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Original Report
Matteo Baldisserotto 1
Deise Regina Maffazzoni 2
Marcelo Dourado Dora 3

Sonographic Findings of Meckels

Diverticulitis in Children
OBJECTIVE. We know of only one previous study that has described the sonographic appearances of the inflamed Meckels diverticulum in several cases (nine patients). Our study
reviews sonographic, clinical, and pathologic findings in 10 patients with an inflamed
Meckels diverticulum. We also describe unique findings on color Doppler sonography for
two of our patients.
CONCLUSION. Sonographic findings of an inflamed Meckels diverticulum may mimic
findings for acute appendicitis or intestinal duplication. In patients with rectal bleeding due to
diverticulitis, the visualization of a tubular hyperechoic structure on sonography is suggestive
of Meckels diverticulum. The inflamed Meckels diverticulum may present as a cyst, but its
mucosal layer is more irregular than that found in an intestinal duplication. We found that routine color Doppler sonography revealed anomalous vessels and signs of inflammation on the
wall of the Meckels diverticulum.

Received February 11, 2002; accepted after revision

July 22, 2002.
1

Departamento de Radiologia, Hospital da Criana

ConceioMinistrio da Sade, Rua Francisco Trein 596,
Porto Alegre, RS, Brazil 91350-200. Address
correspondence to M. Baldisserotto.
2
Department of Patologia Hospital da Criana Conceio
Ministrio da Sade, Porto Alegre, RS, Brazil 91350-200.
3

Departamento de Pediatria, Hospital da Criana

ConceioMinistrio da Sade, Porto Alegre, RS Brazil
91350-200.
AJR 2003;180:425428

0361803X/03/1802425
American Roentgen Ray Society

AJR:180, February 2003

he most frequent clinical sign of an

inflamed Meckels diverticulum is
painless rectal bleeding [1]. For
patients presenting with intense rectal bleeding, 99mTc pertechnetate scintigraphy has high
positive and negative predictive values for the
diagnosis of an inflamed Meckels diverticulum. However, for patients with less intense
bleeding and hemoglobin levels of less than
11.0 g/dL, the sensitivity of 99mTc pertechnetate scintigraphy is low [2]. Moreover, 50% of
children who are symptomatic present with an
acute abdomen, and the diagnosis can be made
only at surgery [1].
A study by Daneman et al. [3] assessed the
value of different imaging methods in the diagnosis of complications from Meckels diverticulum such as inflammation or intestinal
invagination. Those authors showed that in
many patients, the inflamed Meckels diverticulum can be identified on sonography. In nine
of their patients, sonographic findings were
specific for complications of Meckels diverticulum. The spectrum of features they identified were as follows: in four patients, the

Meckels diverticulum appeared as a cystlike

mass that had a thick, irregular internal wall
with an external hypoechoic rim corresponding to the muscle layer and an internal hyperechoic line corresponding to the submucosal
and mucosal layers, an appearance that has
also been called the gut signature [4]; in two
patients, the Meckels diverticulum had a teardrop shape; in one patient, a tubular shape; in
another, a cul-de-sac shape; and in the ninth
patient, a round masslike shape. Sonography
was reported to be an alternative option when
scintigraphic findings are negative for this disease or when the patient presents with atypical
clinical signs and symptoms. Apart from the
study by Daneman et al., few cases of
Meckels diverticulum detected on sonography
have been reported [510].
We have retrospectively studied 10 cases
of inflamed Meckels diverticula for which
sonographic findings were obtained. Only
two patients presented with rectal bleeding,
whereas six presented with clinical signs suggestive of acute appendicitis. In addition, two
patients in this series also underwent color

425

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Baldisserotto et al.
Fig. 1.11-year-old boy who presented with 1-day
history of diarrhea and periumbilical pain with guarding.
A, Gray-scale sonogram shows hypoechoic tubular
cul-de-sac in longitudinal plane corresponding to
Meckels diverticulum (arrows) surrounded by hyperechoic mass (arrowheads). B = urinary bladder.
B, Gray-scale sonogram shows rounded hypoechoic
structure (arrows) in transverse plane corresponding
to Meckels diverticulum surrounded by free peritoneal fluid (arrowheads).

Doppler sonography for assessment of the lesion. We present these clinical, sonographic,
surgical, and pathologic findings.
Materials and Methods
From 1999 to 2001, 17 children with Meckels
diverticulum complications were seen in our service:
11 cases of diverticulitis and six cases of intestinal
intussusception caused by Meckels diverticulum.
Of the 11 patients with diverticulitis, 10 underwent
sonography. These 10 patients were our study populationnine boys and one girl whose ages ranged
from 1 to 11 years (mean, 6.5 years). All 10 children

underwent surgery, and surgical specimens were

sent for pathologic examination.
Nine patients presented with abdominal pain, the
most frequently reported symptom. Six of these patients also presented with clinical signs suggestive of
acute appendicitis: pain in the right iliac fossa that
resulted in guarding behavior and hemographic results that were indicative of infection. Only two patients presented with rectal bleeding. In one patient,
the bleeding was severe and in the other, moderately
intense. Both presented with nonspecific clinical
signs and symptoms, such as abdominal distention
and vomiting. The patient with the less intense rectal
bleeding had pain in the right iliac fossa with guarding; the other patient had no pain.
Sonographic examinations were performed with
either a SSD-630 scanner (Aloka, Tokyo, Japan)
with a curved 5.0-MHz transducer and a linear 7.5MHz transducer or with a 128XP-10 scanner (Acuson, Mountain View, CA) with a curved 3.75-MHz
transducer and a linear 7.0-MHz transducer. The two
patients with rectal bleeding underwent 99mTc
pertechnetate scintigraphy in addition to color Doppler sonography. The sonography equipment was
adjusted to detect low-velocity blood flow.

Results

Fig. 2.10-year-old girl who had been experiencing

hypogastric pain with guarding, vomiting, and diarrhea for 2 days. Gray-scale sonogram shows hypoechoic dead-ended tubular structure corresponding
to Meckels diverticulum (large arrows), with gas
(small arrow) and fecalith in lumen (arrowhead).

426

In six patients, the inflamed Meckels diverticulum presented as a fixed, noncompressible

hypoechoic structure in the shape of a cul-desac in the right iliac fossa next to the anterior abdominal wall, with a diameter ranging from 0.8
to 1.2 cm (Fig. 1). These structures were interpreted as corresponding to the inflamed cecal
appendix. In one patient, a fecalith was visualized in the lumen of a diverticulum, which gave
the structure the appearance of an abnormal appendix (Fig. 2). In the seventh patient, a complex mass in the umbilical region near the
abdominal wall was visualized, and the sonographic diagnosis was that this finding repre-

sented a case of perforated appendicitis

surrounded by an inflammatory mass.
In two patients, the Meckels diverticulum
was visualized as an oval cystlike structure in
the right iliac fossa next to the anterior abdominal wall; the wall of the structure exhibited the
gut signature (Figs. 3 and 4). This structure was
compressible when pressure was applied with
the transducer and mobile when there was peristaltic activity of the adjacent bowel loops. In
one patient, the Meckels diverticulum filled
with air during the sonographic examination
(Fig. 3B). Doppler sonography in both patients
revealed hypervascularization of the Meckels
diverticulum wall and the presence of a largecaliber anomalous artery that supplied blood to
the lesion (Figs. 3C, 3D, and 4).
In all 10 patients, surgical and pathologic
findings indicated that the Meckels diverticulum showed signs of inflammation, and the
cecal appendix was removed. At pathology,
the appendix from all the patients proved to
be normal.
Surgical and pathologic findings revealed
that the diverticular inflammation in six patients
was a result of the presence of ectopic gastric
mucosa; wall ulceration was observed in three
of these patients (Fig. 3E). In the four other patients, inflammation was caused by obstruction
of the lumen with vascular involvement. In two
of these patients, the obstruction was caused by
the mesodiverticular band with an internal hernia; in another patient, the presence of an intestinal volvulus around the omphalomesenteric
band caused obstruction of the base of the diverticulum. A volvulus of the diverticulum was
identified in the fourth patient.
In three of the six Meckels diverticula that
were visualized as cul-de-sac tubular struc-

AJR:180, February 2003

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Sonography of Diverticulitis in Children

Fig. 3.1-year-old boy who had experienced intense enterorrhagia for 24 hr before presentation; scintigraphic
findings were negative.
A, Gray-scale sonogram shows cystlike structure
(arrows) with gut signature (arrowheads) in right iliac
fossa; structure corresponds to Meckels diverticulum
and measures 2.0 1.4 cm.
B, Gray-scale sonogram obtained 10 min after A shows
echogenic material filling lumen of Meckels diverticulum
(arrows). Hyperechoic fixed air collection (arrowhead)
associated with ulceration is visible on anterior wall.
C, Color Doppler sonogram shows hypervascularized
Meckels diverticulum (large arrows) with anomalous artery (small arrow) in longitudinal plane.
D, Color Doppler sonogram shows hypervascularized
Meckels diverticulum (arrows) in transverse plane.
E, Photograph of gross pathologic specimen shows ulceration (arrow) in Meckels diverticulum.

D
tures on sonography, inflammation was associated with ectopic gastric mucosa.
Inflammation in the other three patients was
related to a mesodiverticular band with hernia, an intestinal volvulus around the omphalomesenteric band, and a volvulus of the
diverticulum. However, the two patients with
an internal band also had intestinal obstruction, and distended loops of small bowel with
increased peristaltic activity were observed
on sonography. The Meckels diverticulum
was inflamed and presented as a perforated
ulceration and an abscess in a seventh patient,
in whom sonography revealed a complex
mass in the umbilical region.
For the two patients in whom a cystlike structure with a gut signature was visualized on
sonography, surgical and pathologic findings revealed that the diverticular inflammation resulted from ectopic gastric mucosa with wall
ulceration. Scintigraphic findings were negative
for one of these patients. Sonographic findings
for the 10th patient suggested an intestinal subocclusion (i.e., loops of small bowel distended
with increased peristaltic activity), and the
Meckels diverticulum was not visualized.

AJR:180, February 2003

Discussion

Meckels diverticulum is the most common

congenital anomaly of the gastrointestinal
tract, with an incidence of 13% of the population, although only 4% of those affected become symptomatic [11]. When the vitelline
(omphalomesenteric) duct fails to obliterate
during fetal development, several anomalies
appear, Meckels diverticulum being the most
frequent. It occurs on the antimesenteric border of the ileum, 40100 cm (average, 50 cm)
proximal relative to the ileocecal valve [12].
The diverticulum is approximately 5 cm long
and can be as wide as 2 cm.
The frequency rates of the different clinical
presentations of the Meckels diverticulum are
as follows: inflammation with hematochezia,
40%; an intestinal obstruction, 30%; inflammation without hemorrhaging, 20%; and umbilical disease, 6% [1]. In our study, however,
only two patients had hematochezia, and most
patients presented with clinical signs and
symptoms that mimicked acute appendicitis.
We do not know why our findings differ
from those reported in the literature. We
will, therefore, continue this investigation to

E
assess clinical presentations in a larger number of cases.
We believe that the more important findings
of our study are that in our patients, diverticulitis
mimicked appendicitis clinically and on sonography and that the inflamed Meckels diverticulum was wrongly interpreted as an abnormal
cecal appendix in several patients. Although the
sonographic diagnosis was incorrect, the identification of an abnormal intraabdominal structurea tubular hypoechoic structure (six
patients) or a complex mass (one patient)led
to the correct therapeutic measures because
both Meckels diverticulum and an abnormal intraabdominal structure require surgery. Little
has been reported concerning the fact that the
presence of an inflamed Meckels diverticulum
can result in false-positive results in the sonographic diagnosis of appendicitis [3].
The cystlike structure with characteristics
of the intestinal wall, such as an inner hyperechoic surface corresponding to the mucosa
and an external hypoechoic rim corresponding
to the muscle layer (the gut signature), has
been described as highly suggestive of an intestinal duplication cyst on sonography [3].

427

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Baldisserotto et al.
Fig. 4.8-year-old boy who had experienced hypogastric pain without
guarding for 24 hr before presenting.
A, Color Doppler sonogram shows
cystlike structure (arrows) with gut
signature (arrowheads) in right iliac
fossa (longitudinal view), measuring
2.0 1.4 cm and corresponding to
Meckels diverticulum with hypervascularization caused by inflammation.
B, Color Doppler sonogram reveals
inflammation in Meckels diverticulum (arrows) with gut signature
(arrowheads) in transverse plane.

A
Daneman et al. [3] observed this sonographic
feature in four patients and drew attention to
the fact that the Meckels diverticulum has a
more irregular wall than a duplication cyst, a
finding that we also observed in two of our patients. We also found this sign in six patients in
whom the inflamed Meckels diverticulum
presented as a tubular structure. It is important
to remember that the gut signature can also be
found on sonography in patients with normal
or abnormal appendixes.
Other case reports have illustrated the
same cystlike appearance of this disease on
sonography [710]. In one of our patients
with enterorrhagia, the identification of the
Meckels diverticulum on sonography was
useful in establishing the diagnosis because
scintigraphic findings had been negative. A
similar case was reported by Panuel et al. [7];
the findings of scintigraphy had been negative, and the Meckels diverticulum was identified only on sonography.
Another characteristic feature we noted
was the change in the appearance of the
Meckels diverticulum during the sonographic examination (Fig. 3). The presence of
air inside the Meckels diverticulum and its
mobility during the peristaltic activity of the
adjacent bowel loops can give the Meckels
diverticulum an appearance that is similar to
the rest of the intestine. In this case, a detailed
examination of the intestine in the right lower
quadrant with high-frequency transducers is
necessary to identify the Meckels diverticulum, especially when an inflamed Meckels
diverticulum is clinically suspected.
We found color Doppler sonography to be
important in revealing hypervascularization
and signs of inflammation of the Meckels diverticulum in the two patients in whom cysts

428

were visualized. Color Doppler sonography

was also useful in showing the presence of
anomalous vessels, an appearance not found in
the rest of the intestine.
Only one case of Meckels diverticulum
was not identified on sonography. This patient
presented with nonspecific clinical signs and
symptoms, such as abdominal distention and
pain. On sonography, only distended smallbowel loops with increased peristaltic activity
were visualized. Surgery revealed an inflamed
Meckels diverticulum with a band running to
the umbilicus, causing intestinal obstruction.
Daneman et al. [3] described two patients with
a teardrop-shaped Meckels diverticulum, but
we found no such Meckels diverticulum in
our study population.
We do not believe that sonography will
supersede 99mTc pertechnetate scintigraphy
because scintigraphy is a highly accurate tool
to use in establishing the diagnosis of an inflamed Meckels diverticulum. Sonography
may, however, be useful in patients who have
rectal bleeding and whose scintigraphic findings are negative. For patients with diverticulitis and clinical signs and symptoms
suggestive of appendicitis, a sonographic
diagnosis may be made if the Meckels diverticulum presents as a cystlike structure
with a wall exhibiting the gut signature.
Routine color Doppler sonography reveals
anomalous vessels and signs of inflammation on the wall of the Meckels diverticulum. In patients in whom appendicitis is
clinically suspected, the finding of a hypoechoic tubular structure in the iliac fossa on
sonography is not a specific sign of appendicitis, and the possibility of an inflamed
Meckels diverticulum must be considered
in the differential diagnosis.

B
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AJR:180, February 2003