Updated: 4/3/2018

Meckel Diverticulum

Topic
Review Topic
0
0
Questions
7
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0
Evidence
5
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Snapshot
  • A 2-year-old boy with no significant past medical history presents with bright red blood per rectum in his diaper. His parents were immediately concerned and called the pediatrician. The patient is not in much pain but cries when the RLQ is palpated. A technetium-99m scan comes back positive for Meckel’s diverticulum.
Introduction
  • Congenital diverticulum presenting in childhood
    • note, is a “true” diverticulum, with all 3 layers of the gut wall outpouched
    • note, distinct from diverticulosis (false diverticula) and diverticulitis (inflammation of diverticula)
  • Pathogenesis
    • persistence of vitelline (omphalomesenteric) duct in small intestine
    • may have ectopic acid-secreting gastric or pancreatic tissue
  • Epidemiology
    • most common congenital anomaly of gastrointestinal tract
  • Rule of 2’s
    • affects 2% of population
    • 2 feet from ileocecal valve
    • 2 inches long
    • 2 types of epithelia tissue: gastric and pancreatic
    • male:female ratio 2:1
    • patients < 2 years old
    • 2% symptomatic
Presentation
  • Symptoms
    • painless rectal bleeding
      • due to gastric acid secretion causing damage to small bowel tissue
    • RLQ pain
    • may serve as lead point for intussusception
      • small bowel obstruction
Evaluation
  • Most commonly discovered as incidental finding on laparotomy
  • Technetium-99m scan aka Meckel scan
    • most accurate test
    • technetium-99m pertechnetate radioisotope is taken up by ectopic gastric mucosa
  • Upper GI series with small bowel follow-through can also detect
Differential Diagnosis
  • Intussusception
  • Appendicitis
  • Hirschsprung’s disease
Treatment
  • Surgical removal
Prognosis, Prevention, and Complications
  • Complications
    • hemorrhage (most common)
    • SBO
    • diverticulitis
    • perforation
 

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Questions (7)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.GI.4740) A mother brings her 2-year-old son to the pediatrician following an episode of abdominal pain and bloody stool. The child has otherwise been healthy and growing normally. On physical exam, the patient is irritable with guarding of the right lower quadrant of the abdomen. Based on clinical suspicion, pertechnetate scintigraphy demonstrates increased uptake in the right lower abdomen. Which of the following embryologic structures is associated with this patient’s condition? Review Topic

QID: 108653
1

Metanephric mesenchyme

6%

(13/213)

2

Ductus arteriosus

3%

(6/213)

3

Vitelline duct

69%

(146/213)

4

Paramesonephric duct

8%

(16/213)

5

Allantois

12%

(26/213)

M1

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PREFERRED RESPONSE 3
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(M1.GI.64) A concerned father brings his 2 year-old son to the clinic for evaluation. In the past 24 hours, the child has had multiple episodes of painless bloody stools. On physical examination, the child's vital signs are within normal limits. There is mild generalized discomfort on palpation of the abdomen but no rebound or guarding. A technetium-99m (99mTc) pertechnetate scan indicates increased activity in two locations within the abdomen. Cells originating in which organ account for the increased radionucleotide activity? Review Topic

QID: 106459
1

Stomach

56%

(10/18)

2

Pancreas

11%

(2/18)

3

Small intestine

28%

(5/18)

4

Gallbladder

0%

(0/18)

5

Liver

0%

(0/18)

M1

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PREFERRED RESPONSE 1

(M1.GI.70) A 1-year-old previously healthy male presents to the emergency department with 3 hours of intermittent abdominal pain, vomiting, and one episode of dark red stools. On exam, his abdomen is tender to palpation and there are decreased bowel sounds. A CT scan reveals air fluid levels and a cystic mass in the ileum. Gross specimen histology reveals gastric tissue. What is the cause of this patient's problems?
Review Topic

QID: 106478
1

Obstruction of the lumen of the appendix by a fecalith

7%

(1/14)

2

Abnormal closure of the vitilline duct

57%

(8/14)

3

Twisting of the midgut secondary to malrotation

36%

(5/14)

4

Hypertrophy of the pylorus

0%

(0/14)

5

Ingestion of contaminated water

0%

(0/14)

M1

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PREFERRED RESPONSE 2

(M1.GI.43) A 2-year-old female with abdominal pain undergoes laparoscopic surgery. An outpouching of tissue is excised from the ileum and sent to the laboratory for evaluation. The pathologist notes inflammation and the presence of mucosa, submucosa, and muscle in the walls of the specimen. Which of the following is the most likely diagnosis? Review Topic

QID: 101937
1

Hirschprung's disease

5%

(8/158)

2

Crohn's disease

8%

(13/158)

3

Meckel's diverticulum

83%

(131/158)

4

Appendicitis

3%

(4/158)

5

Henoch-Schonlein purpura

0%

(0/158)

M1

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PREFERRED RESPONSE 3

(M1.GI.33) An 8-month-old boy is brought to the emergency room by his mother who notes that the child has not been passing stool regularly. Palpation and radiographic imaging of the umbilical region reveal the presence of fecal material in an abnormal out-pocketing of bowel. Which of the following is a common complication seen in this condition? Review Topic

QID: 101927
1

Enlarged rugal folds

11%

(9/80)

2

Dysplasia

2%

(2/80)

3

Ulceration

38%

(30/80)

4

Megacolon

41%

(33/80)

5

Paneth cell metaplasia

5%

(4/80)

M1

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PREFERRED RESPONSE 3

(M1.GI.2) A 2-year-old male is brought to his pediatrician by his mother because of abdominal pain and blood in the stool. Scintigraphy reveals uptake in the right lower quadrant of the abdomen. Persistence of which of the following structures is the most likely cause of this patient's symptoms? Review Topic

QID: 101896
1

Urachus

5%

(2/38)

2

Omphalomesenteric duct

63%

(24/38)

3

Paramesonephric duct

5%

(2/38)

4

Allantois

13%

(5/38)

5

Ureteric bud

0%

(0/38)

M1

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PREFERRED RESPONSE 2
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