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From the Archives of the AFIP

Meckel Diverticulum: Radiologic Features with Pathologic Correlation¹

¹ From the Departments of Radiologic Pathology (A.D.L.) and Hepatic and Gastrointestinal Pathology (C.M.H.), Armed Forces Institute of Pathology, 6825 16th St NW, Washington, DC 20306-6000; and the Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (A.D.L.). Received August 28, 2003; accepted October 7. Both authors have no financial relationships to disclose. Address correspondence to A.D.L. (e-mail: levya@afip.osd.mil).

	Abstract

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

 
Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract, occurring in 2%–3% of the population. It results from improper closure and absorption of the omphalomesenteric duct. Meckel diverticulum is the most common end result of the spectrum of omphalomesenteric duct anomalies, which also include umbilicoileal fistula, umbilical sinus, umbilical cyst, and a fibrous cord connecting the ileum to the umbilicus. The formation of Meckel diverticulum occurs with equal frequency in both sexes, but symptoms from complications are more common in male patients. Sixty percent of patients come to medical attention before 10 years of age, with the remainder of cases manifesting in adolescence and adulthood. Heterotopic gastric and pancreatic mucosa are frequently found histologically within the diverticula of symptomatic patients. The most common complications are hemorrhage from peptic ulceration, small intestinal obstruction, and diverticulitis. Although the clinical, pathologic, and radiologic features of the complications of Meckel diverticulum are well known, the diagnosis of Meckel diverticulum is difficult to establish preoperatively.

Index Terms: Enteritis, 742.274 • Intestines, diverticula, 742.1493 • Intestines, hemorrhage, 95.7181 • Intestines, stenosis or obstruction, 742.723 Intussusception, 742.73

	LEARNING OBJECTIVES FOR TEST 6

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

 
After reading this article and taking the test, the reader will be able to:

• Describe the embryologic and clinical features of Meckel diverticulum.
  
• Identify the pathologic and radiologic features of complications of Meckel diverticulum.
  
• Discuss the radiologic evaluation of patients with suspected Meckel diverticulum.
  

	Introduction

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

 
Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract, occurring in 2%–3% of the population (1). Originally described in 1809 by the German anatomist, Johann Friedrich Meckel (1781–1833), the diverticulum is the result of incomplete atrophy of the omphalomesenteric duct (2). Occurring on the antimesenteric border of the distal ileum, Meckel diverticulum is a true diverticulum, composed of all layers of the intestinal wall, and is lined by normal small intestinal mucosa. It frequently contains heterotopic gastric and pancreatic mucosa and less commonly, duodenal, colonic, or biliary mucosa.

Clinical symptoms arise from complications of the diverticulum such as peptic ulceration with hemorrhage; diverticulitis; intestinal obstruction from diverticular inversion, intussusception, volvulus, torsion, or inclusion of the diverticulum in a hernia; formation of enteroliths; and development of neoplasia within the diverticulum. Although most complications manifest during childhood, they may occur during adult life as well. The preoperative diagnosis of a complicated Meckel diverticulum can be challenging and is often difficult to establish. The challenge is especially true in many adult patients because the clinical symptoms and imaging features of a complicated Meckel diverticulum overlap with those of many other disorders that cause acute abdominal pain or gastrointestinal bleeding. The purpose of this article is to review the embryologic, clinical, pathologic, and radiologic features of Meckel diverticulum with an emphasis on radiologic-pathologic correlation.

	Embryologic Features

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

 
The omphalomesenteric (vitelline) duct is the embryonic communication between the yolk sac and the developing midgut. During the 6th week of embryogenesis, the midgut elongates and herniates into the umbilical cord. Within the umbilical cord, the midgut rotates 90° counterclockwise around the axis of the superior mesenteric artery. At the same time, the midgut elongates to form the jejunum and ileum and the lumen of the omphalomesenteric duct closes. By the 10th week of embryogenesis, the midgut returns to the abdominal cavity and the omphalomesenteric duct becomes a thin fibrous band, which eventually disintegrates and is absorbed (3). The omphalomesenteric duct will continue to grow if it fails to completely atrophy and disintegrate.

Incomplete atrophy of the omphalomesenteric duct may result in a variety of anomalies: umbilicoileal fistula, omphalomesenteric duct sinus, omphalomesenteric duct cyst, fibrous connection of the ileum to the umbilicus, or Meckel diverticulum (Fig 1). Umbilicoileal fistula results from a completely patent omphalomesenteric duct and is the least common of these anomalies. The duct remains open through its entire course (Fig 1a). Patients usually come to clinical attention in the newborn period because of fecal drainage from the umbilicus (3). Ileoileal intussusception into the patent duct may occur, appearing clinically as ileal prolapse at the umbilicus (4).

View larger version (83K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. Drawings illustrate the spectrum of anomalies resulting from incomplete atrophy of the omphalomesenteric duct. (a) Umbilicoileal fistula is a completely patent omphalomesenteric duct connecting the ileum to the anterior abdominal wall at the umbilicus. (b) Umbilical sinus results from failure of the umbilical end of the omphalomesenteric duct to close. (c) Umbilical cyst occurs when the midportion of the duct remains patent and each end obliterates. (d) A persistent fibrous cord occurs when the duct obliterates but is not absorbed. (e, f) Meckel diverticulum results when the ileal end of the duct remains patent and the umbilical end atrophies. The diverticulum remains connected to the umbilicus by a fibrous band if the obliterated duct fails to be absorbed (e).

View larger version (78K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. Drawings illustrate the spectrum of anomalies resulting from incomplete atrophy of the omphalomesenteric duct. (a) Umbilicoileal fistula is a completely patent omphalomesenteric duct connecting the ileum to the anterior abdominal wall at the umbilicus. (b) Umbilical sinus results from failure of the umbilical end of the omphalomesenteric duct to close. (c) Umbilical cyst occurs when the midportion of the duct remains patent and each end obliterates. (d) A persistent fibrous cord occurs when the duct obliterates but is not absorbed. (e, f) Meckel diverticulum results when the ileal end of the duct remains patent and the umbilical end atrophies. The diverticulum remains connected to the umbilicus by a fibrous band if the obliterated duct fails to be absorbed (e).

View larger version (79K): [in this window] [in a new window] [Download PPT slide]   Figure 1c. Drawings illustrate the spectrum of anomalies resulting from incomplete atrophy of the omphalomesenteric duct. (a) Umbilicoileal fistula is a completely patent omphalomesenteric duct connecting the ileum to the anterior abdominal wall at the umbilicus. (b) Umbilical sinus results from failure of the umbilical end of the omphalomesenteric duct to close. (c) Umbilical cyst occurs when the midportion of the duct remains patent and each end obliterates. (d) A persistent fibrous cord occurs when the duct obliterates but is not absorbed. (e, f) Meckel diverticulum results when the ileal end of the duct remains patent and the umbilical end atrophies. The diverticulum remains connected to the umbilicus by a fibrous band if the obliterated duct fails to be absorbed (e).

View larger version (78K): [in this window] [in a new window] [Download PPT slide]   Figure 1d. Drawings illustrate the spectrum of anomalies resulting from incomplete atrophy of the omphalomesenteric duct. (a) Umbilicoileal fistula is a completely patent omphalomesenteric duct connecting the ileum to the anterior abdominal wall at the umbilicus. (b) Umbilical sinus results from failure of the umbilical end of the omphalomesenteric duct to close. (c) Umbilical cyst occurs when the midportion of the duct remains patent and each end obliterates. (d) A persistent fibrous cord occurs when the duct obliterates but is not absorbed. (e, f) Meckel diverticulum results when the ileal end of the duct remains patent and the umbilical end atrophies. The diverticulum remains connected to the umbilicus by a fibrous band if the obliterated duct fails to be absorbed (e).

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 1e. Drawings illustrate the spectrum of anomalies resulting from incomplete atrophy of the omphalomesenteric duct. (a) Umbilicoileal fistula is a completely patent omphalomesenteric duct connecting the ileum to the anterior abdominal wall at the umbilicus. (b) Umbilical sinus results from failure of the umbilical end of the omphalomesenteric duct to close. (c) Umbilical cyst occurs when the midportion of the duct remains patent and each end obliterates. (d) A persistent fibrous cord occurs when the duct obliterates but is not absorbed. (e, f) Meckel diverticulum results when the ileal end of the duct remains patent and the umbilical end atrophies. The diverticulum remains connected to the umbilicus by a fibrous band if the obliterated duct fails to be absorbed (e).

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 1f. Drawings illustrate the spectrum of anomalies resulting from incomplete atrophy of the omphalomesenteric duct. (a) Umbilicoileal fistula is a completely patent omphalomesenteric duct connecting the ileum to the anterior abdominal wall at the umbilicus. (b) Umbilical sinus results from failure of the umbilical end of the omphalomesenteric duct to close. (c) Umbilical cyst occurs when the midportion of the duct remains patent and each end obliterates. (d) A persistent fibrous cord occurs when the duct obliterates but is not absorbed. (e, f) Meckel diverticulum results when the ileal end of the duct remains patent and the umbilical end atrophies. The diverticulum remains connected to the umbilicus by a fibrous band if the obliterated duct fails to be absorbed (e).

Meckel diverticulum is the most common (98% of cases) of the omphalomesenteric duct anomalies (3,6). The diverticulum results from fibrous obliteration of the umbilical end of the omphalomesenteric duct and complete patency of the ileal end of the duct. The diverticulum is on the antimesenteric side of the ileum and may connect to the umbilicus by a fibrous band if the fibrous portion of the duct fails to be completely obliterated and absorbed (Fig 1e, 1f). The diverticulum is usually found within 100 cm of the ileocecal valve on the antimesenteric border of the ileum. The arterial blood supply and venous drainage of a Meckel diverticulum are through remnants of the embryologic omphalomesenteric (vitellointestinal) vessels that lie within a separate fold of the small intestinal mesentery supporting the diverticulum or along the surface of the diverticulum (7).

	Clinical Features

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

 
Meckel diverticulum occurs in 2%–3% of the population (1). There is no known gender predilection for the formation of Meckel diverticulum. Those found incidentally at autopsy and surgery are found with equal frequency in both sexes (8). However, symptomatic Meckel diverticulum is more common in men than women. The male-to-female ratio of patients with symptoms is reported to be higher in the Japanese population (male:female, 2.4–2.8:1) compared with the United States and European populations (male:female, 1.6–1.8:1) (9–11). Meckel diverticulum has no associations with other major congenital malformations. There is a higher prevalence (5%–8%) of Meckel diverticulum in patients with Crohn disease compared with the general population (12,13). The explanation for and clinical significance of this association are not clear. It has been hypothesized that infectious or inflammatory agents may be present within the diverticulum that increase gastrointestinal permeability or that the diverticulum provides a site of mechanical or motility disturbance in the distal small intestine that promotes ischemia and a predisposition for the development of Crohn disease (12).

In the majority of patients, Meckel diverticulum is asymptomatic. Many Meckel diverticula are discovered incidentally during a radiologic evaluation or surgical procedure performed for other reasons or they are found at autopsy. It is generally stated throughout the medical literature that 25% of Meckel diverticula become symptomatic. However, in a retrospective study of 202 patients, Soltero and Bill (14) calculated that the lifetime risk of developing complications from a Meckel diverticulum is 4% up to the age of 20 years, 2% up to the age of 40 years, and zero in the elderly population.

Clinical symptoms from complications of Meckel diverticulum occur more commonly in children than adults. Sixty percent of Meckel diverticula become symptomatic before patients reach 10 years of age. Hemorrhage is the most frequent complication in the pediatric population, and it is almost always associated with peptic ulceration from heterotopic gastric mucosa located within the diverticulum (15). The mucosal ulcer may be located in the diverticulum or in the adjacent ileum. The bleeding is usually painless. It can be massive and dramatic, manifesting as bright red blood in the stool, or slow and occult, manifesting as guaiac-positive stools or anemia. Profuse bleeding is usually self-limited because of physiologic contraction of the splanchnic vessels in response to hypovolemia (8). The stool of a patient with an actively bleeding Meckel diverticulum is classically bright red and has a texture that is comparable to "current jelly." The phrase "brick red" is also used to describe the color of stool in a patient with a bleeding Meckel diverticulum.

Intestinal obstruction is the second most common complication. It is usually seen in older children and adults. The reported prevalence of complications of Meckel diverticula in adult patients ranges from 26% to 53% (16). Clinical symptoms include bilious vomiting, abdominal distension, periumbilical pain, and constipation. There are many mechanisms for small intestinal obstruction from a Meckel diverticulum. These mechanisms include intussusception; volvulus or internal hernia from persistent attachment of the diverticulum to the umbilicus by the obliterated omphalomesenteric duct, mesodiverticular band, or adhesion; luminal obstruction from an inverted diverticulum, diverticulitis, or foreign body impacted in the diverticulum; inclusion of the diverticulum into a hernia; neoplastic obstruction; or rarely, the inclusion of a Meckel diverticulum in a true knot that forms between the ileum and sigmoid.

Acute Meckel diverticulitis usually manifests as abdominal pain, fever, and vomiting. The clinical presentation may be indistinguishable from that of acute appendicitis. If the diverticulum is located at a distance from the ileocecal valve, the location of maximal abdominal tenderness may be in the left lower quadrant or midabdomen. The pathogenesis of Meckel diverticulitis is related to obstruction or narrowing of the mouth of the diverticulum by an enterolith, fecolith, parasite, foreign body, neoplasm, or inflammation and fibrosis from peptic ulceration.

Enteroliths are considered rare complications of Meckel diverticulum, but they were found in 10% of the cases reported from our institution (17). Patients with enteroliths had a median age of 45 years and presented with chronic, intermittent abdominal pain or gastrointestinal bleeding (17).

Meckel diverticulum entrapped in a hernia has become known as Littre hernia. Although the original description by Alexis Littre in 1700 reported a small intestinal diverticulum incarcerated in a femoral hernia (18), the term is now used to describe the presence of a Meckel diverticulum in a hernia in any location. Fifty percent of Meckel diverticula in hernias occur in the inguinal region (Fig 2); 20%, in a femoral location; 20%, in an umbilical location; and the remanding 10% in other locations (19). The clinical presentation of patients with Littre hernias is indolent. The symptoms of abdominal distension, pain, fever, and vomiting typically evolve slower than the symptoms in patients who have small intestine entrapped in a hernia (19).

View larger version (79K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Drawing depicts Littre hernia, which consists of a Meckel diverticulum entrapped in an inguinal hernia.

	Pathologic Features

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 3a. (a) Intraoperative photograph of a 19-year-old man who presented with gastrointestinal bleeding shows the serosal surface of a 4.0 x 2.5-cm Meckel diverticulum (M) located on the antimesenteric side of the ileum. (b) Intraoperative photograph of the serosal surface of the distal ileum in a 44-year-old woman with guaiac-positive stools and anemia shows a 1-cm diverticulum on the antimesenteric border.

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 3b. (a) Intraoperative photograph of a 19-year-old man who presented with gastrointestinal bleeding shows the serosal surface of a 4.0 x 2.5-cm Meckel diverticulum (M) located on the antimesenteric side of the ileum. (b) Intraoperative photograph of the serosal surface of the distal ileum in a 44-year-old woman with guaiac-positive stools and anemia shows a 1-cm diverticulum on the antimesenteric border.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 4a. Meckel diverticulum. (a) Photomicrograph (original magnification, x16; hematoxylin-eosin [H-E] stain) shows the diverticulum composed of all layers of the intestinal wall. Normal small intestinal mucosa and a focus of gastric mucosa (arrow) line the diverticulum. (b) Photomicrograph (original magnification, x48; H-E stain) shows normal small intestinal mucosa with goblet cells along the luminal surface (arrow).

View larger version (180K): [in this window] [in a new window] [Download PPT slide]   Figure 4b. Meckel diverticulum. (a) Photomicrograph (original magnification, x16; hematoxylin-eosin [H-E] stain) shows the diverticulum composed of all layers of the intestinal wall. Normal small intestinal mucosa and a focus of gastric mucosa (arrow) line the diverticulum. (b) Photomicrograph (original magnification, x48; H-E stain) shows normal small intestinal mucosa with goblet cells along the luminal surface (arrow).

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 5a. Heterotopic gastric mucosa in Meckel diverticulum. (a, b) Photomicrographs (original magnification, x40; H-E stain) show gastric fundic mucosa surfaced by foveolar cells (straight arrow). Oxyntic glands (curved arrow in b) contain eosinophilic parietal cells adjacent to basophilic chief cells. (c) Photomicrograph (original magnification, x40; H-E stain) shows small intestinal epithelium with goblet cells (*) adjacent to typical gastric epithelium (arrow). (d) Photomicrograph (original magnification, x16; H-E stain) shows erosions in the mucosa (arrowhead) with underlying heterotopic gastric antral glands (arrow).

View larger version (168K): [in this window] [in a new window] [Download PPT slide]   Figure 5b. Heterotopic gastric mucosa in Meckel diverticulum. (a, b) Photomicrographs (original magnification, x40; H-E stain) show gastric fundic mucosa surfaced by foveolar cells (straight arrow). Oxyntic glands (curved arrow in b) contain eosinophilic parietal cells adjacent to basophilic chief cells. (c) Photomicrograph (original magnification, x40; H-E stain) shows small intestinal epithelium with goblet cells (*) adjacent to typical gastric epithelium (arrow). (d) Photomicrograph (original magnification, x16; H-E stain) shows erosions in the mucosa (arrowhead) with underlying heterotopic gastric antral glands (arrow).

View larger version (176K): [in this window] [in a new window] [Download PPT slide]   Figure 5c. Heterotopic gastric mucosa in Meckel diverticulum. (a, b) Photomicrographs (original magnification, x40; H-E stain) show gastric fundic mucosa surfaced by foveolar cells (straight arrow). Oxyntic glands (curved arrow in b) contain eosinophilic parietal cells adjacent to basophilic chief cells. (c) Photomicrograph (original magnification, x40; H-E stain) shows small intestinal epithelium with goblet cells (*) adjacent to typical gastric epithelium (arrow). (d) Photomicrograph (original magnification, x16; H-E stain) shows erosions in the mucosa (arrowhead) with underlying heterotopic gastric antral glands (arrow).

View larger version (159K): [in this window] [in a new window] [Download PPT slide]   Figure 5d. Heterotopic gastric mucosa in Meckel diverticulum. (a, b) Photomicrographs (original magnification, x40; H-E stain) show gastric fundic mucosa surfaced by foveolar cells (straight arrow). Oxyntic glands (curved arrow in b) contain eosinophilic parietal cells adjacent to basophilic chief cells. (c) Photomicrograph (original magnification, x40; H-E stain) shows small intestinal epithelium with goblet cells (*) adjacent to typical gastric epithelium (arrow). (d) Photomicrograph (original magnification, x16; H-E stain) shows erosions in the mucosa (arrowhead) with underlying heterotopic gastric antral glands (arrow).

View larger version (175K): [in this window] [in a new window] [Download PPT slide]   Figure 6a. Heterotopic pancreatic tissue in Meckel diverticulum. (a) Photomicrograph (original magnification, x10; H-E stain) shows a round focus of heterotopic pancreatic tissue (arrow) and multiple heterotopic gastric glands (arrowheads). Extensive ulceration is seen. (b) Photomicrograph (original magnification, x160; H-E stain) shows pancreatic acini. (c) Photomicrograph (original magnification, x80; H-E stain) shows pancreatic acinar cells and islets (arrow). (d) Photomicrograph (original magnification, x64; H-E stain) shows pancreatic ducts (*) surrounded by smooth muscle.

View larger version (191K): [in this window] [in a new window] [Download PPT slide]   Figure 6b. Heterotopic pancreatic tissue in Meckel diverticulum. (a) Photomicrograph (original magnification, x10; H-E stain) shows a round focus of heterotopic pancreatic tissue (arrow) and multiple heterotopic gastric glands (arrowheads). Extensive ulceration is seen. (b) Photomicrograph (original magnification, x160; H-E stain) shows pancreatic acini. (c) Photomicrograph (original magnification, x80; H-E stain) shows pancreatic acinar cells and islets (arrow). (d) Photomicrograph (original magnification, x64; H-E stain) shows pancreatic ducts (*) surrounded by smooth muscle.

View larger version (191K): [in this window] [in a new window] [Download PPT slide]   Figure 6c. Heterotopic pancreatic tissue in Meckel diverticulum. (a) Photomicrograph (original magnification, x10; H-E stain) shows a round focus of heterotopic pancreatic tissue (arrow) and multiple heterotopic gastric glands (arrowheads). Extensive ulceration is seen. (b) Photomicrograph (original magnification, x160; H-E stain) shows pancreatic acini. (c) Photomicrograph (original magnification, x80; H-E stain) shows pancreatic acinar cells and islets (arrow). (d) Photomicrograph (original magnification, x64; H-E stain) shows pancreatic ducts (*) surrounded by smooth muscle.

View larger version (174K): [in this window] [in a new window] [Download PPT slide]   Figure 6d. Heterotopic pancreatic tissue in Meckel diverticulum. (a) Photomicrograph (original magnification, x10; H-E stain) shows a round focus of heterotopic pancreatic tissue (arrow) and multiple heterotopic gastric glands (arrowheads). Extensive ulceration is seen. (b) Photomicrograph (original magnification, x160; H-E stain) shows pancreatic acini. (c) Photomicrograph (original magnification, x80; H-E stain) shows pancreatic acinar cells and islets (arrow). (d) Photomicrograph (original magnification, x64; H-E stain) shows pancreatic ducts (*) surrounded by smooth muscle.

Histologic features of inflammation that may be seen in a Meckel diverticulum include the presence of neutrophils in the lamina propria or epithelium and expansion of the lamina propria by chronic inflammatory cells. Attenuation of the superficial epithelium, villous atrophy, and mucosal erosion may also be present (Fig 7). With severe inflammation, ulceration (Fig 8), mucosal hemorrhage, and edema may occur. Lymphoid aggregates and hyperplasia may be present. With more substantial inflammation and subsequent bacterial superinfection, abscesses form within the wall of the Meckel diverticulum and perforation may occur.

View larger version (153K): [in this window] [in a new window] [Download PPT slide]   Figure 7a. Meckel diverticulitis. (a) Photomicrograph (original magnification, x16; H-E stain) shows submucosal edema and hemorrhage (S). There is a microabscess within the muscularis propria (arrow), as well as an inflammatory infiltrate in the subserosal fat (*). (b) Photomicrograph (original magnification, x40; H-E stain) shows regenerative epithelium (arrow) over a healing ulcer with granulation tissue. There is abundant fibropurulent exudate in the lumen (*).

View larger version (172K): [in this window] [in a new window] [Download PPT slide]   Figure 7b. Meckel diverticulitis. (a) Photomicrograph (original magnification, x16; H-E stain) shows submucosal edema and hemorrhage (S). There is a microabscess within the muscularis propria (arrow), as well as an inflammatory infiltrate in the subserosal fat (*). (b) Photomicrograph (original magnification, x40; H-E stain) shows regenerative epithelium (arrow) over a healing ulcer with granulation tissue. There is abundant fibropurulent exudate in the lumen (*).

View larger version (190K): [in this window] [in a new window] [Download PPT slide]   Figure 8a. Ulceration in Meckel diverticulum. (a) Photomicrograph (original magnification, x16; H-E stain) shows marked ulceration of the mucosal surface (arrow). An inflammatory infiltrate and hemorrhage are present. There is a focus of heterotopic pancreatic ducts (*). (b) Photomicrograph (original magnification, x16; H-E stain) shows peptic ulceration in an area of oxyntic gastric epithelium.

View larger version (193K): [in this window] [in a new window] [Download PPT slide]   Figure 8b. Ulceration in Meckel diverticulum. (a) Photomicrograph (original magnification, x16; H-E stain) shows marked ulceration of the mucosal surface (arrow). An inflammatory infiltrate and hemorrhage are present. There is a focus of heterotopic pancreatic ducts (*). (b) Photomicrograph (original magnification, x16; H-E stain) shows peptic ulceration in an area of oxyntic gastric epithelium.

	Radiologic Features

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

It has been shown that conventional barium studies can help diagnose Meckel diverticulum accurately when meticulous technique is used (5,28,29). Meckel diverticulum is identified as a saccular, blind-ending structure located on the antimesenteric border of the ileum. The antimesenteric location can be confirmed from the position of the diverticulum, which faces away from the axis of the root of the small intestinal mesentery (Fig 9). Meckel diverticulum is usually found in the right lower quadrant and pelvic region, but it may have a periumbilical location (Fig 10). Periumbilical or midabdominal locations may be secondary to adhesions or congenital bands that fix the diverticulum to the umbilicus or adjacent intestinal segments.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 9a. Barium examination of the small intestine demonstrating Meckel diverticulum. (a) Image from a small bowel follow-through study in a 10-year-old girl with intermittent bloody stools and anemia shows a wide-mouthed Meckel diverticulum (arrow) on the antimesenteric border of the ileum. The tip of the diverticulum points away from the root of the small bowel mesentery. (b) Image from a small bowel follow-through study in an 11-year-old girl with abdominal pain and anemia shows an elongated Meckel diverticulum extending from the antimesenteric border of the distal ileum. The neck of the diverticulum is narrow (arrow). (Fig 9b courtesy of William M. Thompson, MD, Duke University, Durham, NC.)

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 9b. Barium examination of the small intestine demonstrating Meckel diverticulum. (a) Image from a small bowel follow-through study in a 10-year-old girl with intermittent bloody stools and anemia shows a wide-mouthed Meckel diverticulum (arrow) on the antimesenteric border of the ileum. The tip of the diverticulum points away from the root of the small bowel mesentery. (b) Image from a small bowel follow-through study in an 11-year-old girl with abdominal pain and anemia shows an elongated Meckel diverticulum extending from the antimesenteric border of the distal ileum. The neck of the diverticulum is narrow (arrow). (Fig 9b courtesy of William M. Thompson, MD, Duke University, Durham, NC.)

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 10a. Enteroliths in a Meckel diverticulum in a 40-year-old man with chronic, intermittent abdominal pain. (a) Supine abdominal radiograph demonstrates multiple stones with peripheral calcification (arrow) in the right upper quadrant. (b) Image from a small bowel follow-through study shows a Meckel diverticulum in the right midabdomen (arrow). The dense collection of barium obscures the stones.

View larger version (165K): [in this window] [in a new window] [Download PPT slide]   Figure 10b. Enteroliths in a Meckel diverticulum in a 40-year-old man with chronic, intermittent abdominal pain. (a) Supine abdominal radiograph demonstrates multiple stones with peripheral calcification (arrow) in the right upper quadrant. (b) Image from a small bowel follow-through study shows a Meckel diverticulum in the right midabdomen (arrow). The dense collection of barium obscures the stones.

View larger version (163K): [in this window] [in a new window] [Download PPT slide]   Figure 11. Image from a barium study of the small intestine in a 35-year-old woman with abdominal pain shows a Meckel diverticulum. There is a triradiate fold pattern at the junction of the diverticulum with the ileum (arrow). (Courtesy of William M. Thompson, MD, Duke University, Durham, NC.)

	Imaging of Complications of Meckel Diverticulum

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

 
Hemorrhage
Hemorrhage is the most frequent complication of Meckel diverticulum in the pediatric population. Technetium-99m pertechnetate scintigraphy is the modality of choice for evaluating pediatric patients with gastrointestinal hemorrhage and a suspected Meckel diverticulum. The mucus cells in the gastric epithelium accumulate and secrete the pertechnetate anion. After intravenous injection of Tc-99m pertechnetate, a Meckel diverticulum containing gastric mucosa will manifest as a small rounded area of increased activity in the right lower quadrant.

A Meckel diverticulum usually appears within 30 minutes of the injection, but its visualization may take up to an hour if there are small amounts of heterotopic gastric mucosa (30). Normal activity will simultaneously appear in the stomach. Occasionally, the activity of a Meckel diverticulum will be present elsewhere in the abdomen or will change positions during the course of the study (Fig 12a). Intestinal activity may appear simultaneously with the gastric and heterotopic gastric activity or later in the course of the scan (Fig 12b). Care should be taken in interpreting these studies because the presence of intestinal activity may mask the activity of heterotopic gastric mucosa in a Meckel diverticulum (31). Single photon emission computed tomography (SPECT) has been reported to demonstrate a positive Meckel diverticulum when results from conventional planar imaging are negative (32). Improved resolution provided by SPECT makes it a useful adjunct when the clinical suspicion for a bleeding Meckel diverticulum is high and findings from planar Tc-99m pertechnetate imaging are negative.

View larger version (92K): [in this window] [in a new window] [Download PPT slide]   Figure 12a. Meckel diverticulum diagnosed with Tc-99m pertechnetate scintigraphy. (a) Tc-99m pertechnetate scans of a 17-year-old boy with painless rectal bleeding show a small focus of uptake in the right lower quadrant within minutes of radiopharmaceutical injection. The activity changes shape and position during the study (arrows), which is indicative of active hemorrhage and extravasation of radioactivity into the intestinal lumen. (b) Tc-99m pertechnetate scans of a 4-year-old boy who had multiple episodes of bright red bleeding from the rectum show a persistent focus of uptake in the right lower quadrant, a finding consistent with a Meckel diverticulum. There is delayed appearance of proximal small intestinal activity (arrow), most likely secondary to transit of activity from the stomach.

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 12b. Meckel diverticulum diagnosed with Tc-99m pertechnetate scintigraphy. (a) Tc-99m pertechnetate scans of a 17-year-old boy with painless rectal bleeding show a small focus of uptake in the right lower quadrant within minutes of radiopharmaceutical injection. The activity changes shape and position during the study (arrows), which is indicative of active hemorrhage and extravasation of radioactivity into the intestinal lumen. (b) Tc-99m pertechnetate scans of a 4-year-old boy who had multiple episodes of bright red bleeding from the rectum show a persistent focus of uptake in the right lower quadrant, a finding consistent with a Meckel diverticulum. There is delayed appearance of proximal small intestinal activity (arrow), most likely secondary to transit of activity from the stomach.

Scintigraphic studies that demonstrate active gastrointestinal hemorrhage are also useful to localize the site of hemorrhage in patients who are briskly bleeding. Tc-99m–labeled sulfur colloid or red blood cell scintigraphy is sensitive for the localization of the site of gastrointestinal hemorrhage, but neither technique is specific for Meckel diverticulum. Therefore, these studies are less useful for the specific diagnosis of Meckel diverticulum.

Angiography may be useful in the evaluation of an adult patient with occult or intermittent gastrointestinal bleeding for the localization of the site of bleeding, specific diagnosis, and therapeutic preoperative embolization. In these patients, the diagnosis of Meckel diverticulum is often unsuspected. Meckel diverticulum receives arterial blood supply from a remnant of the omphalomesenteric (vitellointestinal) artery, and demonstration of this artery is diagnostic of Meckel diverticulum. In some patients, the primary blood supply may also come from branches of the ileocolic artery (7). The vitellointestinal artery usually arises from a distal ileal branch of the superior mesenteric artery and may have a number of side branches (Fig 13) (36). A vascular blush may also be identified at the site of the Meckel diverticulum (Fig 13b). When active hemorrhage is occurring at the time of angiography, luminal extravasation of contrast material will be present (Fig 14).

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 13a. Meckel diverticulum in a 22-year-old man with chronic abdominal pain and anemia. (a) Angiogram shows a vitellointestinal artery (arrow) arising from a distal ileal branch of the superior mesenteric artery. (b) Late arterial phase image shows a tubular-shaped angiographic blush (arrow) at the site of the diverticulum. (c) Photograph of the opened, resected surgical specimen shows a hemorrhagic Meckel diverticulum.

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 13b. Meckel diverticulum in a 22-year-old man with chronic abdominal pain and anemia. (a) Angiogram shows a vitellointestinal artery (arrow) arising from a distal ileal branch of the superior mesenteric artery. (b) Late arterial phase image shows a tubular-shaped angiographic blush (arrow) at the site of the diverticulum. (c) Photograph of the opened, resected surgical specimen shows a hemorrhagic Meckel diverticulum.

View larger version (134K): [in this window] [in a new window] [Download PPT slide]   Figure 13c. Meckel diverticulum in a 22-year-old man with chronic abdominal pain and anemia. (a) Angiogram shows a vitellointestinal artery (arrow) arising from a distal ileal branch of the superior mesenteric artery. (b) Late arterial phase image shows a tubular-shaped angiographic blush (arrow) at the site of the diverticulum. (c) Photograph of the opened, resected surgical specimen shows a hemorrhagic Meckel diverticulum.

View larger version (162K): [in this window] [in a new window] [Download PPT slide]   Figure 14. Angiogram shows active hemorrhage from a Meckel diverticulum in a 26-year-old man with hematochezia. Selective injection of the ileocolic artery shows hemorrhage from a proximal branch (arrow). There is extravasation of contrast material into the intestinal lumen (arrowheads).

In the setting of intestinal obstruction, the most useful feature for the diagnosis of a Meckel diverticulum on abdominal radiographs is the identification of enteroliths. When present, enteroliths in Meckel diverticula are almost always visualized on abdominal radiographs (Fig 15). Most commonly, enteroliths manifest as peripheral calcification with a radiolucent center and less often have a laminated appearance (17). They are most commonly located in the right lower quadrant of the abdomen, but they may be present in the middle and upper abdomen if adhesions from inflammation or congenital bands fix and alter the location of the diverticulum.

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 15a. Torsion of a Meckel diverticulum causing small intestinal obstruction in a 30-year-old man who presented with abdominal distension and vomiting. Supine (a) and upright (b) abdominal radiographs show features of a mechanical small intestinal obstruction and an oval air collection that contains multiple peripherally calcified stones (arrow) in the right lower quadrant. At surgery, these findings proved to represent torsion of a Meckel diverticulum and multiple enteroliths. (Courtesy of Charles Rohrmann, Jr, MD, University of Washington, Seattle.)

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 15b. Torsion of a Meckel diverticulum causing small intestinal obstruction in a 30-year-old man who presented with abdominal distension and vomiting. Supine (a) and upright (b) abdominal radiographs show features of a mechanical small intestinal obstruction and an oval air collection that contains multiple peripherally calcified stones (arrow) in the right lower quadrant. At surgery, these findings proved to represent torsion of a Meckel diverticulum and multiple enteroliths. (Courtesy of Charles Rohrmann, Jr, MD, University of Washington, Seattle.)

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 16a. Intussuscepted Meckel diverticulum with infarction producing small intestinal obstruction in a 41-year-old woman with diffuse abdominal pain, nausea, and vomiting. (a) Intravenous contrast material-enhanced CT scan shows diffuse small intestinal dilatation. (b) Contrast-enhanced CT scan of the pelvis demonstrates an ileoileal intussusception, which appears as a thickened edematous segment of small bowel (arrowheads) with alternating bands of soft-tissue and fluid attenuation. There is a central focus of fat attenuation (arrow). (c) Photograph of the opened, resected surgical specimen shows an infarcted and necrotic Meckel diverticulum (arrow) that was the lead point of the intussusception.

View larger version (112K): [in this window] [in a new window] [Download PPT slide]   Figure 16b. Intussuscepted Meckel diverticulum with infarction producing small intestinal obstruction in a 41-year-old woman with diffuse abdominal pain, nausea, and vomiting. (a) Intravenous contrast material-enhanced CT scan shows diffuse small intestinal dilatation. (b) Contrast-enhanced CT scan of the pelvis demonstrates an ileoileal intussusception, which appears as a thickened edematous segment of small bowel (arrowheads) with alternating bands of soft-tissue and fluid attenuation. There is a central focus of fat attenuation (arrow). (c) Photograph of the opened, resected surgical specimen shows an infarcted and necrotic Meckel diverticulum (arrow) that was the lead point of the intussusception.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 16c. Intussuscepted Meckel diverticulum with infarction producing small intestinal obstruction in a 41-year-old woman with diffuse abdominal pain, nausea, and vomiting. (a) Intravenous contrast material-enhanced CT scan shows diffuse small intestinal dilatation. (b) Contrast-enhanced CT scan of the pelvis demonstrates an ileoileal intussusception, which appears as a thickened edematous segment of small bowel (arrowheads) with alternating bands of soft-tissue and fluid attenuation. There is a central focus of fat attenuation (arrow). (c) Photograph of the opened, resected surgical specimen shows an infarcted and necrotic Meckel diverticulum (arrow) that was the lead point of the intussusception.

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 17a. Meckel diverticulitis producing small intestinal obstruction in a 40-year-old man who presented with abdominal pain and vomiting. (a) Intravenous and oral contrast-enhanced CT scan shows distended segments of fluid-filled small intestine. (b) CT image of the pelvis shows a Meckel diverticulum (*) as a blind-ending tubular segment of bowel. There is fecal-like material within the inflamed diverticulum and minimal inflammatory changes surrounding it. (c) Photograph of the unopened resected Meckel diverticulum shows an erythematous and edematous serosa.

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 17b. Meckel diverticulitis producing small intestinal obstruction in a 40-year-old man who presented with abdominal pain and vomiting. (a) Intravenous and oral contrast-enhanced CT scan shows distended segments of fluid-filled small intestine. (b) CT image of the pelvis shows a Meckel diverticulum (*) as a blind-ending tubular segment of bowel. There is fecal-like material within the inflamed diverticulum and minimal inflammatory changes surrounding it. (c) Photograph of the unopened resected Meckel diverticulum shows an erythematous and edematous serosa.

View larger version (170K): [in this window] [in a new window] [Download PPT slide]   Figure 17c. Meckel diverticulitis producing small intestinal obstruction in a 40-year-old man who presented with abdominal pain and vomiting. (a) Intravenous and oral contrast-enhanced CT scan shows distended segments of fluid-filled small intestine. (b) CT image of the pelvis shows a Meckel diverticulum (*) as a blind-ending tubular segment of bowel. There is fecal-like material within the inflamed diverticulum and minimal inflammatory changes surrounding it. (c) Photograph of the unopened resected Meckel diverticulum shows an erythematous and edematous serosa.

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 18a. Meckel diverticulitis with abscess producing small intestinal obstruction in a 3-year-old boy who presented with a 1-day history of abdominal pain and nonbilious vomiting. (a) Supine abdominal radiograph shows multiple dilated segments of air-filled small intestine. (b, c) Intravenous and oral contrast-enhanced CT scans show fluid-filled dilated small intestine that is oriented in a radial distribution surrounding small bowel mesentery and vessels. An abscess (arrows in c) containing an air-fluid level was present at the transition point. (d) Intraoperative photograph of the serosal surface of the small intestine shows a Meckel diverticulum (arrow) opening into a contained abscess (arrowheads). At surgery, it was seen that the Meckel diverticulum caused a kink in the intestine, thus producing the closed-loop obstruction observed in b.

View larger version (98K): [in this window] [in a new window] [Download PPT slide]   Figure 18b. Meckel diverticulitis with abscess producing small intestinal obstruction in a 3-year-old boy who presented with a 1-day history of abdominal pain and nonbilious vomiting. (a) Supine abdominal radiograph shows multiple dilated segments of air-filled small intestine. (b, c) Intravenous and oral contrast-enhanced CT scans show fluid-filled dilated small intestine that is oriented in a radial distribution surrounding small bowel mesentery and vessels. An abscess (arrows in c) containing an air-fluid level was present at the transition point. (d) Intraoperative photograph of the serosal surface of the small intestine shows a Meckel diverticulum (arrow) opening into a contained abscess (arrowheads). At surgery, it was seen that the Meckel diverticulum caused a kink in the intestine, thus producing the closed-loop obstruction observed in b.

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 18c. Meckel diverticulitis with abscess producing small intestinal obstruction in a 3-year-old boy who presented with a 1-day history of abdominal pain and nonbilious vomiting. (a) Supine abdominal radiograph shows multiple dilated segments of air-filled small intestine. (b, c) Intravenous and oral contrast-enhanced CT scans show fluid-filled dilated small intestine that is oriented in a radial distribution surrounding small bowel mesentery and vessels. An abscess (arrows in c) containing an air-fluid level was present at the transition point. (d) Intraoperative photograph of the serosal surface of the small intestine shows a Meckel diverticulum (arrow) opening into a contained abscess (arrowheads). At surgery, it was seen that the Meckel diverticulum caused a kink in the intestine, thus producing the closed-loop obstruction observed in b.

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 18d. Meckel diverticulitis with abscess producing small intestinal obstruction in a 3-year-old boy who presented with a 1-day history of abdominal pain and nonbilious vomiting. (a) Supine abdominal radiograph shows multiple dilated segments of air-filled small intestine. (b, c) Intravenous and oral contrast-enhanced CT scans show fluid-filled dilated small intestine that is oriented in a radial distribution surrounding small bowel mesentery and vessels. An abscess (arrows in c) containing an air-fluid level was present at the transition point. (d) Intraoperative photograph of the serosal surface of the small intestine shows a Meckel diverticulum (arrow) opening into a contained abscess (arrowheads). At surgery, it was seen that the Meckel diverticulum caused a kink in the intestine, thus producing the closed-loop obstruction observed in b.

The diagnosis of obstruction caused by volvulus from persistent fibrous attachment to the umbilicus, adhesions, or mesodiverticular bands is generally not possible with CT unless the diverticulum is visualized. In this setting, the CT features are similar to those of small intestinal obstruction secondary to postoperative adhesions: abrupt change in the luminal caliber from the dilated intestine proximal to the obstruction to the collapsed intestine distally; straight, sharp, or slightly curved edges where the band crosses the intestinal lumen; and absence of a soft-tissue mass at the site of the obstruction.

Inverted Meckel Diverticulum
Meckel diverticulum may invaginate or invert into the small intestinal lumen. The mesenteric fat of the Meckel diverticulum is pulled into the center of the diverticulum as it invaginates into the small intestinal lumen. Once inverted, the diverticulum may serve as the site of intestinal obstruction or lead point for an ileoileal or ileocolic intussusception (Fig 19). Twenty-one percent of cases of Meckel diverticulum previously reported from our institution were found to be inverted into the lumen of the small intestine (42).

View larger version (79K): [in this window] [in a new window] [Download PPT slide]   Figure 19a. Drawings illustrate an inverted Meckel diverticulum. (a) Mesenteric fat of the Meckel diverticulum is pulled into the center of the diverticulum as it invaginates into the small intestinal lumen. (b) The inverted diverticulum may serve as the lead point for an ileoileal or ileocolic intussusception.

View larger version (74K): [in this window] [in a new window] [Download PPT slide]   Figure 19b. Drawings illustrate an inverted Meckel diverticulum. (a) Mesenteric fat of the Meckel diverticulum is pulled into the center of the diverticulum as it invaginates into the small intestinal lumen. (b) The inverted diverticulum may serve as the lead point for an ileoileal or ileocolic intussusception.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 20a. Inverted Meckel diverticulum in a 50-year-old man with iron deficiency anemia and occult blood-positive stools. (a) Enteroclysis image shows an elongated tubular filling defect in the ileum (arrowheads). (b) Oral and intravenous contrast-enhanced CT scan shows an intraluminal mass of fat attenuation within the small intestinal lumen. There is a rim of soft-tissue attenuation surrounding the fatty mass. (c) Photograph of the opened, resected surgical specimen shows an inverted Meckel diverticulum on the luminal side of the ileum. The mucosa of the inverted diverticulum is erythematous and edematous. (d). Photograph of the sectioned surgical specimen shows mesenteric fat in the central core of the inverted Meckel diverticulum.

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 20b. Inverted Meckel diverticulum in a 50-year-old man with iron deficiency anemia and occult blood-positive stools. (a) Enteroclysis image shows an elongated tubular filling defect in the ileum (arrowheads). (b) Oral and intravenous contrast-enhanced CT scan shows an intraluminal mass of fat attenuation within the small intestinal lumen. There is a rim of soft-tissue attenuation surrounding the fatty mass. (c) Photograph of the opened, resected surgical specimen shows an inverted Meckel diverticulum on the luminal side of the ileum. The mucosa of the inverted diverticulum is erythematous and edematous. (d). Photograph of the sectioned surgical specimen shows mesenteric fat in the central core of the inverted Meckel diverticulum.

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 20c. Inverted Meckel diverticulum in a 50-year-old man with iron deficiency anemia and occult blood-positive stools. (a) Enteroclysis image shows an elongated tubular filling defect in the ileum (arrowheads). (b) Oral and intravenous contrast-enhanced CT scan shows an intraluminal mass of fat attenuation within the small intestinal lumen. There is a rim of soft-tissue attenuation surrounding the fatty mass. (c) Photograph of the opened, resected surgical specimen shows an inverted Meckel diverticulum on the luminal side of the ileum. The mucosa of the inverted diverticulum is erythematous and edematous. (d). Photograph of the sectioned surgical specimen shows mesenteric fat in the central core of the inverted Meckel diverticulum.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 20d. Inverted Meckel diverticulum in a 50-year-old man with iron deficiency anemia and occult blood-positive stools. (a) Enteroclysis image shows an elongated tubular filling defect in the ileum (arrowheads). (b) Oral and intravenous contrast-enhanced CT scan shows an intraluminal mass of fat attenuation within the small intestinal lumen. There is a rim of soft-tissue attenuation surrounding the fatty mass. (c) Photograph of the opened, resected surgical specimen shows an inverted Meckel diverticulum on the luminal side of the ileum. The mucosa of the inverted diverticulum is erythematous and edematous. (d). Photograph of the sectioned surgical specimen shows mesenteric fat in the central core of the inverted Meckel diverticulum.

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 21a. Inverted Meckel diverticulum in a 61-year-old woman with intermittent abdominal pain. (a) Transverse sonogram of the right lower abdomen shows a targetlike mass with central hyperechogenicity from the core of mesenteric fat surrounded by the wall of the diverticulum and wall of the intestine. (b) Photograph of the unopened, resected surgical specimen shows the serosal surface of the ileum. On the antimesenteric border, there is dimpling at the site of the inverted Meckel diverticulum (arrowhead). (c) Photograph of the opened, resected specimen shows the inverted diverticulum (arrowhead) protruding into the ileal lumen.

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 21b. Inverted Meckel diverticulum in a 61-year-old woman with intermittent abdominal pain. (a) Transverse sonogram of the right lower abdomen shows a targetlike mass with central hyperechogenicity from the core of mesenteric fat surrounded by the wall of the diverticulum and wall of the intestine. (b) Photograph of the unopened, resected surgical specimen shows the serosal surface of the ileum. On the antimesenteric border, there is dimpling at the site of the inverted Meckel diverticulum (arrowhead). (c) Photograph of the opened, resected specimen shows the inverted diverticulum (arrowhead) protruding into the ileal lumen.

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 21c. Inverted Meckel diverticulum in a 61-year-old woman with intermittent abdominal pain. (a) Transverse sonogram of the right lower abdomen shows a targetlike mass with central hyperechogenicity from the core of mesenteric fat surrounded by the wall of the diverticulum and wall of the intestine. (b) Photograph of the unopened, resected surgical specimen shows the serosal surface of the ileum. On the antimesenteric border, there is dimpling at the site of the inverted Meckel diverticulum (arrowhead). (c) Photograph of the opened, resected specimen shows the inverted diverticulum (arrowhead) protruding into the ileal lumen.

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 22a. Inverted Meckel diverticulum with intussusception in a 31-year-old man who complained of abdominal pain, nausea, vomiting, and fever. Oral and intravenous contrast-enhanced CT scans show an ileocolic intussusception composed of concentric rings of soft-tissue and fat attenuation (arrowheads in a). The core of the intussusception contains an elongated mass of fat attenuation (arrow in b), a finding consistent with an inverted Meckel diverticulum.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 22b. Inverted Meckel diverticulum with intussusception in a 31-year-old man who complained of abdominal pain, nausea, vomiting, and fever. Oral and intravenous contrast-enhanced CT scans show an ileocolic intussusception composed of concentric rings of soft-tissue and fat attenuation (arrowheads in a). The core of the intussusception contains an elongated mass of fat attenuation (arrow in b), a finding consistent with an inverted Meckel diverticulum.

Meckel Diverticulitis
Cross-sectional imaging modalities are the radiologic studies of choice for the evaluation of patients with suspected acute inflammatory conditions of the abdomen. The CT diagnosis of Meckel diverticulitis relies on the identification of a blind-ending, tubular, round or oval structure in the right lower quadrant or periumbilical region with surrounding inflammation. In some instances, the diverticulum will extend toward the umbilicus when it is attached to the umbilicus by a fibrous cord (Fig 23) (40). The diverticulum may contain an air-fluid level, fluid only, or fecal-like material (Figs 17, 18) (47). The wall of the diverticulum may show inflammatory changes such as mural thickening and contrast material enhancement. Soft-tissue stranding and adjacent fluid collections are also helpful features of diverticulitis. Occasionally, enteroliths will be present within the inflamed diverticulum (Fig 23b) (48). The presence of a pouchlike structure attached to the adjacent small intestine is a helpful clue to the diagnosis (Fig 23c). Other features that are helpful with the diagnosis include the presence of a secondary small intestinal obstruction and visualization of a normal appendix.

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 23a. Meckel diverticulitis. (a) Intravenous and oral contrast-enhanced CT scan of a 22-year-old man with fever and guaiac-positive stools shows a rim-enhancing tubular structure beneath the umbilicus (arrow). There are surrounding inflammatory changes and thickening of the subjacent small intestine. (b) Intravenous contrast-enhanced CT scan of a 49-year-old man who presented with abdominal pain, nausea, vomiting, and anorexia shows a rounded fluid collection (arrow) in the right pelvis that contains a calcified enterolith. There are inflammatory changes in the adjacent fat. (c) Intravenous contrast-enhanced CT scan of a 57-year-old man with abdominal pain shows a blind-ending rounded structure (arrowheads) attached to the adjacent ileum. Arrow shows site of attachment.

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 23b. Meckel diverticulitis. (a) Intravenous and oral contrast-enhanced CT scan of a 22-year-old man with fever and guaiac-positive stools shows a rim-enhancing tubular structure beneath the umbilicus (arrow). There are surrounding inflammatory changes and thickening of the subjacent small intestine. (b) Intravenous contrast-enhanced CT scan of a 49-year-old man who presented with abdominal pain, nausea, vomiting, and anorexia shows a rounded fluid collection (arrow) in the right pelvis that contains a calcified enterolith. There are inflammatory changes in the adjacent fat. (c) Intravenous contrast-enhanced CT scan of a 57-year-old man with abdominal pain shows a blind-ending rounded structure (arrowheads) attached to the adjacent ileum. Arrow shows site of attachment.

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 23c. Meckel diverticulitis. (a) Intravenous and oral contrast-enhanced CT scan of a 22-year-old man with fever and guaiac-positive stools shows a rim-enhancing tubular structure beneath the umbilicus (arrow). There are surrounding inflammatory changes and thickening of the subjacent small intestine. (b) Intravenous contrast-enhanced CT scan of a 49-year-old man who presented with abdominal pain, nausea, vomiting, and anorexia shows a rounded fluid collection (arrow) in the right pelvis that contains a calcified enterolith. There are inflammatory changes in the adjacent fat. (c) Intravenous contrast-enhanced CT scan of a 57-year-old man with abdominal pain shows a blind-ending rounded structure (arrowheads) attached to the adjacent ileum. Arrow shows site of attachment.

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 24a. Meckel diverticulitis in a 7-year-old girl with vague abdominal pain and occasional vomiting. (a) Longitudinal sonogram of the pelvis shows a blind-ending, tubular cystlike structure containing internal echoes from debris. The diverticular wall has the gut signature. (b) Intravenous and oral contrast-enhanced CT scan shows a periumbilical fluid collection (arrowheads) containing a debris-fluid level. The fluid collection connects to a segment of thickened distal small intestine (arrow). (c) Photograph of the opened, resected surgical specimen shows an inflamed Meckel diverticulum with a thickened wall and erythematous mucosa.

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 24b. Meckel diverticulitis in a 7-year-old girl with vague abdominal pain and occasional vomiting. (a) Longitudinal sonogram of the pelvis shows a blind-ending, tubular cystlike structure containing internal echoes from debris. The diverticular wall has the gut signature. (b) Intravenous and oral contrast-enhanced CT scan shows a periumbilical fluid collection (arrowheads) containing a debris-fluid level. The fluid collection connects to a segment of thickened distal small intestine (arrow). (c) Photograph of the opened, resected surgical specimen shows an inflamed Meckel diverticulum with a thickened wall and erythematous mucosa.

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 24c. Meckel diverticulitis in a 7-year-old girl with vague abdominal pain and occasional vomiting. (a) Longitudinal sonogram of the pelvis shows a blind-ending, tubular cystlike structure containing internal echoes from debris. The diverticular wall has the gut signature. (b) Intravenous and oral contrast-enhanced CT scan shows a periumbilical fluid collection (arrowheads) containing a debris-fluid level. The fluid collection connects to a segment of thickened distal small intestine (arrow). (c) Photograph of the opened, resected surgical specimen shows an inflamed Meckel diverticulum with a thickened wall and erythematous mucosa.

The differential diagnosis of Meckel diverticulitis on cross-sectional images includes appendicitis, inflammatory bowel disease, colonic diverticulitis, perforated neoplasm, and pelvic inflammatory disease in female patients. If findings are limited to the periumbilical region, complications of a urachal remnant should also be considered in the differential diagnosis.

Neoplasms
Neoplasms arising in Meckel diverticula are very rare. The most frequently reported neoplasm complicating a Meckel diverticulum is carcinoid tumor. Carcinoids in Meckel diverticula are usually single, small, and asymptomatic (51). They are most often incidentally discovered at histopathologic evaluation of a resected Meckel diverticulum or at autopsy. The biologic behavior of carcinoids in Meckel diverticula is similar to that of ileal carcinoids. In the largest review of the literature to date, the average age of patients with carcinoids in Meckel diverticula was 57 years, and 72% of patients were men (52). Only 17% of the patients had clinical symptoms related to the carcinoid, and metastases were found at presentation in 24% of patients (52).

At our institution, we have experience with only one case of a carcinoid in a Meckel diverticulum. The patient was a 59-year-old man with anemia and tarry stools. He was found to have a Meckel diverticulum during an enteroclysis evaluation of the small intestine. There was no suggestion of tumor, mass, or luminal irregularity in the Meckel diverticulum at enteroclysis, but an incidental 2-mm focus of carcinoid was found during histologic examination of the resected Meckel diverticulum.

Gastrointestinal stromal tumors (53), leiomyosarcomas (54), and adenocarcinomas (55,56) have also been reported to occur in Meckel diverticula. The imaging features of these tumors are relatively nonspecific and depend on tumor size. Gastrointestinal stromal tumors in Meckel diverticula have been reported to manifest at CT as lobulated masses of heterogeneous attenuation with central areas of necrosis (53). The tumor may extend to invade adjacent mesenteric fat and organs such as the bladder. Adenocarcinoma in a Meckel diverticulum may appear as an annular lesion on barium images but often has a component that infiltrates into the adjacent mesenteric fat (56).

	Surgical Management of Meckel Diverticulum

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

 
There is no doubt that a symptomatic Meckel diverticulum should be surgically excised. With few exceptions, laparoscopic resection has been shown to be a safe, cost-effective, and less invasive technique than traditional laparotomy (57–60). However, management of incidentally discovered, asymptomatic diverticula remains controversial. Weighing the lifetime risk of complications (4% in patients up to age 20 years and 2% in patients up to age 40 years) against the reported complication rates from surgical excision (1%–8%), many authors do not recommend prophylactic removal of an incidentally discovered Meckel diverticulum (11,14). In contrast, other authors support diverticulectomy in all patients regardless of age, because there is no guarantee that the diverticulum will remain uncomplicated (61). Still other authors advocate prophylactic resection in patients with specific clinical features (being male, being younger than 40 years of age) and with morphologic appearances of the diverticulum (over 2 cm in diameter, suspected heterotopic tissue, associated with a mesodiverticular band, and wide diverticula with thin walls in patients over 40 years old) that increase the risk of complications (11,62).

	Conclusions

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

 
Meckel diverticulum is the most common anomaly of the gastrointestinal tract. Clinical symptoms arise from complications of the diverticulum, which are most common in male patients. Complications are more frequent in the pediatric population but manifest in adults as well. Hemorrhage, small intestinal obstruction, and diverticulitis are the most frequent complications. Preoperative diagnosis of a complicated Meckel diverticulum may be challenging because clinical and imaging features overlap with those of other acute inflammatory conditions in the abdomen. Knowledge of the embryologic, clinical, pathologic, and radiologic characteristics of Meckel diverticulum will aid in the early and accurate diagnosis of cases with complications.

	Acknowledgments

 
The authors thank Aletta Ann Frazier, MD, Department of Radiologic Pathology, Armed Forces Institute of Pathology, for the medical illustrations in the article.

	Footnotes

 
Abbreviation: H-E = hematoxylin-eosin

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official nor as reflecting the views of the Departments of the Army or Defense.

	References

Top Abstract LEARNING OBJECTIVES FOR TEST... Introduction Embryologic Features Clinical Features Pathologic Features Radiologic Features Imaging of Complications of... Surgical Management of Meckel... Conclusions References

 

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