1. Case Presentation
CC: vomiting, abdominal pain
PI: 49 y/o man who 36 hours prior to admission
had the onset RUQ abdominal pain. Pain
worsened, went to ER 4 hours later.
CBC, SMA, LFT’s, amylase, lipase all normal.
Abdominal sono normal.
Some relief after GI cocktail, discharged.

2. Case Presentation
Night prior to admission, pain recurred associated with
vomiting.
Next am, ER- repeat testing normal, discharged.
Admitted PHD due to continuing pain and vomiting.
No hematemesis or blood in stool, fever, diarrhea or
constipation. No prior history of similar symptoms.

3. Case Presentation
PMHx- no prior abdominal surgery, only history of GI
problems is occasional GERD.
History of seizure disorder and mild depression.
Meds- Tegretol, Celexa, ASA 81mg, Pepcid prn
ETOH- avg 1 drink/ day

4. Case Presentation
PE- 120/72, HR 66, T 98.4
Normal exam except abdomen tender, voluntary
guarding RUQ and periumbilical. No rebound.
No hepatosplenomegaly, mass. BS’s reduced.
Labs- normal abd. sono, LFT’s, amylase, lipase.
Normal lytes. Bun/Cr= 11/1.2. WBC 7.2K, Hgb 14.6
Normal HIDA scan.
Obstructive series- multiple air/ fluid levels seen
throughout the small bowel consistent with partial
small bowel obstruction

5. Case Presentation
Working diagnosis: distal small bowel obstruction of
uncertain etiology
Initial course- NG tube placed, IV fluids, IV PPI.
CT scan- distended small bowel consistent with distal
partial small bowel obstruction. Appendix and colon
normal.
Surgery consult obtained.

6. Causes of Intestinal Obstruction
1. Intrinsic Bowel Lesions
A. Congenital- atresia / stenosis, malrotation, duplications/cysts
B. Inflammatory
Diverticulitis, TB, actinomycosis
Crohn’s disease
Ischemia
Radiation injury
Chemical (e.g., potassium chloride)
Endometriosis
Postanastomotic
C. Intussusception
D. Obturation
Polypoid neoplasms
Gallstones
Foreign bodies
Bezoars
Feces
E. Neoplastic stricture
II. Extrinsic Bowel Lesions
A. Congenital bands
B. Adhesions (usually postoperative)
C. Hernias (inguinal, femoral, ventral, umbilical, diaphragmatic)
D. Volvulus/ torsion
E. Carcinomatosis, extraintestinal neoplasm
F. Intra-abdominal abscess

7. Case Presentation
Next day- no improvement in x-ray findings, patient
taken to surgery.
Surgical findings: dilated prox sm. bowel with bruising
and torsion of the small bowel due to a Meckel’s
diverticulum as the lead point for the torsion. The
Meckel’s diverticulum was resected.

8. Meckel’s Diverticulum
Phillip M Aronoff, M.D.

9. Meckel’s Diverticulum
• Most common congenital abnormality of the
gastrointestinal tract
• Remnant of the vitelline duct
• antimesenteric border of the ileum
• Often contain heterotropic tissue- gastric, occasionally
pancreatic
• Vast majority of Meckel’s diverticuli are clinically silent

10. Meckel’s Diverticulum
Rule of 2’s
• 2% of the population have one
• 1/2 of symptomatic lesions usually present before the
age of 2 years old, others most commonly in the first 2
decades of life
• Diveriticuli in adult patients only become symptomatic
in about 2%
• 2 times more common in males than females
• Usually found within 2 feet of the ileocecal valve
• Usually are about 2 inches in length
• 1/2 contain heterotrophic mucosa (usually gastric,
occasionally pancreatic)

11. Meckel’s Diverticulum
Clinical presentation
Lower GI bleeding due to ulceration by heterotopic
gastric mucosa
Intestinal obstruction due to internal segmental volvulus
or intussusception
Local inflammation with or without perforation
resembling appendicitis due to diverticulitis
Rare presentations: Neoplasms

12. Meckel’s Diverticulum
Lower GI bleeding due to ulceration by heterotrophic gastric
mucosa
• 25-50% of symptomatic presentations
• Usually painless
• Episodic
• Hematochezia (usually maroon but may be tarry or bright red)
• Not infrequently massive bleeding- occult bleeding is rare
• Most common cause of small intestinal hemorrhage in patients
under 30 y/o
• Meckel’s scan is often positive patients

13. Meckel’s Diverticulum
Intestinal obstruction due to internal segmental
volvulus or
intussusception
• 20-30% of symptomatic presentations
• More common in older patients
• Diverticulum acts as a lead point causing entero-entero or entero-colonic
intussusception which often cannot be reduced hydrostatically. This may
present with “currant jelly” like stool and a palpable mass may be present
• If volvulus can be reduced hydrostatically, the patient should still have a
surgical resection.
• If diverticulum is connected to umbilicus by fibrous cord, this may act as a
focal point for internal herniation of the small bowel or secondary volvulus.

14. Meckel’s Diverticulum
Local inflammation with or without perforation
due to Meckel’s diverticulitis
• 10-20% of symptomatic presentations
• Usually adult patients
• Usually due to ectopic acid producing gastric mucosa
causing significant ulceration and possible perforation.
This may occasionally be related to H. Pylori infection
of the mucosa.
• Rarely caused by perforation due to a foreign body in
the diverticulum.
• Usually these patients are thought to have
appendicitis prior to surgery

15. Meckel’s Diverticulum
Rare Presentations- neoplasms arising in the
diverticulum
• Benign- (most common)
Leiomyomas
Angiomas
Lipomas
• Malignant-
Adenocarcinoma- usually from the gastric
mucosa
Sarcoma
Carcinoid tumor

16. Meckel’s Diverticulum
Diagnostic studies
• Difficult diagnosis
• Most accurate test, especially in children, is “Meckel’s scan”-
sodium 99-Tc-pertechinetate, taken up by gastric mucosa
(sensitivity 85%, specificity 95%, accuracy 90% in pediatric
patients)
• Less accurate in adults due to reduced prevalence of ectopic
gastric mucosa in the diverticulum causing false negatives.
Accuracy improved by giving pentagastrin (increases
metabolism of mucus producing cells), glucagon or H2 blockers
(reduce peristalsis and secretions that may flush out the
radionuclide)
• In adults with a negative scan, abdominal CT scan is often
helpful in cases of obstruction by showing a site of high grade
partial bowel obstruction in the distal ileum.
• If CT is negative barium studies should be performed which may
show the diverticulum (do not do prior to Meckel’s scan as
barium may interfere)
• If bleeding with a negative scan, angiography may be helpful

17. Meckel’s Diverticulum
Treatment
• If symptomatic, prompt surgical intervention to resect the
diverticulum or segment of ileum containing the
diverticulum. If bleeding, the source of bleed is often in
the segment of ileum adjacent to the diverticulum.
• If not symptomatic and found incidentally at surgery in
children under 2 y/o, resection is recommended. In
asymptomatic adults, resection is controversial since only
about 2% of these patient’s will become symptomatic and
there is about a 2% incidence of short or long term
complications (stenosis, adhesions) after prophylactic
resection.

18. Meckel’s Diverticulum
Phillip M Aronoff, M.D.