Transcript Slide 1
Thinking Outside of the Stump the Professor Leah Smith Elizabeth Vonderhaar Jenny Lovegreen History of Present Illness 17 year old female, G0 Periumbilical abdominal pain x 12 hr Worsening (8/10), now in RLQ Nausea, decreased appetite, taking liquids well Denies fever/chills, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, vaginal bleeding/discharge History of Present Illness LMP: unsure, irregular Denies sexual activity (mom in room) PMH/PSH/FH: negative Allergies: NKDA SH: student, lives with parents, denies tobacco/ETOH/drugs Physical Exam VS: T 37.3 P 84 R 18 BP 99/56 O2 100% Gen: NAD, lying very still Abdominal: soft, nondistended, BS+ Tenderness to palpation periumbilical and RLQ; involuntary guarding No rebound tenderness No mass palpated Differential Diagnosis? Clinical Work-Up? Labs HPD: WBC 16.9 (85% neuts, 5% bands, 6% lymphs) CMP: Alk Phos 147 UA: WNL Urine HCG: negative Imaging Management? Surgery Operative Report Procedure: Exploratory laparotomy with resection of perforated Meckel's diverticulum with primary anastomosis of small bowel. Operative Findings: Perforated Meckel's diverticulum approximately 45 cm proximal to the ileocecal valve. Meckel diverticulum Early in embryonic life, the fetal midgut receives its nutrition from the yolk sac via the vitelline duct The duct then undergoes progressive narrowing and usually disappears by 7 weeks' gestation When the duct fails to fully obliterate, various vitelline duct anomalies appear Vitelline Duct Anomalies Most common: 97% Meckel diverticulum May contain heterotopic mucosa 50% contain gastric mucosa 5% contain pancreatic mucosa True diverticulum = contains all layers of the ileum Found on the antimesenteric border of the ileum Usually 40-60 cm proximal to the ileocecal valve Epidemiology Most common congenital anomaly of the GI tract Found in 2-3% of individuals at autopsy Prevalence of symptomatic Meckel diverticula is estimated to be 4-35% of the at-risk population No racial biases have been reported The male-to-female ratio is 3:1 Most patients with symptoms present <10 y/o Presentation Children = painless rectal bleeding Heterotopic gastric mucosa → acid secretion → tissue damage/vessel erosion → acute lower GI bleeding Adults = intestinal obstruction and inflammation Most often due to volvulus or intussusception Diagnosis The diagnosis is notoriously difficult Most patients are asymptomatic All common imaging modalities are nonspecific The most sensitive technique is scintigraphy Most Meckel diverticula are diagnosed during surgery or autopsy, with imaging playing a secondary role References Smoot, Rory, et al, “Meckel’s Diverticulum in Adults – More Common Than You Think,” www.residentandstaff.com. Dec 2005. eMedicine “Meckel Diverticulum”