Meckel’s Diverticulum and Jejunal Diverticulum

H-H Yen, Changhua Christian Hospital, Changhua, Taiwan

r 2013 Elsevier GmbH. Open access under CC BY-NC-ND license.

Received 27 July 2012; Revision submitted 27 July 2012; Accepted 1 August 2012

Abstract

The most common congenital anomaly of the gastrointestinal tract is Meckel’s diverticulum, occurring in 2–3% of the
general population. Bleeding is the most common complication of Meckel’s diverticulum. Here the author demonstrates
the case of a 31-year-old patient with acute hematochezia. Meckel’s diverticulum was diagnosed by double-balloon
enteroscopy. This article is part of an expert video encyclopedia.

Keywords
Double-balloon endoscopy; Enteroscopy; Meckel’s diverticulum; Obscure gastrointestinal bleeding; Video.

Video Related to this Article
Video available to view or download at doi:10.1016/S2212-
0971(13)70109-2
Technique
Double-balloon enteroscopy.
Material
• Double-balloon endoscope: Fujinon EN-450T5 (Fujinon
Inc, Saitama-City, Japan).
Background and Endoscopic Procedure
A 31-year-old man was referred to the hospital because
of acute onset of hematochezia. He reported having
colicky abdominal pain 4 h before the onset of hematochezia.
He had had similar attacks 4 times in the previous 10 years.
Repeated upper endoscopy, colonoscopy, computed tomo-
graphy (CT), and angiography all failed to identify the source
of bleeding.
Two episodes of hematochezia with hypovolemic shock
occurred within 2 h after admission. He was then transferred
to the intensive care unit for fluid resuscitation. Emergent CT
angiography disclosed only blood clots in the colon. A retro-
grade double-balloon enteroscopy identified a diverticulum
60 cm proximal to the ileocecal valve and a clinical diganosis
of Meckel’s diverticulum was made. The diverticulum was
marked by ink tatooing for identification at subsequent
laparoscopy and laparoscopic resection of the lesion. Lapar-
oscopy disclosed a 2-cm long, inflamed diverticulum in the
This article is part of an expert video encyclopedia. Click here for the full
Table of Contents.
antimesenteric side of the terminal ileum. Pathologic exam-
ination confirmed the clinical diagnosis of Meckel’s di-
verticulum by showing ectopic gastric mucosa in the distal
third of the diverticulum.
Meckel’s diverticulum is the most common congenital
anomaly of the gastrointestinal tract, occurring in 2–3% of
the general population.1–3 Bleeding is the most common
complication of Meckel’s diverticulum. Although its pathologic
and clinical features are well known, it remains difficult to
make a preoperative diagnosis. The Tc-99-m pertechnetate
scintigraphy is the most commonly used diagnostic tool.1–3
It has a high accuracy (90%) in pediatric patients but a low
accuracy (46%) in the adult population. Angiography
might identify the location of active bleeding, but Meckel’s di-
verticulum cannot be diagnosed. Both capsule endoscopy and
double-balloon enteroscopy are useful to investigate obscure
gastrointestinal bleeding caused by Meckel’s diverticulum.
Compared with capsule endoscopy, double-balloon entero-
scopy is more invasive, but is more useful for precise
localization of the lesion found, as shown in this case.3,4 This
allows the surgeon to locate the lesion easily, especially during
laparoscopic surgery. Moreover, it is conceivable that flexible
enteroscopy is more sensitive than capsule endoscopy, because
Meckel’s diverticulum might be easily overlooked without air
insufflation.
Key Learning Points/Tips and Tricks
1. Meckel’s diverticulum is the most common source of severe
acute small bowel bleeding in young patients.
2. In cases with suspected Meckel’s diverticulum enteroscopy
from the anal route is the diagnostic procedure of choice,
because the diverticulum is usually located 50–80 cm
proximal to the ileocecal valve.
3. In many cases ectopic gastric mucosa within the di-
verticulum causes the bleeding.
4. Marking the lesion with ink tattooing facilitates identifi-
cation at subsequent laparoscopic surgery.

Video Journal and Encyclopedia of GI Endoscopy http://dx.doi.org/10.1016/S2212-0971(13)70109-2 254

255 Meckel’s Diverticulum and Jejunal Diverticulum
Scripted Voiceover
Time (min:sec) Voiceover text
00:00 This is a retrograde double-balloon enteroscopy in
a 31-year-old patient with intermittent acute
hematochezia. About 60 cm proximal of the
ileocecal valve we identify this opening. This is a
typical location and appearance of a medium-
sized Meckel’s diverticulum. There is no obvious
active bleeding at this time. The base of the
diverticulum cannot be completely visualized.
00:30 Here is another case of a patient with intermittent
small bowel bleeding. Here we see a small bowel
diverticulum but this time it is not Meckel’s
diverticulum, but a large acquired diverticulum
within the jejunum. Characteristically, these
diverticula have large openings and the mucosa
inside the diverticulum is usually atrophic. To
facilitate identification at subsequent
laparoscopic resection, a submucosal tattooing
is performed.
00:49 During laparoscopic surgery, the tattoo is clearly
visible as a blue area. The lesion is located at the
anti-mesenteric side.
References
1. Levy, A. D.; Hobbs, C. M. From the Archives of the AFIP. Meckel Diverticulum:
Radiologic Features with Pathologic Correlation. Radiographics 2004, 24,
565–587.
2. Zeisler, B.; Moyer, S. M.; Farrell, M.; Collins, M. H.; Tomer, G. Electronic
Clinical Challenges and Images in GI. Meckel Diverticulum. Gastroenterology
2008, 134, e3–e4.
3. Yen, H. H.; Chen, C. J.; Lee, M. H. Obscure Gastrointestinal Bleeding for 10
years in a 31-year-old man. Gastroenterology 2011, 140(2), e3–e4.
4. Yen, H. H.; Chen, Y. Y.; Yang, C. W.; Soon, M. S. The Clinical Significance
of Jejuna Diverticular Disease Diagnosed by Double-Balloon Enteroscopy
for Obscure Gastrointestinal Bleeding. Dig. Dis. Sci. 2010, 55(12),
3473–3478.