, Phoenix, AZ, USA.
Abstract
A Meckel’s diverticulum is the most common congenital abnormality of the gastrointestinal tract
and can present a variety of diagnostic and surgical challenges. A longstanding surgical dictum
is that a Meckel’s diverticulum must be anti-mesenteric. This study reports the case of an adult
male who presented with an obscure gastrointestinal bleed and was ultimately found to have a
Meckel’s diverticulum on the mesenteric intestinal border which was resected laparoscopically.
Diagnostic characteristics that facilitate identification of a Meckel’s diverticulum along with
reported deviations from these characteristics are reviewed in this study.
© Int J Anat Var (IJAV). 2013; 6: 145–148.
Kristi Harold, MD
Mayo Clinic Arizona
5777 E. Mayo Blvd.
Phoenix, AZ 85054 USA.
+1 (480) 342-2849
harold.kristi@mayo.edu
Received July 4th, 2012; accepted September 30th, 2012
Introduction
Key words [Meckel’s diverticulum] [mesenteric sided Meckel’s diverticulum] [Meckel’s diverticulitis]
[congenital gastrointestinal anomalies]
Case Report
A Meckel’s diverticulum (MD) is the most common congenital A 35-year-old otherwise healthy gentleman noticed a small
anomaly of the gastro-intestinal tract, and can present quantity of maroon colored stools for one week, worsening over
diagnostic and surgical challenges. Arising from failure time. He eventually reported to a local emergency department
of the omphalomesenteric duct to close properly, MD can with symptoms of orthostasis and required transfusion of 2
occur in up to 2% of the population and can manifest as units of packed red blood cells. Extensive gastroenterologic
obscure gastrointestinal bleeding, Meckel’s diverticulitis, workup included a video-capsule endoscopy which identified
obstruction, and intussusception [1]. While most MDs present blood in the ileum. A subsequent double-balloon enteroscopy
in childhood, adult patients are also at risk for complications, indicated friable ileal mucosa with contact bleeding reportedly
though these tend to decrease with increasing age [2, 3]. 120 cm from the ileocecal valve. A tattoo was placed at the
Several characteristics that facilitate identification of a point of interest. A Meckel’s scan was then performed at the
Meckel’s diverticulum include location two feet proximal to outside facility and was negative.
the ileocecal valve, the presence of an independent vessel No additional intervention was undertaken by the patient
supplying the structure, five layers of small intestine, and until two weeks prior to his presentation to our clinic, which
ectopic mucosa of either gastric, pancreatic or another origin was one year after his first episode. Upon further questioning
other than small intestine in a majority of specimens [4]. the patient had used NSAIDs prior to first episode of
There are very few cases of mesenteric-sided MD reported bleeding and aspirin prior to second episode. Workup at our
in surgical literature (Table 1), and several authors have institution included computed tomography (CT) scanning
suggested that what some call a mesenteric-sided MD may with enterography, as well as a review of the patient’s outside
in fact be an intestinal duplication cyst [4–9]. This study capsule endoscopy. CT enterography revealed a “tubular
reports a case of what the authors believe to be a mesenteric outpouching” adjacent to the distal ileum and ascending
MD and reviews the literature concerning identification and colon that was considered consistent with the expected
appropriate treatment of a MD in the minimally invasive era. appearance of a Meckel’s diverticulum (Figure 1). In light of
Carpenter et al.
146
Table 1. Cases of mesenteric-sided MD reported in surgical literature.
Author & year
Segal et al. 2004,
[7]
Manukyan et al.,
2009, [9]
Sarioglu-Buke et
al., 2008, [5]
Seitun et al., 2011,
[6]
Carpenter et al.,
2013
Presentation
Procedure
performed
Distance from ICV
OR findings
Path findings
19-year-old, M,
acute abdominal
pain
Low transverse
RLQ incision, small
bowel resection,
WLE mesentery
63.5 cm
Adenopathy,
forshortened
mesentery
Gastric mucosa w/
metaplasia
15-year-old, F,
acute abdominal
pain
7-month-old, M
65-year-old, F, RLQ
abdominal pain
35-year-old, M,
obscure GI bleed
Standard
laparotomy
Laparotomy, small
bowel resection
and anastomosis
Lower midline
incision, stapled
transverse
diverticulectomy
Laparoscopic small
bowel resection
Mesenteric MD
40 cm
Mesenteric
lymphadenopathy,
2 cm base, wide
ileal connection
40 cm
Mesenteric abscess
RLQ, inflamed MD
60 cm
Mesenteric MD
Pancreatic, gastric
mucosa with
chronic ulceration
Fibrin
accumulation,
gastric mucosa
Heterotopic
gastric mucosa w/
perforation
Gastric mucosa
M: male; F: female; WLE: wide local excision; RLQ: right lower quadrant; ICV: ileocecal valve; OR: operating room; Path:
pathology
the enterography results, a Meckel’s scan was repeated and
revealed tracer uptake in the right lower quadrant consistent
with a Meckel’s diverticulum (Figure 2).
With this information, the patient was taken to the operating
room where an exploratory laparoscopy with small bowel
resection and side-to-side anastomosis was performed.
The initial dissection was performed using three 5 mm
trochars placed along the lateral left abdominal wall. Upon
examination of the small intestine, a diverticulum was noted
at approximately 60 cm from the ileocecal junction. However,
this was found along the mesenteric border of the ileum
(Figure 3). The tattoo indicating the furthest extent of the
previous outside institution double balloon enteroscopy was
noted to be at least 20 cm distal to the diverticulum (Figure
4). This area was not resected. One of three 5 mm trocars was
upsized to a 12 mm in order to permit use of an Endo-GIA
stapler (Covidien) which was employed for the transaction of
the small bowel and mesentery surrounding the diverticulum
(Figure 5). The diverticulum was sent to pathology where
gross examination as well as frozen and permanent sections
revealed the presence of ectopic gastric mucosa (Figure 6a &
b).
Final pathology revealed a 7 cm x 2.5 cm pouch-like
diverticulum containing a 3.5 cm area of mucosa with a
granular appearance as opposed to the tan folds of the
surrounding ileum. Microscopically, hematoxylin and eosin
staining revealed erosion adjacent to reactive oxyntic gastric
type mucosa.
Figure 1. CT enterography demonstrating intestinal outpouching
consistent with Meckel’s diverticulum.
Mesenteric Meckel’s diverticulum
147
[5]. Another explanation is that the vitelline duct would
simply adhere to the ileal mesentery [1].
Several other authors presenting cases of mesenteric-sided
MD have openly pondered if they may have been dealing
with an intestinal duplication cyst rather than a MD [4]. This
begs the question of how one might differentiate the two.
It seems that the absence of a distinct communication of a
structure with adjacent intestinal lumen would favor intestinal
cyst or duplication [7]. Our patient had a clear connection
between lumens of his MD and the ileum. Another possible
area of distinction is with ectopic gastric mucosa, which our
patient demonstrated. However, ectopic gastric or pancreatic
mucosa can be found in both MD (approximately 55%) and
intestinal duplication cysts (approximately 16-39%) [1, 7, 10].
Figure 2. Meckel’s scan with uptake in right lower quadrant.
Figure 3. Laparoscopic view identifying Meckel’s diverticulum
(arrow) embedded in mesentery.
Figure 4. Tattoo (arrow) of previous double-balloon endoscopy.
Discussion
Several other authors have reported MD presenting on the
mesenteric border. Some argue this can only be an intestinal
duplication cyst, but a case reported by Kurzbart and
colleagues suggests otherwise as contrast was administered
to a newborn infant of 28 weeks gestation via a fourth
lumen in the transected umbilical cord [5, 7, 8]. Contrast
filled the small bowel upon injection. At 3 months of age,
the infant underwent an umbilical hernia repair. No residual
omphalomesenteric structures were present, however a MD
was found 40 cm from the ileocecal junction but adherent
to the mesentery [8]. Several explanations for the reported
mesenteric locations have been offered including that a
shortened vitelline artery could form a mesodiverticular
band from the ileal mesentery to the tip of the diverticulum
which would then divert the diverticulum away from the
antimesenteric border during elongation and fetal growth
Figure 5. Resection of small bowel and mesentery surrounding
diverticulum using Endo GIA stapler (Covidien). (Arrow: mesenteric
staple line)
Carpenter et al.
148
a
b
SIM
GFM
Figure 6. a) Opened diverticulum. Gastric fundic type mucosa is pink granular mucosa on right; small intestinal mucosa is tan mucosa with
folds on left. b) Diverticular mucosa, hematoxylin and eosin, x40. Villi from small intestinal mucosa (thin arrow), erosion at 6 o’clock (short
arrow), reactive oxyntic gastric type mucosa (thick arrow)
Some authors have asserted that the presence of a vitelline
artery or a clear independent blood supply to a diverticulum
is definitive evidence of MD whereas intestinal duplications
share blood supply with the surrounding intestine [7, 11].
However, Kusumoto and colleagues have indicated that
a distinct vitelline artery could be identified in only 10%
of 776 patients with MD [12]. In the case here presented, a
distinct blood supply was identified on CT scan, but attempts
were not made to delineate this vessel intraoperatively or
pathologically. In brief, we are left with the conclusions of
previous authors that while the behavior and presentation
of the lesion were more consistent with MD, we cannot
definitively rule out a simple intestinal diverticulum or
duplication cyst.
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