presentations of Meckelís diverticulum AT KHYBER TEACHING HOSPITAL PESHAWAR

Inayat ur Rehman, Tariq Burki, Said Alam, Fazl e Rahman

Department of Paediatric Surgery, Khyber Teaching Hospital, Peshawar

Background: This study was conducted with an objective to observe various presentations of Meckelís Diverticulum in our setting and compare it with other national and international studies. Methods: It was a retrospective analysis of hospital record carried out at the department of paediatric surgery Khyber Teaching Hospital, Peshawar. A total of 63 patients meeting the inclusion criteria were included in the study who had presented to our unit with signs and symptoms of Meckelís Diverticulum and who were diagnosed either by investigations or at surgery. All the patients were explored and resection and anastomosis performed. We did not do H. Pylori culture. Patients with bleeding per rectum were investigated by Meckelís scan. Analysis of the results was done by SPSS version 10. Results: Majority of our patients presented with obstruction (82.5%) in contrast to the Western studies (around 40%) while only 4.7% presented with bleeding per rectum again in contrast to the Western countries (38Ė56%). Conclusion: There appears to be a geographical and/or racial difference in the presentation of Meckelís diverticulum.

Introduction

According to Charles Mayo ďA Meckelís diverticulum is frequently suspected, often sought for and seldom foundĒ.1 This is a very true statement. Meckelís is frequently suspected in cases of bleeding per rectum but contrary to popular belief it rarely causes bleeding per rectum.2 The more common presentations of Meckelís diverticulum are intestinal obstruction either due to inflammation, bands, internal herniation or intussusception.3 Meckelís causing chronic problems like chronic abdominal pain and unexplained anaemia has also been documented.4,5 Other presentations of Meckelís are due to patent omphalomesenteric duct remnants, which presents as umbilical fistula or sinus or intestinal prolapse through the umbilicus.3 Geographical variations have also been reported.6

Contrary to popular belief bleeding per rectum and intussusception are not the most common presentations of Meckelís diverticulum. Meckelís diverticulum can present in many ways. Majority of the presentations can be traced back to the embryological origin of Meckelís diverticulum.7 The Meckelís diverticulum originates from incomplete involution of Omphalomesenteric duct and this can result in umbilical polyp, umbilical sinus, umbilical fistula, umbilical cyst, various types of bands and omphalomesenteric vessels remnants with or without Meckelís diverticulum.7 Ectopic gastric mucosa near the base of Meckelís diverticulum is responsible for many presentations like inflammation, recurrent abdominal pain due to ulceration of adjacent intestinal mucosa, perforation, and G.I. bleeding.8,9 Pancreatic ectopic mucosa frequently causes intussusception.10 Another variety is inverted Meckelís diverticulum, which also frequently produces intestinal obstruction.5

We conducted a study in our department to get an insight into the different presentations of Meckelís Diverticulum in our part of the world.

Material and Methods

Three years retrospective analysis from January 1999 to December 2001 was conducted at the department of Paediatric Surgery, Khyber Teaching Hospital, Peshawar on the various presentations of Meckelís diverticulum. The record was reviewed for all those patients who presented to our ward with the signs and symptoms of Meckelís diverticulum and who were diagnosed either by investigations or at surgery. Patients with silent Meckelís diagnosed at lapa-rotomy for some other reasons were excluded from the study. Also the patients with umbilical pathologies like umbilical polyps, omphalomes-enteric duct sinus or cysts were not included in this study. However the patients who presented with omphalomesenteric duct fistulas with or without intestinal prolapse were included in the study. All the patients were explored and in every case resection anastomosis was performed. We did not perform culture for Helicobacter Pylori. The patients with bleeding per rectum were investigated by Meckelís scan. Records of those patients who had inflamed Meckelís diverticulum, was also reviewed and included in the study.

Results

We recorded 63 patients with signs and symptoms related to Meckelís diverticulum. Out of these 16 (25%) were females and 47 (75%) were males. Among these 63 patients, 52 (82%) presented with acute intestinal obstruction with age ranging from less than 1 year to 10 years. Out of these 8 (12.6%) patients presented in 1st year of life including 5 (8%) in the neonatal period. 32 (50%) patients were seen between the age group of 2-4 years, while 12 (19%) presented between 5Ė10 years of age. One of the patients was operated for umbilical hernia somewhere else and developed post-operative intestinal obstruction. On exploration we found an inflamed Meckelís diverticulum tip causing obstruction.  The cause of obstruction 41 (65%) cases was internal herniation of the intestine in a gap between the inflamed tip of Meckel's and another part of intestine or mesentery or mesodiverticular bands. In 8 (12.6%) patients volvulus caused obstruction due to a band attached to the tip of the Meckelís Diverticulum and only in three we found Meckelís as a pathologic lead point with intussusception.

Inflamed Meckelís diverticulum without any other complication was found in only five patients. These were operated for appendix but when normal looking appendix was found search for other pathology revealed inflamed Meckelís.

Patent omphalomesenteric duct was found in 4 (6.3%) patients. One of the patients was operated by a general surgeon but unfortunately the baby developed intestinal fistula and the patient came to us for further management.

Massive intestinal bleeding per rectum occurred only in three cases (4.7%). Meckelís scan was positive only in two (3.1%) of these cases.   

Discussion

Meckelís diverticulum can present at any age. It has been documented that majority of Meckelís diverticulum symptoms occur before the age of 40 years.7,11 In paediatric age group it can present at any time right from birth till the end of childhood years.9 The mean age recorded has been 3.5 years, which was also the most common age of presentation in our series.9 In adult population fourth decade seems to be the most common age of presentation.9 Different symptoms appear at different ages.7,12,13 In one study the mean age of bleeding per rectum recorded was 2.8 years, for obstruction 0.6 years and for inflammation 8.2 years.7 In another study obstruction was recorded mainly in less than 10 years of age, but perforation occurred mainly between 10 to 30 years of age.12 We had two peaks of obstruction, one in the neonatal age and the other between 2Ė5 years of age. The overall incidence in a population is between 2Ė3%.13 Although the common belief is that only 2% among these are symptomatic but studies have shown that the incidence of symptomatic patients can be as high as 56%.7,12,16 We also believe that the frequency of symptomatic Meckelís diverticulum is much higher as we see incidental Meckelís diverticulum infrequently.

Various types of clinical presentations of Meckelís diverticulum signify more than one mechanism for production of these symptoms and signs. Curiously different presentations occur at different ages.7,12 Intestinal obstruction is the leading presentation all over the world, in all age groups with frequency ranging from 38% to 80%.9,12,14-16 In a study done in Karachi the patients presenting as emergency, more than 50% had intestinal obstruction due to bands or volvulus, while in another study done in India more than 60% of children presented with acute intestinal obstruction.15 In a large series done at Quebec, Canada only 42% of the children had intestinal obstruction, while in another study done in Netherlands the incidence of acute intestinal obstruction was 39%.12,16 In our study the frequency of intestinal obstruction was much higher, i.e., 82.5%. The cause of this high incidence needs further studies such as presence of hypertrophic gastric mucosa or Helicobacter Pylori in the diverticulum.

In our study we found inflamed Meckelís diverticulum in only 5 cases, which accounts for about only 8% of the total cases. In a study done at Karachi the incidence of diverticulitis was more than double, i.e., 19%.3 In another study in Turkey this incidence was 11.9% while Bemelmen from Netherlands have reported an incidence of  12% and St-Vil from Canada has reported an incidence of 14%.16,17 Although our frequency is close to other international studies, the author from Karachi has not explained the reason for higher incidence3.  We recorded 3 cases (4.76%) with bleeding per rectum caused by Meckelís diverticulum. This incidence is much lower as compared to other international studies. In a study reported by Akhtar et al 100 cases of bleeding per rectum were investigated in children but none turned out to be due to Meckelís diverticulum2, so Meckelís should be considered a very rare cause of bleeding per rectum. In India a study conducted in adult population for massive bleeding per rectum revealed Meckelís diverticulum to be the cause in 12% of the cases.6 In the Western world this incidence is much higher and ranges from 19.5% to 56%.7,9,16,17  We did not find any difference in the incidence of Meckelís diverticulum presenting as umbilical pathology from other studies.7

The causes of these presentations are multiple. The simple obstruction due to bands, volvulous or internal herniation can be explained on the basis of peculiar anatomy of the Meckelís diverticulum. Ectopic gastric mucosa and its colonization by Helicobacter Pylori can explain many complications like ulceration, inflammation, obstruction and bleeding per rectum. In a study from Spain ectopic gastric mucosa and ulceration were related to the symptoms in children but they could not find any H Pylori in the resected specimens.8 In other studies a causal relationship has been documented. Oguzkurt et al concluded from his study that hypertrophic gastric mucosa is mainly associated with bleeding per rectum but it has no association with colonization with Helicobacter Pylori. However hypertrophic gastric mucosa with colonization with Helicobacter Pylori increase the incidence of other complications like obstruction, inflammation and perforation9. Nearly the same results were reproduced by a Bemelmen et el as well as by St-Vil et al.12,16 Interestingly Maieron et al could not find any Helicobacter Pylori in the resected specimens of symptomatic diverticulum and he attributed it to the use of NSAIDs especially in cases of bleeding per rectum.18 In our study the different results could be attributed to difference in the incidence of ectopic gastric mucosa and its colonization with Helicobacter pylori for which we need further studies. The results are summarized in Table 1.

Table-1:

Condition

LRH

Karachi

Canada

Nether-

lands

USA

Obstruction

82.5

51

42

39

33Ė42

Inflammation

8

19

14

12

6Ė14

Bleeding

4.75

0

38

12Ė14

38Ė56

Conclusions

The common beliefs about the presentations of Meckelís diverticulum need to be revised. There appears to be geographical or racial differences in the presentations of Meckelís diverticulum.

Reference

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18.     Maieron R, Stimac D, Avellini C, Zoratti L, Rizzi C, Scott C, et al. Acute gastrointestinal bleeding due to Meckel's diverticulum heterotopic gastric mucosa. Ital J Gastroenterol 1996;28(4):225-8.

Address for correspondence:

Dr. Tariq Burki, 4 Brewery Yard, Ballinasloe, Co. Galway, The Republic of Ireland.

E-mail: drtb19@yahoo.com .