Vitelline Duct Abnormalities

Pathophysiology:

1) During embryonic life the fetal midgut receives its nutrition from the placenta via the Vitellointestinal Duct

2) The duct is then progressively obliterated and usually disappears by the 7th week of gestation

3) If the fails to fully obliterate → different types of Vitelline abnormalities appear:

• Umbilical Fistula: Patent Vitelline Duct

• Fibrous Band that connects the Ileum to the inner surface of the umbilicus
• Umbilical Polyp — patent distal portion

• Enterocele or Polyp in the middle part


• Meckel’s Diverticulum — most common → 97%

Meckel’s Diverticulum

Most common congenital anomaly of the Small Intestines

— due to Incomplete Obliteration of the Vitellointestinal Duct

• Patent proximal portion of the duct

• A Blind-ended true diverticulum that contains all layers of the ileum

• Almost always occurs on the anti-mesenteric border of the ileum

• The rule of two’s:

- Occurs in 2% of the population
- 2% are symptomatic
- Mostly in children <2 years old

- Affects males twice as often as females

- Is located 2 feet proximal to the ileocecal valve

- 2 inches long
- 2 cm wide
- Can have 2 types of mucosa lining (ectopic → gastric + pancreatic)

Clinical Picture & Complications:

1) Asymptomatic in 98%

2) Lower GIT Bleeding:

- 25-50% of symptomatic cases

- Due to ileal ulceration caused by heterotopic gastric mucosa


- Presents with painless rectal bleeding — in children < 5 years old

3) Local Inflammation: (Meckel’s Diverticulitis)

- Clinically → resembles appendicitis
- Usually in adult patients

- Due to ectopic gastric mucosa (acid)

4) Intestinal Obstruction:
- Causes:

• Segmental Volvulus
• Intussusception
• Congenital Band


- Presentation:

• Colicky Abdominal Pain

• Vomiting/Nausea
• Abdominal Distension

• Absolute Constipation
Investigations:

NB: Preoperative diagnosis is difficult

1) Meckel Scintigraphy Scan: (Meckel Scan)

- Most accurate investigation — especially in children

- 90% accuracy in pediatric cases

- Radiolabelled Technetium (99mTc) → absorbed by the gastric mucosa and can identify ectopic gastric mucosa

2) Abdominal CT Scan — helpful

3) Barium Meal & Barium follow-through

Treatment:

Symptomatic Cases Asymptomatic Cases

or Incidentally discovered during surgery

• Surgical intervention → resection of diverticulum or
ileal segment containing diverticulum
• Children → Resection

• Asymptomatic Adults 

↳ Resection is controversial since:
• If Bleeding → source of bleed is usually the adjacent
- Only 2% of patients will become symptomatic

ileal segment
- 2% incidence of complications following
prophylactic resection (stenosis - adhesions)
 Diverticulosis of the Colon

Diverticula are blind pouches that protrude from the GI wall and communicate with the lumen

They develop as a result of herniation of the mucosa and submucosa through points of weakness in the muscular
wall of the colon

Predisposing Factors:

Increased Intraluminal Pressure

1) Diet: Low Fiber + High Carbohydrate

2) Obesity

3) Decreased Physical Activity

4) Cigarette Smoking

5) Disordered Colonic Motility

6) Chronic Constipation
7) Advanced Age

Pathophysiology:

Increased Intraluminal Pressure (e.g. chronic constipation) → mucosal protrusion through points of entry of
arteries into the muscle wall (weak points)

Sites:

Diverticula can occur anywhere in the large intestines 


— except the Rectum

↳ The rectum has a complete muscle coat — no Taenia Coli (weak points in the bowel)
↳ Absence of taenia → prevent protrusion of the mucosa
Clinical Picture & Complications:

1) Asymptomatic (non-complicated)

2) Acute Diverticulitis:
- Stages:

• Acute Diverticulitis → Inflammation of the Diverticulum

• Perforation of the Diverticulum → Pericolic collection of pus + fecal matter

• Pericolic abscess formation

• Generalized Peritonitis


- General Symptoms + Signs:

• Fever — high in perforation or abscess

• Peritonitis → Toxemia


- Local Symptoms:

• Pain:
‣ Mainly on the left side of the abdomen — left iliac fossa

‣ Fixed
‣ Dull Aching

• Anorexia + Vomiting

• History of chronic constipation


- Local Signs:

• Abdominal Distension

• Tenderness in the left side of the abdomen + left iliac fossa (diverticulitis)

• Perforation/Abscess → Tenderness - Rebound Tenderness - Guarding - Rigidity

3) Fistula:
- Colovesical Fistula → Pneumaturia and Recurrent UTIs

- Colovaginal Fistula → Recurrent Vaginitis

4) Colonic Bleeding

5) Intestinal Obstruction

Investigations:

Laboratory

• CBC → Leukocytosis ± Anemia • KFTs + LFTs

Radiology

1) Plain Abdominal X-Ray → Air Under Diaphragm in Perforation

2) Abdominal Ultrasound → detect fluid collections in Perforation

3) Abdominal CT:

— Detects:
- Diverticula
- Fluid collections
- Pericolic abscesses

4) Barium Enema — in non-complicated cases → Saw-tooth appearance

Treatment:

Conservative

indicated in non-complicated cases

1) Conservative Methods:
- Treatment of chronic constipation

- High fiber diet

- Antibiotics: (85% success rate)

• Acute Diverticulitis without Peritonitis

• Diverticular Abscess

2) Percutaneous Drainage — U/S or CT guided in Localized Abscesses

Surgical

• Indications:
- Diffuse Peritonitis
- Failure of conservative treatment

- Failure of percutaneous drainage of pericolic abscess

• Procedures:
- Hartmann’s Procedure:
‣Stage 1: Resection without anastomoses + end colostomy + closure of rectal stump
‣Stage 2: Colorectal anastomoses after 6—8 weeks


- Procedure 2 ?:

‣Stage 1: Resection + Colorectal anastomoses + temporary Ileostomy

‣Stage 2: Closure of Ileostomy