Journal of Medical Imaging and Radiation Oncology  (2016) –

MEDICAL IMAGING—PICTORIAL ESSAY

The many faces of Meckel’s diverticulum and its complications

Seo-Youn Choi,1 Seong Sook Hong,2 Hyun Jeong Park,3 Hae Kyung Lee,1 Hyeong Cheol Shin4 and

Journal of Medical Imaging and Radiation Oncology

Gyo Chang Choi5
1 Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
2 Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Korea
3 Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
4 Department of Radiology, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
5 Department of Radiology, Soonchunhyang University Gumi Hospital, Gumi, Korea

S-Y Choi MD; SS Hong MD; HJ Park MD; Summary

HK Lee MD; HC Shin MD; GC Choi MD.
Correspondence
Associate Professor Seong Sook Hong,
Department of Radiology, Soonchunhyang
University Seoul Hospital, 59, Daesakwan-ro,
Yongsan-gu, Seoul 140-743, Korea.
Email: hongses@schmc.ac.kr
Conflicts of interest: The authors declare that
they have no conflict of interest.
Submitted 17 May 2016; accepted 8 July
2016.
Meckel’s diverticulum is the most frequent congenital malformation of the
gastrointestinal tract, occurring in 2% of the general population. Meckel’s
diverticulum is usually asymptomatic and found incidentally. However, the life-
time risk of complications is 4–40%. In this essay, we describe the clinical and
imaging findings in 12 cases of Meckel’s diverticula with complications over a
5-year period, which were confirmed pathologically. The major complications
of Meckel’s diverticulum include gastrointestinal bleeding, bowel obstruction,
perforation and inflammation. Small bowel follow-through (SBFT), computed
tomography (CT) including CT enterography and RI scintigraphy can be used
to show typical imaging features of Meckel’s diverticulum and its complica-
tions. Knowledge of the clinical and radiologic findings of Meckel’s diverticulum
can aid in the early and accurate diagnosis of this anomaly and its complica-
tions.

doi:10.1111/1754-9485.12505 Key words: diverticulum; gastrointestinal bleeding; intestinal obstruction-

intussusception; intestinal perforation; Meckel diverticulum.

undiscovered, with a lifetime risk of complications

Introduction
Meckel’s diverticulum is the most frequent congenital
anomaly of the gastrointestinal tract, which occurs in
approximately 2% of the general population. The Ger-
man anatomist Johann Friedrich Meckel first described
that this diverticulum results from incomplete atrophy of
the omphalomesenteric (vitelline) duct.1 In early fetal
life, the primitive midgut communicates with the yolk sac
through the vitelline duct. Meckel’s diverticulum results
when the vitelline duct fails to completely regress as nor-
mal. However, it has no association with other major
congenital malformations.
Meckel’s diverticulum is located at the antimesenteric
side wall of the distal ileum, unlike alimentary duplica-
tions and most other bowel diverticula. The diverticulum
may retain a patent opening through the umbilicus, may
be joined to the umbilicus by a fibrous cord, or it may
remain as a freely movable blind pouch of various
dimensions.
Because most patients without complications do not
have symptoms, Meckel’s diverticulum can remain
reported to vary widely from 4–40%. Cases are usually
discovered incidentally during an operation or radiologic
evaluation for other diseases or are occasionally found in
an autopsy.2,3 Almost half of all children with Meckel’s
diverticulum present symptoms of rectal bleeding or
intussusception before 2-years of age. On the other
hand, adult patients tend to present with inflammation
or obstruction rather than bleeding.4
In this essay, we describe and illustrate the various
imaging findings of Meckel’s diverticulum and its compli-
cations.
Imaging diagnosis of Meckel’s
diverticulum
Various imaging methods have been applied for the diag-
nosis of Meckel’s diverticulum. Plain radiographs have
limited value and are usually unrevealing, but may show
enteroliths or bowel obstruction. Conventional barium
studies, such as small bowel follow-through (SBFT), have
been replaced by other imaging techniques for

© 2016 The Royal Australian and New Zealand College of Radiologists 1

S-Y Choi et al.
evaluation of patients with acute symptoms. Upon appli-
cation of barium, Meckel’s diverticulum appears as a
blind-ended pouch originating from the antimesenteric
border of the distal ileum. Filling defects within the diver-
ticulum may represent an ectopic gastric mucosa or
tumour.2
Although it is of limited value, ultrasonography is rou-
tinely used to study children who present with right lower
quadrant pain. In high-resolution ultrasonography, Meck-
el’s diverticulum usually appears as a fluid-filled struc-
ture in the right lower quadrant abdomen with typical
gut features, a blind-ending and thick-walled bowel loop,
and a direct connection with the normal small bowel
loop. Hyperechoic mucosa (‘typical gut signature’) is
observed, and enteroliths are detected as echogenic foci
with posterior acoustic shadowing.5
On CT, Meckel’s diverticulum is usually difficult to dis-
tinguish from a normal small bowel in uncomplicated
patients. However, a fluid- or gas-filled blind-ending
structure continuous with small bowel loops may be
seen. CT may also show enteroliths within the diverticu-
lum, intussusception, diverticulitis and small bowel
obstruction. CT is superior to other imaging techniques
in evaluating the complications of Meckel’s diverticulum.6
In most patients with Meckel’s diverticulum who suffer
from chronic gastrointestinal bleeding, angiography can
reveal a remnant omphalomesenteric artery.7
Radioisotope (RI) scintigraphy is widely used for the
detection of bleeding, which presents as an accumulation
of isotope in the right lower quadrant in a positive scan.3
However, it can only aid in the diagnosis of cases with
ectopic gastric mucosa because the radioisotope is taken
up by mucin-secreting cells of the normal gastric
mucosa. As the age of patients with Meckel’s diverticu-
lum increases, RI scintigraphy tends to exhibit lower
sensitivity.
Imaging findings of complications of
Meckel’s diverticulum
The morbidity and clinical symptoms associated with
Meckel’s diverticulum are due to complications includ-
ing haemorrhage, perforation, volvulus, intussuscep-
tion, enterolith formation, intestinal obstruction and
neoplasm development. Haemorrhage is the most com-
mon complication in symptomatic Meckel’s diverticu-
lum.2,8 Painless gastrointestinal bleeding is a major
complication of Meckel’s diverticulum, and results from
acid-secreting gastric or pancreatic mucosa within the
diverticulum. Detection of heterotopic mucosa is impor-
tant in these cases. The length and base diameter of
the diverticulum are well-recognized as predisposing
factors associated with complications. Among these
factors, long- and narrow-based diverticula are thought
to be more prone to obstruction or inflammation. CT or
CT enterography, SBFT and RI scintigraphy are consid-
ered the most important imaging tools for the
2 © 2016 The Royal Australian and New Zealand College of Radiologists
diagnosis and detection of complications associated
with Meckel’s diverticulum.
Haemorrhage
Bleeding is the most common complication especially in
paediatric populations, and is associated with peptic
ulceration by heterotopic or ectopic gastric mucosa
within the diverticulum in almost all cases. These ectopic
mucosae are found in 20–55% of patients. Approxi-
mately 90% of Meckel’s diverticula manifests with
bleeding due to contained gastric mucosa.2,8 CT can
reveal gastric mucosa within diverticula with well-
enhanced nodular areas. A persistent omphlaomesente-
riac artery can be detected with conventional angiogra-
phy in most patients with gastrointestinal bleeding
due to Meckel’s diverticulum.7 Scintigraphy with 99 mTc-
pertechnetate aids in the detection of heterotopic or
ectopic gastric mucosa, because the isotope is taken
up by mucin-secreting cells of the gastric mucosa
(Figs 1, 2).1,9
Bowel obstruction
The second most common complication is intestinal
obstruction. It usually occurs in older children or adults
and typically presents as abdominal distension, bilious
vomiting, constipation and abdominal pain. Intestinal
obstruction by Meckel’s diverticulum can be caused by
adhesion, intussusception, inverted diverticulum or
diverticulitis, volvulus or internal hernia due to persistent
attachment of the diverticulum to the umbilicus by an
obliterated mesodiverticular band, and neoplasm
(Figs 2–5).1 Multi-detector CT is a sensitive technique for
diagnosing small bowel obstructions.10 The most com-
mon cause of intestinal obstruction is an ileocolic intus-
susception. In these cases, dilated proximal small bowel
loops with an intraluminal mass are evident in the
ascending colon on CT scan.11
Inflammation
Acute Meckel’s diverticulitis frequently mimics acute
appendicitis, and presents as abdominal pain and fever.
The mechanism underlying Meckel’s diverticulitis is
inflammation at the diverticular orifice with subsequent
narrowing due to an enterolith, fecalith, foreign body,
parasite, neoplasm or fibrosis from recurrent peptic
ulcer.1,8,9 CT is a sensitive imaging tool for diagnosing
Meckel’s diverticulitis, which is represented by a vari-
able-sized, blind-ending pouch with mural thickening and
surrounding mesenteric infiltration (Figs 6–9).
Perforation
Perforation is a rare complication of Meckel’s diverticu-
lum. Although it is less frequent, perforation can be a
 Complications of Meckel’s diverticulum

(a) (b) (c)

Fig. 1. (a–c) Meckel’s diverticulum containing ectopic gastric mucosa in a 12-year-old female with melena. Small bowel follow-through (SBFT) (a) showing
the typical imaging findings of Meckel’s diverticulum (i.e. blind-ended outpouching diverticulum; arrows) extending from the antimesenteric border of the pel-
vic ileal loop (I). The pouch showing a focal filling defect (arrowhead), which represents ectopic gastric mucosa. Coronal contrast-enhanced CT (b) shows a
blind-ended pouch (arrows) with a well-enhanced nodular appearance (arrowheads). This case was proven to be ectopic gastric mucosa based on pathology.
Tc-99 m pertechnetate scan (c) shows focal isotope hot uptake (arrowhead) of the right pelvic cavity representing ectopic gastric mucosa.

(a) (b)

Fig. 2. (a, b) Meckel’s diverticulitis containing air-fluid level in a 76-year-old man with intermittent hematochezia. Axial contrast-enhanced CT (a) showing air-
fluid level within a blind-ended pouch (arrows) arising from the terminal ileum (asterisk). Mild-surrounding mesenteric fat infiltration is also seen. Tc-99m
pertechnetate scan (b) showing no accumulation of isotope in the right lower quadrant, indicative of a negative Meckel’s scan. In such a case, a CT scan is
superior to RI scintigraphy for detecting the diverticulum.

(a) (b)

Fig. 3. (a, b) Meckel’s diverticulitis producing small intestinal obstruction in a 55-year-old man with lower abdominal pain. Axial contrast-enhanced CT scans
(a and b) show an air-filled blind pouch (D) communicating with the terminal ileum (TI). The proximal ileum (PI) is distended with distal obstruction. Bowel
wall thickening is seen with surrounding mesenteric fat infiltration (arrowheads).

serious problem. Perforation usually occurs secondary to

inflammation, gangrene, peptic ulceration, ingested for-
Enterolith formation
eign body or intestinal obstruction.12 The presence of Enterolith formation is a relatively rare complication
intra-abdominal free air or localized abscess on CT or of Meckel’s diverticulum, evident in 3–10% of cases.
plain radiograph can suggest perforation in the setting of Clinical symptoms include chronic and intermittent
Meckel’s diverticulum. CT has a higher diagnostic capa- abdominal pain or gastrointestinal bleeding.8
bility than any other imaging technique for detecting per- Enterolith formation is thought to be a result of stasis.
foration (Fig. 10). Plain radiography can reveal approximately 50% of

© 2016 The Royal Australian and New Zealand College of Radiologists 3

S-Y Choi et al.

(a) (b) (c)

Fig. 4. (a–c) Intussuscepted Meckel’s diverticulum which progressed to intestinal obstruction in a 36-year-old woman with hematochezia, nausea and
crampy pain. Axial (a) and coronal (b) contrast-enhanced CT show distal ileal intussusception composed of concentric rings (arrows) of soft-tissue and fat
attenuation. This represents a whirling sign containing a central focus of mesenteric fat (F). Endoscopy (c) showing a protruding congested mass (D) around
the IC valve.

(a) (b) (c)

Fig. 5. (a–c) Small bowel obstruction due to a mesodiverticular band associated with Meckel’s diverticulum in a 4-year-old boy with abdominal distention
and pain. Upright plain radiography (a) showing severe dilatation of the small bowels with different air-fluid levels. Axial contrast-enhanced CT (b) showing a
small outpouching lesion (arrowhead with D) arising from markedly distended ileum (I) with a large amount of fecal content. When tracing to more cranial
direction images, there is abrupt narrowing of ileal lumen, representing mechanical obstruction (c). The linear structure is the presumed mesodiverticular
band (arrows).

(a) (b)

Fig. 6. (a, b) Simple diverticulitis in a 25-year-old woman with abdominal pain. Abdominal ultrasonography (a) showing an approximately 2-cm well-defined
cyst-like structure (D) containing internal echoes (arrow) in the right lower quadrant of the abdomen communicating with the distal ileum (although not visu-
alized on this current scan). Gross image (b) showing a blind-ending round outpouching lesion (D) arising from the distal ileum (I). The orifice (arrows) of the
diverticulum is easily seen.

enteroliths, however, CT examination is superior

to plain radiography for their detection. Furthermore,
non-enhanced CT is more valuable in detecting
enteroliths compared with contrast-enhanced CT
(Fig. 11).
Intussusception or inversion
Meckel’s diverticulum can invert or invaginate into the
small bowel lumen. When this occurs, the mesenteric fat
surrounding the Meckel’s diverticulum is pulled into the

4 © 2016 The Royal Australian and New Zealand College of Radiologists

 Complications of Meckel’s diverticulum

centre of the diverticulum and can progress into intesti-
nal obstruction or intussusceptions.1,11 These cases can
be very dangerous if they are not detected and can pro-
gress to bowel necrosis, perforation and sepsis. Intus-
susception and inversion appear as a smooth marginated
intraluminal mass or pedunculated intraluminal polyp on
SBFT. On CT, an inverted diverticulum typically appears
as a central area of fat attenuation with surrounding soft
tissue attenuation. If the diverticulum serves as the lead-
ing point of ileocolic or ileoileal intussusceptions, it is
commonly seen as a target-shaped mass by edematous
intussuscipiens and intussusceptum on CT.1,11

Fig. 7. Air-filled diverticulum with a narrow neck in a 41-year-old woman
with recurrent abdominal pain. Sagittal contrast-enhanced CT showing an
air-fluid level within a blind-ended pouch (D) arising from the antimesenteric
border of the terminal ileum (I). Air-fluid level within the distended pouch is
noted.
Torsion
Torsion and subsequent necrosis of Meckel’s diverticulum
can simultaneously cause mechanical small bowel
obstruction. It is one of the rarest complications and
may produce non-specific abdominal signs and symp-
toms mimicking acute appendicitis. Torsion results from
the axial twisting of Meckel’s diverticulum around its nar-
row base which can compromise the blood supply, lead-
ing to subsequent gangrene13 (Fig. 11).
Neoplasm
Neoplasms arising from Meckel’s diverticula are very
rare. Carcinoid tumour is the most commonly developed

(a) (b)

Fig. 8. (a, b) Abscess formation within the diverticulum resulting in an adhesive change in the small bowel in a 47-year-old man with abdominal pain. Axial
contrast-enhanced CT (a, b) showing an approximately 1.5-cm blind-ending structure (arrows) arising from the adjacent small bowel. A focal beak-like taper-
ing lesion (arrowhead), transitional zone, in the adjacent small bowel. Dilatation of proximal bowel (P) and collapse of distal bowel (D) is due to mechanical
obstruction by Meckel’s diverticulum. Meckel’s diverticulum shows an ill-defined enhancing wall (arrows) with surrounding mesenteric fat infiltration repre-
senting an inflammatory change.

(a) (b)

Fig. 9. (a, b) Abscess formation within the diverticulum in a 65-year-old man with abdominal pain. Axial contrast-enhanced CT (a) showing an approximately
3-cm blind-ended rounded structure (arrows, D) attached to the adjacent small bowel (arrowhead). Meckel’s diverticulum (D) shows an ill-defined enhancing
wall (arrows) with surrounding fat infiltration, representing an inflammatory change. Gross image (b) shows a blind-ended round outpouch (D) arising from
the small bowel (SB).

© 2016 The Royal Australian and New Zealand College of Radiologists 5

S-Y Choi et al.
(a)
Fig. 10. (a, b) Pneumoperitoneum with microperforated diverticulitis in a 54-year-old man with acute abdominal pain. Axial contrast-enhanced CT (a) show-
ing a small blind-ended outpouching lesion (D), which has enhanced wall thickening with extraluminal free air (arrow) in the right lower quadrant of the abdo-
men. Gross image (b) also shows a blind-ended outpouch (D) arising from the distal ileum (I) with an inflammatory change.
Fig. 11. Air-fluid-filled diverticulum containing multiple stones in a 18-year-
old man with lower abdominal pain. Computed tomography shows an
approximately 8 9 4 cm sized well-marginated thin-walled cystic lesion (D)
arising from the small bowel, containing air-fluid level. Focal calcified high
densities (arrowhead) in the cystic wall seen in a precontrast scan are
probably stones.
Fig. 12. Torsion with gangrene of Meckel’s diverticulum in a 21-year-old
man with acute abdominal pain. Fluid-filled diverticulum with decreased
mural enhancement (arrows) is seen compared with enhancing degree of
adjacent pelvic bowel loops (arrowheads).
neoplasm originating from Meckel’s diverticulum. This
typically presents as single, small and asymptomatic
tumours.1 Most of the tumours are incidentally discov-
ered in a histopathological evaluation of a resected diver-
ticular specimen after surgical resection. Other reported
6 © 2016 The Royal Australian and New Zealand College of Radiologists
(b)
tumours are leiomyomas, leiomyosarcomas, neuromas,
lipomas, angiomas, carcinosarcomas and adenocarcino-
mas.1,2 On CT scan, these tumours show non-specific
imaging findings such as sessile or lobulated masses or
focal wall thickening with contrast enhancement. Malig-
nant neoplasms may extend into the perilesional mesen-
teric fat or adjacent organs including the urinary bladder.
In conclusion, it is well-recognized that Meckel’s diver-
ticulum is the most common anomaly of the gastroin-
testinal tract. Clinical symptoms are usually related to
complications from the diverticulum rather than the
diverticulum itself. Physicians agree that symptomatic
Meckel’s diverticulum should be surgically excised. Blind-
ending, fluid- or gas-filled structures continuous with the
small bowel can aid in the diagnosis of Meckel’s divertic-
ulum. Its major complications include bleeding, intestinal
obstruction, inflammation, perforation, stones or neo-
plasm. Because clinical and imaging findings overlap with
those of other acute inflammatory lesions, preoperative
diagnosis of Meckel’s diverticulum and its complications
can be challenging. Knowledge of these imaging findings
and combining radiologic characteristics of Meckel’s
diverticulum with its clinical features will help in the early
and accurate diagnosis of the diverticulum and its com-
plications.
Acknowledgement
This work was supported by the Soonchunhyang Univer-
sity Research Fund.
References
1. Levy AD, Hobbs CM. From the archives of the AFIP.
Meckel diverticulum: radiologic features with
pathologic correlation. Radiographics 2004; 24: 565–
87.
2. Elsayes KM, Menias CO, Harvin HJ, Francis IR. Imaging
manifestations of Meckel’s diverticulum. AJR Am J
Roentgenol 2007; 189: 81–8.
3. Fink AM, Alexopoulou E, Carty H. Bleeding Meckel’s
diverticulum in infancy: unusual scintigraphic and

ultrasound appearances. Pediatr Radiol 1995;
25: 155–6.
4. Rossi P, Gourtsoyiannis N, Bezzi M et al. Meckel’s
diverticulum: imaging diagnosis. AJR Am J Roentgenol
1996; 166: 567–73.
5. Mostbeck GH, Liskutin J, Dorffner R, Bittmann B,
Resinger M. Ultrasonographic diagnosis of a bleeding
Meckel’s diverticulum. Pediatr Radiol 2000; 30: 382.
6. Paulsen SR, Huprich JE, Fletcher JG et al. CT
enterography as a diagnostic tool in evaluating small
bowel disorders: review of clinical experience with over
700 cases. Radiographics 2006; 26: 641–57;
discussion 57–62.
7. Mitchell AW, Spencer J, Allison DJ, Jackson JE. Meckel’s
diverticulum: angiographic findings in 16 patients. AJR
Am J Roentgenol 1998; 170: 1329–33.
8. Kusumoto H, Yoshida M, Takahashi I, Anai H, Maehara
Y, Sugimachi K. Complications and diagnosis of
Meckel’s diverticulum in 776 patients. Am J Surg 1992;
164: 382–3.
© 2016 The Royal Australian and New Zealand College of Radiologists
Complications of Meckel’s diverticulum
9. Sfakianakis GN, Conway JJ. Detection of ectopic gastric
mucosa in Meckel’s diverticulum and in other
aberrations by scintigraphy: ii. Indications and
methods–a 10-year experience. J Nucl Med 1981; 22:
732–8.
10. Aufort S, Charra L, Lesnik A, Bruel JM, Taourel P.
Multidetector CT of bowel obstruction: value of
post-processing. Eur Radiol 2005; 15: 2323–
9.
11. Dujardin M, de Beeck BO, Osteaux M. Inverted
Meckel’s diverticulum as a leading point for ileoileal
intussusception in an adult: case report. Abdom
Imaging 2002; 27: 563–5.
12. Schmidt C, Brown LM, Klomp HJ, Henne-Bruns D.
Perforated Meckel’s diverticulum. Surgery 2001; 129:
643–4.
13. Malhotra S, Roth DA, Gouge TH, Hofstetter SR, Sidhu
G, Newman E. Gangrene of Meckel’s diverticulum
secondary to axial torsion: a rare complication. Am J
Gastroenterol 1998; 93: 1373–5.
7