Meckel's Diverticulum - UpToDate

17/7/2018 Meckel's diverticulum - UpToDate
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Meckel's diverticulum
Authors: Patrick J Javid, MD, Eric M Pauli, MD
Section Editors: David I Soybel, MD, Melvin B Heyman, MD, MPH
Deputy Editor: Wenliang Chen, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2018. | This topic last updated: Feb 07, 2018.
INTRODUCTION — Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. It results
from incomplete obliteration of the vitelline duct leading to the formation of a true diverticulum of the small intestine [1].
Meckel's diverticula are uncommon and often clinically silent, particularly in the adult. Asymptomatic Meckel's diverticulum
may be discovered during abdominal exploration for the evaluation of unrelated pathology. Less commonly, they are found
incidentally on diagnostic imaging. When symptomatic, Meckel's diverticulum may present with abdominal pain or
symptoms of gastrointestinal bleeding or bowel obstruction.
The embryology, clinical features, diagnosis, and treatment of Meckel's diverticulum are reviewed here. The clinical
evaluation of various gastrointestinal symptoms (abdominal pain, gastrointestinal bleeding, bowel obstruction) in children
and adults is found in separate topic reviews. General considerations for the management of other congenital anomalies of
the gastrointestinal tract are reviewed elsewhere. (See "Intestinal malrotation in children" and "Intestinal malrotation in
adults".)
ANATOMY AND EMBRYOLOGY — Meckel's diverticulum is a true diverticulum, containing all layers of the small bowel
wall. They arise from the antimesenteric surface of the middletodistal ileum. The diverticulum represents a persistent
remnant of the omphalomesenteric duct, which connects the midgut to the yolk sac in the fetus. The normal development
of the intestine is discussed elsewhere. (See "Overview of the development of the gastrointestinal tract".)
The omphalomesenteric duct normally involutes between the fifth and sixth weeks of human gestation as the bowel settles
into its permanent position within the abdominal cavity. The persistence of the omphalomesenteric duct beyond fetal
development may result in a variety of anatomic patterns (figure 1), including omphalomesenteric cysts,
omphalomesenteric fistulae that drain through the umbilicus, and fibrous bands from the diverticulum to the umbilicus
(picture 1) that predispose to bowel obstruction [2,3]. The most common form is a diverticulum without additional
attachment, commonly referred to as Meckel's diverticulum [4]. The rich blood supply to the diverticulum is provided by the
vitelline artery, which is a branch of the superior mesenteric artery (figure 2). The embryological origin of the ectopic tissue
within the walls of the diverticulum is not known; theories include a local erroneous association between neural crest and
endodermal tissue and a missing restrictive mesodermal effect on the local endoderm within the diverticulum.
EPIDEMIOLOGY — Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract [1].
There is probably no familial predisposition for Meckel's diverticulum, although a few cases of occurrence within the same
family have been reported [2]. The prevalence of Meckel's diverticulum is increased in children born with major
malformation of the umbilicus, alimentary tract, nervous system, or cardiovascular system, in descending order [3].
The prevalence of Meckel's diverticulum depends upon the population studied. The subset of surgical patients undergoing
abdominal exploration or diverticulectomy is the most studied population. In a study of 7927 patients (all ages) who
underwent appendectomy, Meckel's diverticulum was present in 3 percent of patients [5]. In the general population, the
prevalence of Meckel's diverticulum has been estimated to be approximately 2 percent, although a systematic review
found a prevalence of 1.2 percent among 31,499 autopsies in seven studies [1,6].
The rule of twos is the classic description of the essential features of Meckel's diverticulum [1,7]. It states that Meckel's
occurs in approximately 2 percent of the population with a maletofemale ratio of 2:1, is located within two feet from the
ileocecal valve, and can be two inches in length, although, in practice, the size of a Meckel's diverticulum can vary [4,5,8].
Approximately 2 to 4 percent of patients develop a complication over the course of their lives, typically before the age of
two. A Meckel's diverticulum that bleeds is usually lined by two different types of mucosa: the native intestinal mucosa and
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a heterotopic mucosa. The most common type of heterotropic mucosa is gastric; pancreatic or colonic heterotropic mucosa
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have also been reported [9].
or find out more.
NATURAL HISTORY — The natural history of Meckel's diverticulum has been difficult to define. It is thought that the
incidence of symptoms from a Meckel's diverticulum decreases with age in the adult patient, although data on this pattern
are not conclusive [10].
Many studies have attempted to assess the incidence of symptomatic Meckel's diverticulum, but since there is no simple
screening technique to identify Meckel's diverticulum in the general population, population estimates have been used. For
adult patients, one study analyzed the incidence of complications from Meckel's diverticulum over a 42year period in a
rural midwest county in the United States [10]. Using 2 percent as an estimate of the prevalence of Meckel's diverticulum in
the general population, the authors estimated a 6.4 percent cumulative incidence of needing surgery to treat complications
of Meckel's diverticulum up to 80 years of age. In this study, there was a higher incidence of symptomatic Meckel's
diverticulum in the adult male (124 per 100,000 personyears) compared with the adult female (50 per 100,000 person
years). An older populationbased study performed over a 15year period from a single county in the Pacific Northwest
region of the United States estimated a 4.2 percent incidence of symptoms over a lifetime due to Meckel's diverticulum [8].
Risk factors for developing symptoms — Meckel's diverticulum can cause symptoms or can remain clinically silent.
Asymptomatic Meckel's diverticulum is occasionally identified incidentally on imaging but is more commonly diagnosed
during abdominal exploration for an unrelated pathology. (See 'Incidental Meckel's diverticulum' below and 'Asymptomatic
Meckel's diverticulum' below.)
Clinical features associated with an increased risk of developing symptoms from a Meckel's diverticulum identified on
logistic regression in a study of 1476 patients followed over 50 years at a single institution included [11]:
Age <50 years (odds ratio [OR] 3.5, 95% CI 2.64.8)
Male sex (OR 1.8, 95% CI 1.32.4)
Diverticulum length greater than 2 cm (OR 2.2, 95% CI 1.14.4)
Presence of histologically abnormal tissue (OR 13.9, 95% CI 9.919.6)
The proportion with symptomatic Meckel's diverticulum when only one criterion was met was 17 percent. When two, three,
or four of the first of these criteria were met, the proportion increased to 25, 42, and 70 percent, respectively [11]. Although
the presence of histologically abnormal tissue is the most important of these factors, whether to obtain an imaging study
(ie, Meckel's scan) to identify heterotopic tissue is controversial, since prophylactic removal of Meckel's diverticulum found
on imaging alone is generally not supported by the available evidence. (See 'Meckel's scan' below and 'Asymptomatic
CLINICAL PRESENTATIONS
Overview — Meckel's diverticulum is usually clinically silent but can be found incidentally or can present with a variety of
clinical manifestations including gastrointestinal bleeding or other acute abdominal complaints [1,1113]. Between 25 and
50 percent of patients with symptoms present under 10 years of age (figure 3) [6,10,11,14]. Meckel's diverticula that
contain ectopic gastric mucosa are generally associated with bleeding. Those that do not may remain silent or present with
nonhemorrhagic symptoms such as bowel obstruction or diverticular inflammation (ie, Meckel's diverticulitis) or perforation.
The clinical manifestations and initial approach to the patient with gastrointestinal bleeding or intestinal obstruction are
reviewed elsewhere. (See "Approach to acute lower gastrointestinal bleeding in adults" and "Evaluation of suspected small
bowel bleeding (formerly obscure gastrointestinal bleeding)" and "Lower gastrointestinal bleeding in children: Causes and
diagnostic approach" and "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults".)
Many of the case series documenting the clinical presentation of Meckel's diverticulum include both pediatric and adult
patients, and it is difficult to define any true difference in presenting symptoms between age groups. It is generally thought
that children present more often than adults with bleeding, and adults more often than children with symptoms of small
bowel obstruction [1,4,12,15]. It should be noted that the available data are not conclusive on this point, and some large
case series suggest the opposite with respect to presenting symptoms in children and adults [11,14]. Thus, all varieties of
symptomatic presentation should be considered in any age group.
Most patients who come to clinical attention have symptoms; however, Meckel's diverticulum is often not the first diagnosis
considered in the differential diagnosis for many abdominal complaints. The clinical features (symptoms, laboratory, exam,
imaging) of the patients with Meckel's diverticulum are nonspecific, but the age of the patient, along with clues from the
clinical history or abdominal imaging during the evaluation of the primary complaint, may suggest the possibility of a
Meckel's diverticulum.
or find out more.
Meckel's diverticulum should be suspected in:
Children with painless lower gastrointestinal bleeding (see 'Gastrointestinal bleeding' below)
Children with intussusception, particularly recurrent or atypical intussusception (see 'Intestinal obstruction' below)
Patients with features of acute appendicitis, particularly when the appendix has already been removed (see 'Acute
abdominal pain' below)
Adults with gastrointestinal bleeding but no source identified with upper endoscopy or colonoscopy (see
'Gastrointestinal bleeding' below)
A definitive diagnosis of Meckel's diverticulum is generally made in one of three ways depending upon the initial clinical
presentation: a Meckel's scan, mesenteric arteriography, or abdominal exploration. The clinical features and diagnosis
associated with the typical clinical presentations are discussed separately below.
Incidental Meckel's diverticulum — A Meckel's diverticulum is occasionally identified incidentally on imaging studies.
Features that may suggest a Meckel's diverticulum on routine abdominal imaging studies are given in the table (table 1)
[1622]. When an asymptomatic Meckel's diverticulum is identified on imaging studies (image 1), there are no data
supporting a role for obtaining a Meckel's scan [6]. (See 'Incidental Meckel's on imaging studies' below and 'Asymptomatic
Asymptomatic Meckel's diverticula, however, are rarely identified by routine imaging studies. In one study, none of 26
asymptomatic patients had their Meckel's diverticulum identified prospectively on computed tomography (CT) imaging [23].
Meckel's diverticulum is more likely to be discovered incidentally during abdominal exploration performed for another
purpose (picture 2). The decision as to whether to remove asymptomatic, incidentally discovered Meckel's diverticulum is
discussed elsewhere. (See 'Normal Meckel's found during abdominal exploration' below.)
Gastrointestinal bleeding — Gastrointestinal bleeding related to Meckel's diverticulum is caused by ulceration of the
small bowel due to acid secretion by ectopic gastric mucosa within the diverticulum. The site of mucosal ulceration and
bleeding is adjacent to or just downstream from the diverticulum, not from the mucosa or ectopic tissue within the
diverticulum.
Case series have found that 12 to 21 percent of patients with Meckel's diverticula have ectopic tissue within the
diverticulum [5,11,24,25]. Gastric heterotopia is more common in patients with symptomatic versus asymptomatic Meckel's
diverticula [6,11,26]. In a systematic review, 43 percent of symptomatic patients compared with 12 percent of asymptomatic
patients had heterotopic tissue contained within the Meckel's diverticulum [6]. Although the most common ectopic tissue is
gastric in origin, pancreatic and duodenal mucosa has also been identified [27]. Due to the association of gastric
heterotopia and gastrointestinal bleeding in the Meckel's patient, a Meckel's scan is more likely to be positive in patients
who present with bleeding compared with those who present with other nonspecific symptoms (26 versus 2 percent, in one
study) [28].
Signs and symptoms — Bleeding from Meckel's diverticulum may be chronic and insidious or acute and massive.
Although the incidence of each type of bleeding is poorly reported in the literature, transfusions are uncommonly reported
for Meckel'sassociated bleeding. Children often present with dark red or maroon stools, while adults typically present with
melena, which may be attributable to slower colonic transit time in adults [12].
The abdominal examination is typically benign in patients with gastrointestinal bleeding.
Laboratory studies obtained in patients with gastrointestinal bleeding may be consistent with volume depletion or anemia
but do not help distinguish Meckel's diverticulum from any other source of gastrointestinal bleeding. Similarly, plain
abdominal radiography in patients with gastrointestinal bleeding is nonspecific (table 1). Bleeding diverticula cannot be
routinely seen with standard CT.
Adult and pediatric patients with gastrointestinal bleeding are initially evaluated using standard algorithms. Patients who
present with gastrointestinal bleeding may undergo routine upper or lower gastrointestinal endoscopy, neither of which can
demonstrate a Meckel's diverticulum. However, Meckel's diverticulum has been identified using advanced endoscopy
techniques (double balloon enteroscopy, capsule endoscopy), but these studies are not routinely obtained [29,30]. The
diagnostic approach to the adult or pediatric patient with gastrointestinal bleeding is discussed in detail elsewhere. (See
"Approach to acute lower gastrointestinal bleeding in adults" and "Evaluation of suspected small bowel bleeding (formerly
obscure gastrointestinal bleeding)" and "Lower gastrointestinal bleeding in children: Causes and diagnostic approach".)
or find out more.
Diagnosis — The diagnosis of a bleeding Meckel's diverticulum can typically be made using Meckel's scan or
mesenteric arteriography, but doubleballoon enteroscopy and capsule endoscopy are also described [31]. If diagnostic
testing is unrevealing, or the patient is hemodynamically unstable, abdominal exploration may be necessary to determine
whether a Meckel's diverticulum is the source of bleeding.
A suspicion for Meckel's diverticulum as a source for lower gastrointestinal bleeding should be increased for:
Children, particularly those less than 10 years of age, who present with painless lower gastrointestinal bleeding
without symptoms or signs of gastroenteritis (diarrhea), or inflammatory bowel disease (abdominal pain, diarrhea)
(figure 4).
Adult patients, particularly in young adults <40 years of age, with gastrointestinal bleeding but no source identified with
standard endoscopic and possibly radiographic evaluation (eg, colonoscopy, CT angiography, small bowel studies, or
radionuclide scanning). (See "Evaluation of suspected small bowel bleeding (formerly obscure gastrointestinal
bleeding)".)
Arteriography — Conventional contrast mesenteric arteriography may be appropriate if a source of gastrointestinal
bleeding is brisk enough to require transfusion and the source has not been identified using other imaging modalities,
given that for some lesions (eg, arteriovenous malformation), but not typically Meckel's diverticulum, therapeutic
maneuvers may be possible. (See "Evaluation of suspected small bowel bleeding (formerly obscure gastrointestinal
bleeding)", section on 'Angiography' and "Approach to acute lower gastrointestinal bleeding in adults", section on
'Angiography'.)
With conventional contrast arteriography, a diagnosis of Meckel's diverticulum can be established based upon the finding
of an anomalous superior mesenteric artery branch feeding the diverticulum. The artery feeding the Meckel's diverticulum
is long and nonbranching and traverses the mesentery toward the right lower quadrant where it terminates in several small,
irregular vessels [32]. Active contrast extravasation may be seen in patients with ongoing hemorrhage.
In patients with less brisk bleeding, highresolution CT angiography is increasingly being used. In a metaanalysis of 22
studies, it was noted that CT was able to detect as bleeding of as little as 0.3 mL/minute [33]. CT angiography can detect
active signs of bleeding, such as that from a Meckel's diverticulum (image 2), that may be undetectable when other
techniques such as tagged red blood cell scan, colonoscopy, or conventional arteriography are performed. However, CT
angiography subjects the patient to ionizing radiation and requires intravenous contrast, which may be less desirable in
certain patient populations (eg, children, pregnant women, renal dysfunction, contrast allergy). (See "Approach to acute
lower gastrointestinal bleeding in adults", section on 'CT angiography'.)
Singlephoton emission computed tomography (SPECT)/CT fusion imaging was also used to diagnose Meckel's
diverticulum in a case report [34]. Others have used magnetic resonance enterography (MRE) for obscure gastrointestinal
bleeding in children with negative upper and lower endoscopy [35].
Meckel's scan — In hemodynamically stable patients with less severe or intermittent gastrointestinal bleeding and
for whom suspicion for Meckel's diverticulum is high, a Meckel's scan should be performed. A Meckel's scan is a nuclear
medicine study in which 99m technetium pertechnetate, which has an affinity for gastric mucosa, is first administered
intravenously and subsequently scintigraphy is performed to identify areas of ectopic gastric mucosa [36]. Theoretically,
the scan should identify only those diverticula that contain ectopic gastric mucosa, which occurs in less than 25 percent of
cases [5,11,24,25]. Meckel's diverticula lacking gastric mucosa will not be seen on a Meckel's scan.
Meckel's diverticula that contain ectopic gastric mucosa present earlier in life with gastrointestinal bleeding relative to other
clinical manifestations of Meckel's diverticulum. Thus, in children, a Meckel's scan is performed very early in the course of
the evaluation of gastrointestinal bleeding because it is more likely to be positive compared with adults. In addition, the
study is noninvasive, associated with few side effects, and not likely to require general anesthesia. In adults, a Meckel's
scan is appropriate in hemodynamically stable patients whenever the evaluation of lower gastrointestinal bleeding has
failed to define the source of bleeding.
The Meckel's scan has a sensitivity of 85 to 97 percent in the pediatric patient, but its sensitivity and positive predictive
value are lower in the adult at approximately 60 percent each [28,36]. The specificity of a Meckel's scan is approximately
95 percent (pediatric and adult), and false negative studies can occur [28]. False positives can be seen in the presence of
small bowel duplication cysts, intussusception, and inflammatory bowel disease.
Agents used in the initial management of gastrointestinal bleeding can affect the uptake of 99m technetium pertechnetate.
Uptake by gastric mucosa is independent of luminal acidification. However, aluminum hydroxide, which is found in some
or find out more.
antiulcer medications, limits the mucosal localization of radiotracer. On the other hand, cimetidine or ranitidine promotes
retention of pertechnetate in the gastric mucosa and can be used as an adjunct maneuver to augment an initially negative
scan by permitting a higher level of radiotracer to be retained in the ectopic mucosa [37,38].
Wireless capsule endoscopy — With the more common use of wireless capsule endoscopy for the workup of
gastrointestinal bleeding of uncertain origin, case reports of the endoscopic appearance of normal, ulcerated, bleeding,
and inverted Meckel's diverticula can be found in the literature. In a study that identified Meckel's diverticulum as the
source of bleeding in 13 patients, wireless capsule endoscopy had a positive predictive value of 84.6 percent for the
diagnosis of Meckel's diverticulum associated with gastrointestinal bleeding of uncertain origin [39]. (See "Wireless video
capsule endoscopy", section on 'Indications'.)
Doubleballoon enteroscopy — Doubleballoon enteroscopy (DBE) has also been reported in small case series in
patients undergoing evaluation for gastrointestinal bleeding or abdominal pain [40]. Both prograde (per os) and retrograde
(per rectum) DBE have been used to confirm the diagnosis of Meckel's diverticulum based upon a suspicion from other
imaging studies (eg, CT, Meckel's scan), or to evaluate the distal small bowel directly in patients with a negative
radiographic studies but in whom a high suspicion of a Meckel’s diverticulum remains. Endoscopy confirms the diagnosis
by direct vision but can also identify complications (mucosal ulceration, active bleeding) and, in some cases, permits
therapy [41,42]. One retrospective series found that DBE had a higher diagnostic accuracy for Meckel's diverticulum than
Meckel's scan in the adult population [43]. (See "Overview of deep small bowel enteroscopy" and 'Resection of
symptomatic Meckel's diverticulum' below.)
Differential diagnosis — The differential diagnosis of Meckel's diverticulum includes any etiology that can cause
gastrointestinal bleeding. There are no specific clinical features that can distinguish Meckel's diverticulum as a cause of
gastrointestinal bleeding. The tables provided list the common and rarer causes of gastrointestinal bleeding (table 2 and
figure 4 and table 3).
Intestinal obstruction — Intestinal obstruction related to Meckel's diverticulum can result from any of the mechanisms
described below. In children, volvulus and intussusception appear to be the most common etiology of intestinal obstruction,
whereas in adults, these are uncommon [6,11,27,44].
Intussusception – Intussusception refers to the invagination of a part of the intestine into itself. Meckel's diverticulum
can act as the lead point [27]. Meckel's diverticulum should be considered in the differential diagnosis of
intussusception in all patients, but particularly in children who present with recurrent small bowel intussusception. In
adults, tumor in a Meckel's diverticulum can serve as a lead point for intussusception. Intussusception in children is
discussed in more detail elsewhere. (See "Intussusception in children" and 'Acute abdominal pain' below.)
Volvulus – The intestines, usually the small bowel, can twist around the fibrous cord or band often associated with
Meckel's diverticulum such as those from the tip of the diverticulum to the peritoneal lining of the anterior abdominal
wall, or other adhesions [27,45,46].
Torsion – Torsion of the diverticulum alone can result in small bowel obstruction [47,48].
Abdominal wall hernia – Meckel's diverticulum can incarcerate in an abdominal wall or internal hernia, which is
referred to as a Littre's hernia [4951]. Incarcerated hernias can also present with gastrointestinal bleeding [52]. The
anatomic sites of Littre hernia can be inguinal (50 percent), femoral (20 percent), or umbilical (20 percent) [53]. (See
"Overview of abdominal wall hernias in adults".)
Meckel's diverticulitis – Inflammation of the diverticulum or adjacent small bowel can result in reduced intestinal
luminal diameter that leads to partial or complete bowel obstruction.
Inversion of Meckel's diverticulum – A Meckel’s diverticulum can also become inverted into the bowel lumen, and this
may serve as a point of intermittent obstruction (image 3).
Signs and symptoms — Obstruction related to Meckel's diverticulum presents similarly to other sources of small bowel
obstruction, with abdominal distention, nausea, vomiting, and signs of obstruction. (See "Epidemiology, clinical features,
and diagnosis of mechanical small bowel obstruction in adults".)
In patients with inflammation related to the Meckel's diverticulum, typical physical findings include abdominal tenderness
and distention. Abdominal tenderness is located more toward the midline compared with appendicitis, but the position of
the Meckel's diverticulum can vary; thus, the location of pain and tenderness is not particularly helpful. Perforation of
Meckel's diverticulum will manifest with signs of peritoneal irritation, usually localized in the lower abdomen. An abscess
related to Meckel's diverticulum may produce a palpable mass on abdominal or digital rectal examination, but, again, this
finding is not specific to Meckel's. or find out more.
Most patients undergo initial laboratory testing for the evaluation of bowel obstruction that includes a complete blood count
and electrolytes. These studies may help identify patients who are volume depleted, or experiencing complications such as
elevated white blood cell count associated with bowel perforation, but do not help establish a diagnosis of Meckel's
diverticulum. Certain clinical features on routine imaging studies to evaluate intestinal obstruction may suggest a diagnosis
of Meckel's diverticulum, but these findings are usually nonspecific (table 1) [1622].
Diagnosis — Patients who present with small bowel obstruction often undergo abdominopelvic CT, which can
sometimes diagnose Meckel's diverticulum as the cause of bowel obstruction. In one study of 10 patients who were
confirmed to have bowel obstruction attributed to Meckel's diverticula at surgical exploration, the correct preoperative
diagnosis was made by CT in 50 percent patients [54].
Children and adults who present with symptoms of bowel obstruction without evidence for an abdominal wall or groin
hernia, or adhesions from prior surgery, may have a Meckel's diverticulum as the source of obstruction. A suspicion for
Meckel's diverticulum should be higher in children presenting with symptoms of bowel obstruction, particularly in those who
have a recurrent intussusception following successful reduction, compared with adults. In children who present with
multiple recurrent episodes of intussusception, a pathologic lead point should be suspected. Diagnostic options in this
setting include a Meckel's scan or diagnostic laparoscopy to evaluate for a Meckel's diverticulum, or other lead point. (See
"Intussusception in children", section on 'Lead point' and "Intussusception in children", section on 'Recurrence' and
"Overview of management of mechanical small bowel obstruction in adults".)
In adults, malignancy is more often the lead point, and surgical reduction of the intussusception is not recommended;
rather, the affected small intestine should be resected en bloc for pathologic examination. Meckel's diverticulum may be
identified in the resected specimen.
During abdominal exploration for bowel obstruction, the bowel should be evaluated methodically, as it can be easy to miss
a short diverticulum or one that is adherent along its length to the antimesenteric border of the ileum, particularly with
laparoscopy. (See 'Treatment' below.)
Differential diagnosis — The differential diagnosis of Meckel's diverticulum includes any etiology that can cause bowel
obstruction. (See "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults".)
There are no specific clinical features that can distinguish Meckel's from any of these other causes of bowel obstruction;
however, Meckel's diverticula may be suspected based upon the patient's clinical history or clues from routine imaging
studies (table 1). The table lists the common causes of small bowel obstruction (table 4).
Acute abdominal pain — Acute abdominal pain related to Meckel's diverticulum can be the result of diverticular
inflammation, similar to acute appendicitis, or related to bowel obstruction, or perforation of the Meckel's or adjacent bowel
leading to peritonitis. Entrapment of a foreign body, such as an enterolith or parasite, within a Meckel's diverticulum is
another rare presentation that can lead to diverticulitis or perforation [5557]. The presence of multiple enteroliths within a
Meckel's diverticulum leading to obstruction and ischemia of the diverticulum has been reported [58].
Acute inflammation of the diverticulum (ie, Meckel's diverticulitis) is thought to be due to obstruction of the diverticular
opening as a result of an enterolith, inflammatory tissue, food or other foreign body, or tumor [5961]. Obstruction leads to
bacterial overgrowth and inflammation similar to acute appendicitis [24]. Meckel's diverticulitis can also result from torsion
or incarceration of the diverticulum or from peptic ulceration due to heterotopic gastric mucosa.
The incidence of tumors within a Meckel's diverticulum ranges from 0.5 to 3.2 percent [8,13,24]. The majority of these
tumors are benign (lipomas, leiomyomas, angiomas); however, malignancies within a Meckel's diverticulum such as
adenocarcinoma, gastrointestinal stromal tumor (GIST), sarcoma, and carcinoid have been reported [25,57,6264].
Signs and symptoms — The description of abdominal pain and the physical examination of the patient with Meckel's
diverticulum are nonspecific. In patients with obstruction or inflammation related to the Meckel's diverticulum, typical
physical findings include abdominal tenderness and abdominal distention. Abdominal tenderness is located more toward
the midline compared with appendicitis, but the position of the Meckel's diverticulum can vary; thus, the location of pain
and tenderness is not particularly helpful. Perforation of Meckel's diverticulum will manifest with signs of peritoneal
irritation, usually localized in the lower abdomen. An abscess related to Meckel's diverticulum may produce a palpable
mass on abdominal or digital rectal examination, but, again, this finding is not specific to Meckel's.
Most patients undergo initial laboratory testing for the evaluation of abdominal pain that includes a complete blood count,
electrolytes, and possibly a coagulation test. These studies may help identify patients who are volume depleted or
or find out more.
experiencing complications but do not help establish a diagnosis of Meckel's diverticulitis from other sources of intestinal
inflammation. Features of Meckel's diverticulum on routine abdominal imaging are given in the table (table 1) [1622].
Diagnosis — An inflamed Meckel's diverticulum and complications related to a Meckel's diverticulum may be very
difficult to distinguish from acute appendicitis on physical examination or preoperative imaging (image 4 and image 5).
During abdominal exploration for presumed appendicitis, a finding of a normal appendix should prompt a thorough
evaluation of the midtodistal ileum to rule out a Meckel's diverticulum as the source of the patient's symptoms. The bowel
should be evaluated methodically, since it is easy to miss a short diverticulum or one that is adherent along its length to the
antimesenteric border of the ileum, particularly with laparoscopy. (See 'Treatment' below.)
Differential diagnosis — The differential diagnosis of Meckel's diverticulitis includes any etiology that can cause lower
abdominal pain. There are no specific clinical features that can distinguish Meckel's from any of these other causes. The
tables provided list the causes of acute abdominal pain (table 5 and table 6). (See "Causes of abdominal pain in adults".)
Meckel's diverticulitis is clinically indistinguishable from other more common intraabdominal inflammatory conditions.
Meckel's diverticulitis is frequently confused with acute appendicitis, colonic diverticulitis, or inflammatory bowel disease. A
preoperative diagnosis of Meckel's diverticulitis is made in fewer than 10 percent of patients with a Meckel's; acute
appendicitis is the most common preoperative diagnosis [6567].
TREATMENT
Treatment approach — Patients with suspected Meckel's diverticulum are initially managed according to their clinical
presentation. If Meckel's diverticulum is found to be the source of symptoms, we resect the Meckel's diverticulum. Whether
to resect asymptomatic, incidentally discovered Meckel's diverticulum is controversial. Based upon the natural history of
Meckel's diverticulum, evidence from systematic reviews, and our clinical experience [1,5,6,8,11,15,25,27,65,66,6873], we
use the following approach to manage asymptomatic Meckel's diverticulum. The evidence supporting this approach is
discussed in more detail in the following sections.
For children and adults with Meckel's diverticulum discovered incidentally on imaging studies, we suggest not
performing elective resection.
For asymptomatic Meckel's diverticulum identified during the course of abdominal exploration:
• We suggest resecting the diverticulum in most children, up to young adulthood (otherwise healthy).
• We suggest resecting the Meckel's diverticulum in otherwise healthy, young adults (<50 years of age) if there is a
palpable abnormality or the Meckel's diverticulum is longer than 2 cm.
• We suggest not resecting the Meckel's diverticulum in patients >50 years of age, unless there is a palpable
abnormality associated with the diverticulum.
Initial management — Initial medical management of symptomatic Meckel's diverticulum is directed toward managing the
clinical manifestations that brought the Meckel's diverticulum to clinical attention.
Intravenous lines should be placed and fluid and electrolyte therapy administered, as needed. (See "Maintenance and
replacement fluid therapy in adults" and "Treatment of hypovolemia (dehydration) in children" and "Maintenance fluid
therapy in children".)
Patients with symptoms and signs of bowel obstruction may require nasogastric decompression. (See "Nasogastric
and nasoenteric tubes" and "Overview of management of mechanical small bowel obstruction in adults".)
Patients with gastrointestinal bleeding should be initiated on protonpump inhibitor therapy. The use of protonpump
inhibitors does not alter the sensitivity or specificity of a Meckel's scan. Aluminum hydroxide should be avoided. (See
'Meckel's scan' above and "Approach to acute lower gastrointestinal bleeding in adults" and "Approach to upper
gastrointestinal bleeding in children", section on 'Initial assessment and resuscitation'.)
Resection of symptomatic Meckel's diverticulum — Symptomatic Meckel's diverticulum refers to clinical manifestations
related directly to the diverticulum, which may include gastrointestinal bleeding related to heterotopic gastric mucosa,
bowel obstruction related to intraluminal obstruction, adhesive bands, herniation of the diverticulum (Littre's hernia), and
diverticular inflammation (Meckel's diverticulitis). We resect symptomatic Meckel's diverticulum in children and adults to
relieve symptoms. (See 'Clinical presentations' above.)
Resection technique — Meckel's diverticulum can be resected by simple diverticulectomy (excision of the diverticulum
at its base) or by segmental small bowel resection and primary anastomosis. Endoscopic resection of inverted Meckel's
or find out more.
diverticulum has also been reported (simple diverticulectomy) [74]. (See 'Doubleballoon enteroscopy' above.)
Surgical procedures can be performed using handsewn or stapling techniques via an open or laparoscopic (including both
conventional and single incision) approach [7577]. There are no studies comparing the various techniques for resecting
Meckel's diverticulum.
Diverticulectomy is most easily performed using a linear gastrointestinal stapler applied to the base of the diverticulum.
However, we suggest segmental resection if the small bowel lumen is in jeopardy of being narrowed, a palpable
abnormality is present at the base of the diverticulum, or the neck of the diverticulum is wide (>2 cm) [78]. Also, a broad
based, short diverticulum (one with a heighttodiameter ratio of less than 2.0) with features warranting resection is best
addressed by a formal small bowel resection rather than a simple diverticulectomy due to the risk of leaving behind ectopic
tissue at the base [79].
When gastrointestinal bleeding is the primary clinical manifestation, it is likely that both segmental small bowel resection
and simple diverticulectomy are effective surgical approaches. Segmental resection removes the gastric mucosa within the
diverticulum as well as the mucosal ulceration located in the adjacent small bowel. There are no definitive data
demonstrating superiority of segmental resection over diverticulectomy. Diverticulectomy alone has been used in the
setting of bleeding and appears to be safe with a low incidence of complications [15,80].
Asymptomatic Meckel's diverticulum — Asymptomatic Meckel's diverticulum may rarely be identified on imaging, but
more commonly an asymptomatic, normal Meckel's diverticulum is found during the course of abdominal exploration (open
or laparoscopic).
Incidental Meckel's on imaging studies — In patients with Meckel's diverticulum discovered incidentally on imaging,
we suggest not performing elective resection. The bulk of evidence, which consists primarily of retrospective reviews
[1,6,8,11,68], does not support elective resection of asymptomatic Meckel's diverticulum. The lifetime risk of developing
complications related to Meckel's diverticulum is overall low (4 to 6 percent). A large number of elective Meckel's
resections would need to be performed to prevent a single death related to complications from a Meckel's diverticulum
[6,8]. In one study, to prevent one death would require removing approximately 800 asymptomatic Meckel's diverticula,
unnecessarily exposing these patients to the risk of surgical complications [8]. (See 'Natural history' above.)
Normal Meckel's found during abdominal exploration — Management of a normalappearing Meckel's diverticulum
identified during abdominal exploration is controversial. Although this issue has been evaluated in multiple case series and
systematic reviews [1,5,8,11,15,27,66,6872], there are no definitive prospective data supporting resection over no
resection. Since most published studies combine adult and pediatric populations, it is difficult to define an appropriate
algorithm for resection based solely upon age. Comparisons are further complicated by the varying definition of "child"
used by various authors. Some authors suggest leaving incidentally detected Meckel's in situ regardless of age [5,8,69,81].
Others advocate resection of all incidentally detected Meckel's diverticulum because gastric heterotopia in the resected
Meckel's specimen is a common finding [10,67,68].
When asymptomatic Meckel's diverticulum is identified during abdominal exploration, we do not routinely resect all
Meckel's diverticula; rather, we take into consideration the patient's clinical status, his/her lifelong risk of Meckel'srelated
complications, and anatomic features associated with developing symptoms [11,71,73]. A risk score has been used by
some to guide decision making [71]. (See 'Risk factors for developing symptoms' above.)
We suggest a selective approach resecting the Meckel's diverticulum in otherwise healthy, young adults (<50 years of age)
with anatomic risk factors (length >2 cm, palpable abnormality, fibrous bands) associated with Meckel's complications
[11,73]. Patients without these features should not undergo Meckel's resection. Older patients (>50 years) and those with
medical comorbidities should not undergo resection of incidental Meckel's, unless there is a palpable abnormality. This
selective approach is further supported by a systematic review that compared complication rates of patients with resected
asymptomatic Meckel's diverticulum with those who did not undergo resection [6]. Mortality associated with Meckel's
resection was overall low, but, among those who died, 94 percent were older than 44 years of age. The incidence of
perioperative complications was significantly higher in those who underwent resection of the Meckel's compared with those
who did not (5.3 versus 1.3 percent). In four studies, 91 patients were followed for a variable period of time after an
incidental Meckel's diverticulum was left in situ; no patient developed clinical manifestations.
The risk of complications of Meckel's diverticulum may be higher for children compared with adults. In a review of 74
children, the risk of Meckel'srelated complications in children under two years and between two and eight years of age
was significantly higher compared with children older than eight years [44]. Thus, some authors have suggested removal of
all asymptomatic diverticula in children younger than eight years of age. Our practice is to resect Meckel's diverticulum
incidentally identified on abdominal exploration in most children. The Meckel's diverticulum can remain in place for
or find out more.
selected children with medical comorbidities provided risk factors associated with complications of Meckel's diverticulum
are not present. (See 'Risk factors for developing symptoms' above.)
Counseling asymptomatic patients — Patients with asymptomatic Meckel's diverticulum that remains in situ should
be counseled regarding potential future symptoms. If symptoms do develop, the Meckel's diverticulum will require
resection. (See 'Clinical presentations' above and 'Resection of symptomatic Meckel's diverticulum' above.)
PERIOPERATIVE MORBIDITY AND MORTALITY — In contemporary practice, death related specifically to the resection
of Meckel's diverticulum is rare, with an estimated incidence of 0.001 percent [6,7]. The anticipated complication rate for
Meckel's resection is overall approximately 5 percent [5,10,11,25], and the most common complications are surgical site
infection, prolonged postoperative ileus, and anastomotic leak, which are essentially those of any small bowel surgery.
(See "Bowel resection techniques".)
The risk of perioperative morbidity and mortality from surgical resection of symptomatic Meckel's diverticulum is likely
higher than that of an incidentally diagnosed, asymptomatic diverticulum. However, the incidence of complications is
difficult to estimate in patients who have undergone resection for incidental, asymptomatic diverticula during the course of
another procedure. Populationbased studies have estimated a 2 to 20 percent complication rate from resection of an
asymptomatic Meckel's diverticulum, but few of these complications (apart from rare anastomotic leaks) could be directly
attributed to resection of the diverticulum. In a systematic review, the perioperative morbidity was 12 percent for resection
of symptomatic Meckel's, and the cumulative risk of longterm postoperative complications was 7 percent [10]. By
comparison, the complication rate for elective Meckel's resection was 2 percent.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond
the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition. These articles are best for patients
who want a general overview and who prefer short, easytoread materials. Beyond the Basics patient education pieces
are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are
best for patients who want indepth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to
your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the
keyword(s) of interest.)
Basics topics (see "Patient education: Meckel's diverticulum (The Basics)")
SUMMARY AND RECOMMENDATIONS
Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. Meckel's diverticulum is a
true diverticulum that arises from the antimesenteric surface of the midtodistal ileum that results from incomplete
obliteration of the vitelline duct. (See 'Introduction' above and 'Anatomy and embryology' above.)
The rule of twos is the classic description of the essential features of Meckel's diverticulum. Meckel's diverticulum
occurs in approximately 2 percent of the population with a male to female ratio of 2:1, is found approximately two feet
from the ileocecal valve, and is approximately two inches long. Approximately 2 percent of patients develop a
complication over their lifetime, typically before the age of two. Symptomatic Meckel's diverticula most often contain
both native intestinal and heterotropic gastric mucosa. There is no familial predisposition for Meckel's diverticulum, but
the prevalence is increased in children with major malformations of the umbilicus, alimentary tract, nervous system, or
cardiovascular system. (See 'Epidemiology' above.)
Meckel's diverticulum is often clinically silent, particularly in the adult. Incidental Meckel's diverticulum is most
commonly identified during abdominal exploration for an unrelated pathology. When symptomatic, Meckel's
diverticulum can present with gastrointestinal bleeding or acute abdominal pain related to bowel obstruction, Meckel's
diverticulitis, or perforation. Between 25 and 50 percent of symptomatic patients present at less than 10 years of age.
Specific anatomic factors related to the Meckel's diverticulum (length >2 cm, palpable abnormality) increase the risk of
developing symptoms. (See 'Clinical presentations' above and 'Risk factors for developing symptoms' above.)
Meckel's diverticulum is often not the first diagnosis considered for many abdominal complaints. A diagnosis of
Meckel's diverticulum should be suspected in patients with the following clinical features:
• Children with painless lower gastrointestinal bleeding
• Children and adults with intussusception, particularly children with recurrent small bowel intussusception
• Patients with features of appendicitis, particularly when the appendix has already been removed
or find out more.
• Adults with gastrointestinal bleeding but negative upper endoscopy and colonoscopy
Certain features on routine imaging studies (eg, plain abdominal films, ultrasound, computed tomography) obtained to
evaluate abdominal pain or intestinal obstruction may suggest a diagnosis of Meckel's diverticulum, but these findings
are usually nonspecific. In patients without immediate indications for abdominal exploration (eg, perforation), a
suspicion for a bleeding Meckel's diverticulum can be investigated with a Meckel's scan, which identifies the presence
of ectopic gastric mucosa within the diverticulum. A Meckel's scan should be obtained earlier in the evaluation of
gastrointestinal bleeding in children compared with adults. Meckel's diverticula without ectopic gastric mucosa will not
be visible on a Meckel's scan. Abdominal exploration will be needed to establish the diagnosis. The differential
diagnosis of Meckel's diverticulum includes any etiology that can cause gastrointestinal bleeding, small bowel
obstruction, or acute abdominal pain. There are no specific clinical features that reliably distinguish symptomatic
Meckel's diverticulum from other causes (figure 4 and table 2 and table 3 and table 4 and table 5 and table 6).
Symptomatic Meckel's diverticulum should be resected in all patients (children and adults) to relieve symptoms.
Whether an incidentally discovered, asymptomatic diverticulum should be removed is controversial in children and
adults. For children and adults with asymptomatic Meckel's diverticulum identified on imaging studies, we suggest not
performing elective resection (Grade 2B). For patients with a normalappearing Meckel's diverticulum identified on
abdominal exploration, we use a selective approach that takes into consideration the patient's clinical status, his/her
lifelong risk of Meckel'srelated complications, and anatomic features associated with developing symptoms. (See
'Normal Meckel's found during abdominal exploration' above.)
• For most children to young adulthood, we suggest resection of the normalappearing Meckel's diverticulum given
an increased lifelong risk for complications (Grade 2C).
• For otherwise healthy, young adults (<50 years of age), we suggest resection of the normalappearing Meckel's
diverticulum if there is a palpable abnormality or the Meckel's diverticulum is longer than 2 cm (Grade 2C).
• For patients >50 years of age, and patients with significant comorbidities, we suggest not resecting the normal
appearing Meckel's diverticulum, unless there is a palpable abnormality associated with the diverticulum (Grade
2C).
For patients undergoing resection of a symptomatic Meckel's diverticulum due to gastrointestinal bleeding, it is likely
that both segmental small bowel resection and simple diverticulectomy are effective surgical approaches, although
there are no highquality data to compare the two techniques. (See 'Resection technique' above.)
Death related to resection of Meckel's diverticulum is rare. The anticipated complication rate for Meckel's resection is
overall approximately 5 percent. The most common complications are surgical site infection, prolonged postoperative
ileus, and anastomotic leak, which are essentially those of any small bowel surgery. (See 'Perioperative morbidity and
mortality' above.)
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GRAPHICS
or find out more.
Anomalies of the omphalomesenteric duct
A) Umbilical polyp. B) Meckel's diverticulum. C) Fibrous band. D)
Omphalomesenteric duct cyst. E) Patent omphalomesenteric duct. F) Patent
omphalomesenteric duct with prolapse.
Reproduced with permission from: The American Pediatric Surgical Association.
http://www.eapsa.org/.
Graphic 50824 Version 1.0
Omphalomesenteric cyst
or find out more.
Surgical resection of an omphalomesenteric cyst with fibrosed band in a child.
(A) Fibrous band (dashed arrow) with cyst (arrow) detached from the umbilicus (U).
(B) Closeup view of the resected specimen.
Courtesy of Patrick J Javid, MD.
Midgut formation
or find out more.
Left side views (A and B) of the counterclockwise 180° rotation of the midgut loop as it is withdrawn
into the abdominal cavity. C) The descent of the cecum takes place later.
Reproduced with permission from: Snell, MD, PhD, Clinical Anatomy, 7th ed. Lippincott Williams & Wilkins,
2003. Copyright © 2003 Lippincott Williams & Wilkins.
Meckels diverticulum age distribution in children
or find out more.
The age distribution in children (lower graph) includes all pathologic
presentations of Meckels diverticulum including the more common presentations,
such as bleeding or diverticulitis, as well as a variety of other presentations, such
as persistent omphalomesenteric ducts that result in chronic umbilical drainage,
intussusception, and volvulus around a Meckel’s band.
Reproduced with permission from: Park JJ, Wolff BG, Tollefson MK, et al. Meckel
diverticulum: the Mayo Clinic experience with 1476 patients (19502002). Ann Surg
2005; 241:529. Copyright © 2005 Lippincott Williams & Wilkins.
Features of Meckel's diverticulum on imaging studies
or find out more.
Modality Features and caveats
Plain abdominal May demonstrate nonspecific signs of intestinal obstruction
film An enterolith may be seen in the lower abdomen, but cannot be definitively localized to the Meckel's as
opposed to the appendix
Ultrasonography An obstructed Meckel's diverticulum may be identified as a fluidfilled pouch off the distal small intestine
Ultrasound findings are nonspecific and are easily confused with appendicitis
Intussusception can be diagnosed with ultrasound, but attributing the lead point to be a Meckel's diverticulum
cannot be determined with any certainty
Computed Asymptomatic or bleeding diverticula are rarely or infrequently identified with computed tomography
tomography A distinction between a Meckel's diverticulum and normal small intestinal loops is virtually impossible in the
absence of associated inflammation
Acutely inflamed diverticula can be identified as a blind pouch off the distal small intestine, and is typically
with associated bowel wall thickening of the peridiverticular fat
Upper Small bowel series have demonstrated Meckel's diverticulum, but are unreliable even using enteroclysis in
gastrointestinal experienced hands
series False negative rates are high due to:
Rapid emptying of contrast from the diverticulum
Obscured visualization of the diverticulum due to overlying contrastfilled small bowel loops
Poor filling of the diverticulum (occlusion or narrowing of the entrance)
Mesenteric A diagnosis of Meckel's is based upon the finding of an anomalous superior mesenteric artery branch feeding
arteriorgraphy the diverticulum; active contrast extravasation may be seen in patients with ongoing hemorrhage
Meckel's scan Identifies areas of ectopic gastric mucosa, if present
Incidental Meckels on CT scan
or find out more.
Incidental note of a noninflamed Meckel's diverticulum (arrow) in the axial view (A) and coronal
reconstruction (B) of the abdominal CT scan.
CT: computed tomography.
Meckel's diverticulum
or find out more.
An asymptomatic Meckel's diverticulum (M) found during an open abdominal wall reconstruction.
SB: small bowel.
Courtesy of Eric M Pauli, MD.
Major causes of lower gastrointestinal bleeding in children by
age group or find out more.
This figure depicts the major causes of gastrointestinal bleeding in the pediatric age group.
The age categories are approximate, and most of these disorders can occur outside of the
given age group.
* Rarely, inflammatory bowel disease (IBD) presents before six years of age. This presentation is
sometimes termed very early onset IBD (VEOIBD), or infantile IBD if it presents before two
years of age. The disease tends to be severe, with more rapid progression and poor
responsiveness to most conventional therapies. The distinct phenotype and early age of onset
suggests a pronounced genetic susceptibility and dysregulated immune response.
Bleeding Meckels diverticulum on CT scan
or find out more.
Hemorrhage into a Meckel's diverticulum is demonstrated by highdensity material within the diverticulum
(arrow in A and B).
Common causes of lower gastrointestinal bleeding
or find out more.
Anatomic
Diverticulosis
Vascular
Angiodysplasia
Hemorrhoids
Ischemic
Post biopsy or polypectomy
Radiationinduced telangiectasia
Inflammatory
Infectious
Inflammatory bowel disease
Ulcer
Neoplastic
Polyp
Carcinoma
Causes of small bowel bleeding
or find out more.
Common causes Rare causes
Under age 40 years Over age 40 years HenochSchoenlein purpura
Inflammatory bowel disease Angioectasia Small bowel varices and/or portal

hypertensive enteropathy
Dieulafoy lesions Dieulafoy lesions Amyloidosis
Neoplasia Neoplasia Blue rubber bleb nevus syndrome
Meckel diverticulum NSAID ulcers Pseudoxanthoma elasticum
Polyposis syndromes Hereditary hemorrhagic telangiectasia
(OslerWeberRendu syndrome)
Kaposi sarcoma with AIDS
PlummerVinson syndrome
EhlersDanlos syndrome
Inherited polyposis syndromes (FAP,
PeutzJeghers)
Malignant atrophic papulosis
Hematobilia
Aortoenteric fistula
Hemosuccus entericus
FAP: familial adenomatous polyposis; NSAID: nonsteroidal antiinflammatory drug.
Reprinted by permission from Macmillan Publishers Ltd: American Journal of Gastroenterology. Gerson LB, Fidler JL, Cave DR, Leighton
JA. ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol 2015; 110:1265. Copyright © 2015.
www.nature.com/ajg.
Inverted Meckel's diverticulum
or find out more.
Lower endoscopic view of an inverted Meckel's diverticulum (M). This lesion was thought to be a polyp based on initial computed
tomography findings but was later confirmed to be a Meckel's diverticulum on diagnostic laparoscopy.
Courtesy of Matt Giefer, MD.
Causes of bowel obstruction
or find out more.
Lesion Etiology Risk factors
Extrinsic lesions Adhesions Prior surgery, diverticulitis, Crohn disease, VP

shunt, peritonitis (eg, tuberculous peritonitis)
Hernia (congenital, acquired) Abdominal wall hernia, inguinal hernia, femoral
hernia, diaphragmatic hernia
Volvulus Chronic constipation, congenital abnormal
mesenteric attachments
Intraabdominal abscess Diverticulitis, appendicitis, Crohn disease
Peritoneal carcinomatosis Ovarian cancer, colon cancer, gastric cancer
Endometriosis
Sclerosing mesenteritis Prior surgery, abdominal trauma, autoimmune
disorders, malignancy, neuroendocrine tumor
Desmoid tumor/other soft tissue sarcoma (rare)
Superior mesenteric artery syndrome Rapid weight loss
Intrinsic lesions Congenital malformations, atresia, duplication See appropriate topic reviews
Large bowel neoplasm
Adenocarcinoma Hereditary colorectal cancer syndromes (HNPCC, FAP),
inflammatory bowel disease, bowel irradiation, others
(see appropriate topic reviews)
Desmoid
Carcinoid
Neuroendocrine tumor
Lymphoma
Small bowel neoplasm*
Adenocarcinoma Hereditary cancer syndomes (HNPCC, FAP, Peutz
Jeghers, MUTYHassociated polyposis, attenuated FAP)
Leiomyosarcoma
Paraganglioma
Schwannoma
Metastatic disease Melanoma, breast cancer, cervical cancer, colon cancer
(see appropriate topic reviews)
Gastrointestinal stromal tumor
Neuroendocrine tumor
Lymphoma Chronic inflammation
Benign lesions PeutzJeghers polyps, xanthomatosis, leiomyoma
Anastomotic stricture Prior intestinal surgery
Inflammatory stricture Crohn disease, diverticular disease, NSAID
enteropathy
Ischemic stricture Peripheral artery disease, aortic surgery, colon
resection
Radiation enteritis/stricture Prior abdominal or pelvic irradiation
Intraluminal Intussusception* Small bowel tumor (see above)

obstruction of normal
Gallstones Cholecystitis
bowel
Congenital webs
Feces or meconium Cystic fibrosis, severe constipation
Bezoar (phytobezoar, pharmacobezoar) Intestinal motility disorders
Intramural hematoma
Traumatic Blunt abdominal trauma
Spontaneous Antithrombotic therapy
Foreign body
Ingested Psychiatric disturbance
Medical device migration PEG tube, jejunal tube
Parasites Ascaris lumbricoides, Strongyloides stercoralis
VP: ventriculoperitoneal; HNPCC: hereditary nonpolyposis colorectal cancer; FAP: familial adenomatous polyposis; NSAID: nonsteroidal
antiinflammatory drug; PEG: percutaneous endoscopic gastrostomy.
* May be due to an intrinsic lesion serving as a lead point.
or find out more.
Meckels diverticulitis
or find out more.
The abdominal CT scan in this 82yearold patient with Meckel's diverticulitis demonstrates an airfilled
diverticulum (arrow) surrounded by significant induration (arrowhead). A stone is demonstrated within
the diverticulum (dashed arrow).
CT: computed tomography
Ruptured Meckel's diverticulum on CT
or find out more.
This 21yearold male had a surgically proven ruptured Meckel's diverticulum. The nonspecific CT findings
include induration of the omentum (arrow) with bubbles of free air noted in the subumbilical region
(arrowhead) suggesting a ruptured viscus. A thick walled bowel loop with contrast in the lumen noted in
image C (short arrow) was thought to represent a focal region of abnormal small bowel, and likely
represented the ruptured Meckel's diverticulum. Free fluid is noted in the cul de sac (dashed arrow).
CT: computed tomography.
Classification of causes of abdominal pain
or find out more.
Visceral Somatic
1. Mechanical obstruction of hollow viscera 1. Parietal peritoneal inflammation
a. Obstruction of the small or large intestine a. Bacterial contamination, eg, perforated appendix, pelvic
inflammatory disease
b. Obstruction of the biliary tree
b. Chemical irritation, eg, perforated ulcer, pancreatitis,
c. Obstruction of the ureter
mittelschmerz
2. Distention of visceral surfaces, eg, hepatic or
2. Abdominal wall
renal capsules
a. Distortion or traction of mesentery
3. Vascular disturbances
b. Trauma or infection of muscles
a. Embolism or thrombosis
3. Spine, eg, radiculitis from arthritis
b. Vascular rupture
4. Neurogenic causes
c. Pressure or torsional occlusion
a. Tabes dorsalis
d. Sickle cell anemia
b. Herpes zoster
4. Referred from nonabdominal viscera
c. Causalgia and others
a. Thorax, eg, pneumonia, referred pain from coronary
occlusion d. Functional
5. Metabolic causes
a. Black widow spider bite
b. Lead poisoning and others
c. Uremia
b. Diabetic ketoacidosis
c. Porphyria
d. Allergic factors (C'1 esterase inhibitor deficiency)
Reproduced with permission from: Howard, FM. Acute Abdominal Pain. In: Primary Care for Women., Leppert, PC, Peipert, P (Eds),
Lippincott, Williams and Wilkins 2004. Copyright ©2004 Lippincott Williams & Wilkins.
Selected extraabdominal causes of acute abdominal pain
or find out more.
Cardiac Hematologic
Myocardial ischemia and infarction Sickle cell anemia
Myocarditis Hemolytic anemia
Endocarditis HenochSchönlein purpura
Heart failure Acute leukemia
Thoracic Toxins
Pneumonitis Hypersensitivity reactions: insect bites, reptile
venoms
Pleurodynia, Bornholm's disease
Heavy metals and corrosives (eg, lead or iron)
Pulmonary embolism and infarction
Pneumothorax Infections
Empyema Herpes zoster
Esophagitis Osteomyelitis
Esophageal spasm Typhoid fever
Esophageal rupture (Boerhaave's syndrome) Miscellaneous
Neurologic Muscular contusion, hematoma, or tumor
Radiculitis: spinal cord or peripheral nerve tumors, degenerative arthritis of Narcotic withdrawal
spine Familial Mediterranean fever
Abdominal epilepsy Psychiatric disorders
Tabes dorsalis (tertiary syphilis) Heat stroke
Metabolic
Uremia
Diabetes mellitus (ketoacidosis)
Porphyria
Acute adrenal insufficiency
Hyperlipidemia
Hyperparathyroidism
Reproduced with permission from: Glasgow RE, Mulvihill SJ. Abdominal pain, including the acute abdomen. In: Gastrointestinal and Liver
Disease, Feldman M, Scharschmidt BF, Sleisenger MH (Eds), W.B. Saunders, Philadelphia 1998. p.80. Copyright © 1998 W.B. Saunders.

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17/7/2018 Meckel's diverticulum - UpToDate

Under age 40 years Over age 40 years HenochSchoenlein purpura

Inflammatory bowel disease Angioectasia Small bowel varices and/or portal

Dieulafoy lesions Dieulafoy lesions Amyloidosis

Neoplasia Neoplasia Blue rubber bleb nevus syndrome

Meckel diverticulum NSAID ulcers Pseudoxanthoma elasticum

Extrinsic lesions Adhesions Prior surgery, diverticulitis, Crohn disease, VP

Intrinsic lesions Congenital malformations, atresia, duplication See appropriate topic reviews

Intraluminal Intussusception* Small bowel tumor (see above)

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Meckel&#39;s Diverticulum - UpToDate

Hochgeladen von

Copyright:

Verfügbare Formate

17/7/2018 Meckel's diverticulum - UpToDate

Under age 40 years Over age 40 years Henoch­Schoenlein purpura

Inflammatory bowel disease Angioectasia Small bowel varices and/or portal

Dieulafoy lesions Dieulafoy lesions Amyloidosis

Neoplasia Neoplasia Blue rubber bleb nevus syndrome

Meckel diverticulum NSAID ulcers Pseudoxanthoma elasticum

Extrinsic lesions Adhesions Prior surgery, diverticulitis, Crohn disease, VP

Intrinsic lesions Congenital malformations, atresia, duplication See appropriate topic reviews

Intraluminal Intussusception* Small bowel tumor (see above)

Das könnte Ihnen auch gefallen

Meckel's Diverticulum - UpToDate

Meckel's Diverticulum - UpToDate

Under age 40 years Over age 40 years HenochSchoenlein purpura