Alex Herrera, HMS III
Gillian Lieberman, MD
Meckel’s Diverticulum
Alex Herrera, Harvard Medical School Year III
Gillian Lieberman, MD
January 2007
2
Alex Herrera, HMS III
Gillian Lieberman, MD
Meckel’s Embryology
• Remnant of
omphalomesenteric
(vitelline) duct
– Complete obliteration
normally occurs between
week 5 and 7 of gestation
• Maintains blood
supply from remnant
of vitelline artery
– branch of ileal or (less
commonly) ileocecal artery
Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with pathologic Correlation. Radiographics. 2004 Mar-
Apr;24(2):565-87
Patent Duct
Fibrous connection Meckel’s
3
Alex Herrera, HMS III
Gillian Lieberman, MD
Anatomy of Meckel’s
• Blind sac
• ANTI-mesenteric
• Usually within 40-100
cm of ileocecal valve
• True diverticulum
• Normal: 5 cm length,
2 cm diameter
Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with pathologic Correlation. Radiographics. 2004
Mar-Apr;24(2):565-87.
4
Alex Herrera, HMS III
Gillian Lieberman, MD
Epidemiology
• 2% of population = most common
congenital abnormality of GI tract
• Most patients present before age 2 (~60%)
• Complications occur in 4-16%
– 3-4x more frequent in males
5
Alex Herrera, HMS III
Gillian Lieberman, MD
Heterotopic tissue
• Gastric mucosa
– 60% of symptomatic pts
• Pancreatic tissue
– 6% of symptomatic pts
• Combined gastric and
pancreatic
• Other (jejunal, duodenal,
etc.) Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with
pathologic correlation. Radiographics. 2004 Mar-Apr;24(2):565-87.
Ileal mucosa Gastric mucosa
6
Alex Herrera, HMS III
Gillian Lieberman, MD
Clinical Presentation
Meckel’s only presents when there
are complications!
7
Alex Herrera, HMS III
Gillian Lieberman, MD
Clinical Presentation
Children
• Painless GI bleeding is
most common
presentation
– Peptic ulcer from
heterotopic gastric mucosa
Adults
• Intestinal obstruction is
most common
presentation
– Strangulation of bowel
– Intussusception
– Littre’s hernia
– Neoplasms
• Diverticulitis
– Gastric acid
– Enterolith
8
Alex Herrera, HMS III
Gillian Lieberman, MD
Companion Patient 1: Enterolith in
Diverticulum on Plain Film
Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with pathologic Correlation. Radiographics. 2004
Mar-Apr;24(2):565-87
Enterolith Dilated Meckel’s
9
Alex Herrera, HMS III
Gillian Lieberman, MD
Companion Patient 2: Inverted
Meckel’s on SBFT
Turkington JR, Devlin PB, Dace S, Madden M. An unusual cause of intermittent abdominal pain (2006: 5b).
Inverted Meckel's diverticulum. Eur Radiol. 2006 Aug;16(8):1862-4. Epub 2006 Jun 3
Tubular
Filling
Defect
10
Alex Herrera, HMS III
Gillian Lieberman, MD
Companion patient 3: Intussusception
of Meckel’s on CT Scan
Turkington JR, Devlin PB, Dace S, Madden M. An unusual cause of intermittent abdominal pain (2006: 5b). Inverted
Meckel's diverticulum. Eur Radiol. 2006 Aug;16(8):1862-4. Epub 2006 Jun 3
Meckel’s
telescoped into
normal bowel
Ring of mesenteric
fat
11
Alex Herrera, HMS III
Gillian Lieberman, MD
Possible Imaging Modalities
• Abdominal plain film
• Ultrasound
• CT
• Barium studies
• Nuclear medicine scans
– Meckel’s scan
– GI Bleeding scan
• Angiography
Unreliable for
diagnosis of Meckel’s
12
Alex Herrera, HMS III
Gillian Lieberman, MD
Abdominal Plain Film and
Companion Patient 4
• Poor sensitivity
Radiographic signs are
nonspecific:
• Intestinal obstruction
• Enterolith
• Air/fluid levels
Outpouching suggestive of Meckel’s
Ojha S, Menon P and Rao K. Meckels diverticulum with segmental dilatation of the ileum: radiographic diagnosis
in a neonate. Pediatr Radiol. 2004 Aug;34(8):649-51. Epub 2004 Mar 12.
13
Alex Herrera, HMS III
Gillian Lieberman, MD
Ultrasound and Companion Patient 5
• Hypoechoic, fluid-filled,
tubular structure in RLQ
• Can be cystic
• Hypervascularization on
Doppler
Can visualize:
Diverticulitis
Intussusception
Ddx:
• Appendicitis
• Intestinal duplication
M Baldisserotto, et al. AJR 2003; 180:425-428
Hyper-
vasculariztion
14
Alex Herrera, HMS III
Gillian Lieberman, MD
CT and Companion Patient 6 and 7
• Non-specific findings unless
attached to umbilicus or
there is complication
Common findings:
• Pouch containing fluid and
air or particulate material
• Inflammatory changes in
surrounding mesenteric fat
• Mural enhancement
Ectopic pancreatic
tissue
Bennett GL, Birnbaum BA, Balthazar EJ. CT of
Meckel's diverticulitis in 11 patients. AJR Am J
Roentgenol. 2004 Mar;182(3):625-9.
Connection to
umbilicus
Mural
enhancement
15
Alex Herrera, HMS III
Gillian Lieberman, MD
Possible Imaging Modalities
• Abdominal plain film
• Ultrasound
• CT
• Barium studies
• Nuclear medicine scans
– Meckel’s scan
– GI Bleeding scan
• Angiography
Preferred diagnostic
tests for diagnosing
Meckel’s diverticulum
16
Alex Herrera, HMS III
Gillian Lieberman, MD
Barium Studies: SBFT and Enteroclysis
• Unreliable for detection of
Meckel’s
Findings:
• Blind ending pouch
• Filling defect (inverted)
• Mucosal pattern:
– Triradiate
– Triangular plateau
Limitations:
– Stenosis of neck
– Intestinal contents
– Peristalsis
– Small size
Triradiate
(surrounding bowel is
collapsed)
Triangular Plateau
(surrounding bowel is patent)
Eisenberg RL. GI Radiology: A Pattern Approach, 2nd edition.
Philadelphia: Lippincott, 1990. 536-538.
17
Alex Herrera, HMS III
Gillian Lieberman, MD
Companion patients 8 and 9: Mucosal
Pattern of Meckel’s on SBFT
Triradiate patternTriangular plateau
Meckel diverticulum: Radiologic features with
pathologic Correlation. Radiographics. 2004
Mar-Apr;24(2):565-87.
Eisenberg RL. GI Radiology: A Pattern Approach,
2nd edition. Philadelphia: Lippincott, 1990. 536-
538.
18
Alex Herrera, HMS III
Gillian Lieberman, MD
Enteroclysis
• Preferred by some radiologists
– Continuous distension of abnormal loops
– Frequent flouroscopy
• Limitations:
– Discomfort
– Side effects
– Increased radiation exposure
19
Alex Herrera, HMS III
Gillian Lieberman, MD
Meckel’s Scan
• 99mTc-Pertechnetate concentrates in mucus-
secreting cells of gastric mucosa
– Uptake in stomach and Meckel’s simultaneous within 10 minutes
of administration
– Pharmacologic enhancement (pentagastrin, cimetidine, glucagon)
Advantages:
• Highly sensitive and specific (>90%) in children
Disadvantages:
• Less sensitive and specific in adults
• 99mTc-Pertechnetate concentrates in areas of increased
blood flow
20
Alex Herrera, HMS III
Gillian Lieberman, MD
Limitations of Meckel’s Scan
False Positive “Fake-outs”
• Intestinal duplication
• Hemangiomas/AVMs
• Neoplasm (e.g. carcinoid)
• IBD and small bowel
inflammation
(hyperemia)
False Negatives
• Absence of gastric
mucosa
• Impaired vascular
supply
• Brisk hemorrhage
21
Alex Herrera, HMS III
Gillian Lieberman, MD
Companion Patient 10: Meckel’s Scan
http://gamma.wustl.edu/ms001te272.html
Focus of Tc
uptake in RLQ
Anterior View
Stomach
Meckel’s
typically appears
in RLQ, but can
present on either
side of midline
22
Alex Herrera, HMS III
Gillian Lieberman, MD
GI Bleeding Scan
• 99mTc-labeled autologous RBC accumulate in
bowel at sites of active hemorrhage
• Sensitive for bleeding Meckel’s, but not specific
– Specificity ~100% if subsequent Meckel’s scan is positive
Advantages:
• Can detect intermittent bleeding
• High sensitivity for low bleeding rate
– Bleeding rate of only 0.1 cc/sec required for detection
23
Alex Herrera, HMS III
Gillian Lieberman, MD
Companion Patient 11: GI Bleeding Scan
PACS, BIDMC
Posterior
View
Area of
increased
activity
• Meckel’s
usually present
as increased
activity in RLQ
• Can appear
more superiorly
or on either side
of midline
24
Alex Herrera, HMS III
Gillian Lieberman, MD
Angiography
Indications:
• Active GI bleeding
• High suspicion for Meckel’s with negative Meckel’s scan and
barium studies
Technique:
• Superselective SMA or ileal arteriography
Positive findings:
• Extravasation = at least 0.5cc bleeding/sec
• Persistent vitelline artery supplying tubular structure in RLQ
25
Alex Herrera, HMS III
Gillian Lieberman, MD
Companion Patient 12: Selective SMA
and Ileal Arteriography
Mitchell AW, Spencer J, Allison DJ, Jackson JE. Meckel's diverticulum: angiographic findings in 16 patients. AJR Am J
Roentgenol. 1998 May;170(5):1329-33.
SMA Ileal artery
Vascular blush Vitelline artery
26
Alex Herrera, HMS III
Gillian Lieberman, MD
Suggested Meckel’s Work-up
• Barium stuides can be helpful, but…
• Most sensitive and specific test is a
Meckel’s scan!
• If setting of acute GI bleeding, GI bleeding
scan and/or angiography is indicated
– Meckel’s scan may be falsely negative
27
Alex Herrera, HMS III
Gillian Lieberman, MD
Radiologic Work-up Algorithm
Meckel’s Scan
Findings suggestive
of Meckel’s on KUB,
Barium, CT, or U/S
Self-limited GI bleed
prompts suspicion
of Meckel’s
Acute GI
hemorrhage
GI Bleeding Scan
Angiography
Surgery
Acute abdomen
Indeterminate
EGD/Colonoscopy
+
-
+
-
28
Alex Herrera, HMS III
Gillian Lieberman, MD
Patient Presentation, 8/22/04
JD is a 20 year old male who presents to an OSH
with:
• 10 episodes of blood per rectum over 24 hours
• He becomes pale and diaphoretic after having
another bloody stool while waiting in the ED
• No history of aspirin or NSAID use
PMH: non-contributory
PE: significant for tachycardia to 122, BP 99/49, and
gross blood on rectal exam. No abdominal
tenderness or external hemorrhoids noted.
29
Alex Herrera, HMS III
Gillian Lieberman, MD
OSH Hospital Course
Significant labs: Hct 24.2, WBC 13.5, normal PT, PTT, INR
Diagnostics:
• Colonoscopy showed dark red blood throughout colon
without active bleeding site
• EGD normal to 2nd portion of duodenum
• 99mTc GI bleeding scan showed small focus of increased
activity at region of terminal ileum
• Meckel’s scan showed possible uptake at L5 level
Therapeutics:
• JD received IV fluids and 7 units of PRBCs over the
course of his stay
30
Alex Herrera, HMS III
Gillian Lieberman, MD
Transfer to BIDMC, 8/30/04
JD was transferred to the BIDMC for further
work-up.
• On 8/31, JD underwent a Meckel’s scan and
a GI bleeding scan.
31
Alex Herrera, HMS III
Gillian Lieberman, MD
Our Patient JD: Meckel’s Scan
8/31/04
Anterior View
Bladder
PACS, BIDMC
• Negative Scan
32
Alex Herrera, HMS III
Gillian Lieberman, MD
JD: GI Bleeding Scan 8/31/04
Posterior View
Spleen
PACS, BIDMC
• Negative Scan
33
Alex Herrera, HMS III
Gillian Lieberman, MD
Discharge
• On 9/01, colonoscopy, EGD, and capsule
endoscopy were negative.
• JD was stabilized and discharged on 9/2
without a clear etiology for his GI bleeding.
34
Alex Herrera, HMS III
Gillian Lieberman, MD
Differential Diagnosis
The differential diagnosis based on his course
included:
• Meckel’s diverticulum
• AVM or angiodysplasia
• IBD
• Infectious ileitis/colitis
• Neoplasia
35
Alex Herrera, HMS III
Gillian Lieberman, MD
14 months later, 11/12/05
JD, now 21 years old, is admitted directly to
the medical ICU with massive GI bleeding.
A GI bleeding scan is performed on the same
day…
36
Alex Herrera, HMS III
Gillian Lieberman, MD
Our patient JD: GI Bleeding Scan
11/12/05
Posterior View
0-60 min
60-90 min
90-120 min
PACS, BIDMC
Bleeding in terminal
ileum
37
Alex Herrera, HMS III
Gillian Lieberman, MD
Findings and Differential Diagnosis
• Tracer activity in center of pelvis at 90 minutes,
corresponding to terminal ileum
– Extends antegrade into ascending colon
DDx for terminal ileum hemorrhage:
• AVM or angiodysplasia
• Meckel’s
Colonoscopy was performed to localize and
potentially treat (if found to be AVM) the lesion
38
Alex Herrera, HMS III
Gillian Lieberman, MD
JD: Colonoscopy, 11/12/04
• A clot and then fresh
blood was seen coming
from the ileocecal valve
• Old blood was pooled
throughout the colon
• Angiography
recommended to
localize lesion and
embolize possible AVM
PACS, BIDMC
39
Alex Herrera, HMS III
Gillian Lieberman, MD
JD: SMA Arteriogram 11/13/05
PACS, BIDMC
Negative
arteriogram
• Selective ileal
arteriogram
recommended
40
Alex Herrera, HMS III
Gillian Lieberman, MD
Selective Ileal Arteriogram 11/14/05
PACS, BIDMC
Persistent vitelline
artery
41
Alex Herrera, HMS III
Gillian Lieberman, MD
Conclusion
JD underwent successful surgery to remove
the Meckel’s diverticulum seen on ileal
arteriography.
Pathology demonstrated a 3cm Meckel’s
diverticulum with diffuse gastric
heterotopia.
42
Alex Herrera, HMS III
Gillian Lieberman, MD
Summary
• Meckel’s diverticulum commonly presents
as GI bleeding in the pediatric population
• Meckel’s presents less commonly in adults,
usually as obstruction or diverticulitis
• 99mTc-Pertechnetate scan is the best test for
diagnosing a Meckel’s diverticulum
• For active GI bleeding, GI bleeding scan
and/or angiography can aid diagnosis
43
Alex Herrera, HMS III
Gillian Lieberman, MD
References
• Rossi P, Gourtsoyiannis N, Bezzi M, Raptopoulos V, Massa R, Capanna G, Pedicini V, Coe M.
Meckel’s Diverticulum: Imaging Diagnosis. AJR Am J Roentgenol. 1996 Mar;166(3):567-73.
• Bennett GL, Birnbaum BA, Balthazar EJ. CT of Meckel's diverticulitis in 11 patients. AJR Am J
Roentgenol. 2004 Mar;182(3):625-9.
• Baldisserotto M, Maffazzoni DR, Dora MD. Sonographic findings of Meckel's diverticulitis in
children. AJR Am J Roentgenol. 2003 Feb;180(2):425-8.
• Mitchell AW, Spencer J, Allison DJ, Jackson JE. Meckel's diverticulum: angiographic findings in 16
patients. AJR Am J Roentgenol. 1998 May;170(5):1329-33.
• Pantongrag-Brown L, Levine MS, Buetow PC, Buck JL, Elsayed AM. Meckel's enteroliths: clinical,
radiologic, and pathologic findings. AJR Am J Roentgenol. 1996 Dec;167(6):1447-50.
• Eisenberg RL. GI Radiology: A Pattern Approach, 2nd edition. Philadelphia: Lippincott, 1990. 536-
538.
• Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with pathologic Correlation.
Radiographics. 2004 Mar-Apr;24(2):565-87.
• Turkington JR, Devlin PB, Dace S, Madden M. An unusual cause of intermittent abdominal pain
(2006: 5b). Inverted Meckel's diverticulum. Eur Radiol. 2006 Aug;16(8):1862-4. Epub 2006 Jun 3.
• Ojha S, Menon P and Rao K. Meckels diverticulum with segmental dilatation of the ileum:
radiographic diagnosis in a neonate. Pediatr Radiol. 2004 Aug;34(8):649-51. Epub 2004 Mar 12.
• Nagi B, Kochhar R, Malik AK. Inverted Meckel diverticulum shown by enteroclysis. AJR Am J
Roentgenol. 1991 May;156(5):1111-2.
• http://gamma.wustl.edu
44
Alex Herrera, HMS III
Gillian Lieberman, MD
Acknowledgements
I would like to thank:
• Jacques Tham, MD
• Anthony Parker, MD, PhD
• Gillian Lieberman, MD
• Pamela Lepkowski
• Larry Barbaras
Meckel’s Diverticulum
Meckel’s Embryology
Anatomy of Meckel’s
Epidemiology
Heterotopic tissue
Clinical Presentation
Clinical Presentation
Companion Patient 1: Enterolith in Diverticulum on Plain Film
Companion Patient 2: Inverted Meckel’s on SBFT
Companion patient 3: Intussusception of Meckel’s on CT Scan
Possible Imaging Modalities
Abdominal Plain Film and Companion Patient 4
Ultrasound and Companion Patient 5
CT and Companion Patient 6 and 7
Possible Imaging Modalities
Barium Studies: SBFT and Enteroclysis
Companion patients 8 and 9: Mucosal Pattern of Meckel’s on SBFT
Enteroclysis
Meckel’s Scan
Limitations of Meckel’s Scan
Companion Patient 10: Meckel’s Scan
GI Bleeding Scan
Companion Patient 11: GI Bleeding Scan
Angiography
Companion Patient 12: Selective SMA and Ileal Arteriography
Suggested Meckel’s Work-up
Radiologic Work-up Algorithm
Patient Presentation, 8/22/04
OSH Hospital Course
Transfer to BIDMC, 8/30/04
Our Patient JD: Meckel’s Scan 8/31/04
JD: GI Bleeding Scan 8/31/04
Discharge
Differential Diagnosis
14 months later, 11/12/05
Our patient JD: GI Bleeding Scan 11/12/05
Findings and Differential Diagnosis
JD: Colonoscopy, 11/12/04
JD: SMA Arteriogram 11/13/05
Selective Ileal Arteriogram 11/14/05
Conclusion
Summary
References
Acknowledgements