Dyspepsia Meckeli · 2020. 1. 13. · Dyspepsia Meckell TABLE 1 Clinical features of six cases of...

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Dyspepsia Meckeli

DON CLARK, MD, FRCPC, D1ur G PATEL, MD, FRCPC,

ABSTRACT: A 40-year-ol<l male was seen for evaluation of minor gastrointestinal bleeding. The patient had received an H z blocker as an oulpatient for ,uspicion of duodenal ulce r disease. At endoscopy no lesion wa~ seen anJ Hz hlockers were discontinueJ. The patient developed acute abdomen and at surgery a perforated Meckel's diverticulum was found . Can J Gastroenterol 1990;4(4): 157-159

Key Words: H2 blockers, Meckel's diverticulum

Dyspepsie du diverticule de Meckel

RESUME: Un patient age de 40 ans et souffrant de saignements gastriques legers a ere examine. Soup<yonnant un ulcere gastroduo<lenal, le medecin a prescrit un anti-H2 sans hospitaliser le sujet . L'endoscopic n'ayant <lecclc: aucune lesion, le traiteme-.:- par anti-Hz a ere interrompu. Le patient a developpe un syndrome ahdominal aigu et l' incervention chirurgicale a revele un d iverricule de Meckel rerfore.

A 40-Yl:.AR-OLD MALE PRESENTED with a one year history o( perium

hilical crampy dbcomfort. The pain began 30 to 60 mins after eating and d1sappeareJ 2 to 3 h later. There were no other precipitating or mod ifying factors and the patient had no other gastrointestinal complaints. H e was not on any meJications, nor did he smoke or drink alcohol; he had a positive fami-1)' history of duodenal ulcer disease. Outpatient investigations included a normal complete blooJ count and upper gastrointestinal series with small bowel follow through. Small bowel enema anc.l stool testing for occult

blood were not performe<l. The patient's physical examination was normal and no treatment was prescribed.

Two weeks prior co admission he had mclena, one stool daily for two clays and was placed on oral raniti<line 150 mg bid. The patient noted a rapid and marked improvement in his abdommal pain. Ten clays later ranitidine was discontinued when esophagogascro<luodenoscopy was normal. The patient's abdominal pain returned within 24 h and steadily increased in intensity for three <lays until his arriva l at the emergency <leparcment. On arrival he had

Division of Gastroenterology, O{(awa Civic Hospital, Ottawa, Ontario Correspondence and reprints: Dr Dil,p G Pace/ , Associate Prnfessor, Division of

Gasrroenterology, Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, Ontario K IY 4L9. Tdephone(613) 761 -4501

Received for publication November 19, 1989. Acce/)(ed Feln-uary 13, 1990

CAN J GASTROENTERt)l VOL 4 No 4 MAY/JUN!,, 1990

generalized, severe, constant abdominal pain and clinical signs of peritonitis. He was taken to surgery when a Meckel's diveniculum lined with gastric mucosa and a perfora red ilea I ulcer was found (Figures 1,2).

DISCUSSION An unusual diverciculum o( the

small intestine was first described by H ii Janus in 1598 (l) and was con· siderecl to be clue to increased intestinal pressure. This most common congenital anomaly of the gastrointestinal tract is clue to fai lure of obli terat ion of the omphalomesenteric duce connecting yolk sack to intestinal tract at five co seven weeks of gestation. Johann Friedrich Meckel established the condition on a sound embryological and anatomic basis in writings between 1808 and 1820 (2). He was incorrect, however, in predicting a 25% complication rate; t he actual figures are 0.03 to 0.96% per year with a life long risk of approximately 4% (3 ).

The clinical diagnosis of symptomatic Meckel's diverticulum can be difficult as illuscrated by ch is case. Some physicians fee l chat chis is a disease of childhood and are not aware of the difference in adult presentation. Symptomatic Meckel's diverciculum in adults has a male to female ratio of 1.8 co 1.0 and the risk is greatest in the 16 to 25 year age group (mean 39, range 16 to 87) ( 4 ). In children, rectal bleeding and obstruction are the most common complications, while 30 co 50% of adults experience inflammation, 33 to

157

Ct ARK ANll PA TU

Figure l) Gross af,pearance of pcrforaied ilea/ ulcer

\

-. Figure 2) Mrcroscoprr appearance of /ierf ormed rleal ulcer ( X 4 .5)

36% obstruction , 19°;.i perfora tion and 10 to 19% bleeding.

Any young adult wi th s ignific;:int gam ointestina l hleed mg and a negative endoscopic evaluanon sho uld be investigated for a possible Meckel 's d1verticulum. Patients with inflammation are likely to be diagno ed as appendicitis and managed surgically ar an ea rly stage.

A computer search of the world literature to l 989 revealed o nly fi ve case reports of H2 blocker therapy in Mecke l's Jiverticulum and several

no teworthy features were found (Table 1 ). Bleeding fro m a Meckc l's diverticulum is rare above age 30 years ( 4 ) and the present pa t1em was significantly olde r than the others treated. O ne-ha lf of the patients had postprandial pain, and fi ve of six had obvious rectal bleeding. Upper in testina l series performed in four cases were falsely nega tive hut two small bowel enemas were positive for Meckel 's diverticulum. Four Meckel's scans were reported m three patien ts with two positive anJ two negat ive results.

A q uestio n rai:,ed by the prc~cnt case concerns the diagnosuc and therapeutic va lue of H2 blockers in

symptomatic Meckcl 's Ji verticulum. In the five cases wh ere deta il \1,1s

provided, all mentioned rapiJ improvement in ahdommal pa in with institu· tion of 112 blockade. In all th ree ca,r, m which the Hz blocker was discnnunued the pa in rewrned. The data su1•· gest that ,1bdominal pain whKh responds to Hz blockers in the ah,ence of evide nce of upper im estinal disease should prompt an investigation for Mecke l's d iverticulum.

A therapeutic role for 112 hlochr~ has been advocated by some (5-7), while othe rs noted rebleeding and per• £oratio n during treatment (8,9). The fac t rhac H2 blockers were ineffecme for reduc ing bleeding from duodenal ulcers plu5 the fact that such blecclm~ resolved spon taneously in 80% of ca:.ci is impo rtant; however, it is not possible to d raw any th erapeutic conclusion from thi5 sma ll group of patiem s.

The present patient h ad gastric CIS·

sue present in his Meckcl's <livcruculum which has been correlated w1th the presence and nature of symptoms m chis condition. Dependmg upon the thoroughness of the search, ectopic t1,sue 1s present in 25 to 72% of symr· tomatic patie nts (1 0, 11 ). In one largt series only l 6% of pat ients with ectopic tissue were asympw matic ( 4 ). T issue types include gastric (60%), pancrcauc (1 6%) and mixed (22% ) (10, 11 ); 92 to 100% of M ecke l's diverticula complicateJ by bleeding arc associated with he terotopic t issue ( 4, I 0). Efforts have been made to corre late the presence of gastric mucosa with the likelihood of bleeding. Parietal c.e lls present m gastric mucosa have been demon· strated to ecrete acid, and isle ts of Langerham are pre ' cnt in pancreatic rests (10).

What ave nues are ava ilable to the cl inic ian for diagnosmg Meckcl's divercic ulum ? Uppe r gastro intestinal series are insensitive hecnuse the w1Je mouth of the divem c ulum empties well and holds only a sma ll amount of residual ba rium (1 2). A number of authors fee l that enteroclysis is the most reliable method for preoperative

158 CAN j GASTROENTEROL VOL 4 No 4 MAY/JUNE 1990

Dyspepsia Meckell

TABLE 1 Clinical features of six cases of Meckel's diverticulum treated with H2 blockers

A e Sex Symptom ~n -- -- Treatment Outcome

27 M Abdominal pain Bloody stool Cimetidine 300 mg orally qid Surgery for rebleeding ofter tor 3 months therapy

40 M Peri-umbilical Melena Ronihdine 150 mg bid for 10 days Urgent surgery. perforation ofter cramps, postprandial therapy

23 M Sharp Infra-umbilical Clmetidine 300 mg orally every 6 h Semi-elective surgery postprandial pain tor Sdoys

26 F Peri-umbilical pain Maroon stool Cimetldine ? dose orally for 7 days Semi-elective surgery

25 M Nonspecific post- Maroon stool Cimetidine 300 mg orally every 6 h Urgent surgery, bleeding prond1ol pain for 2 days

12 M Nonspecific pain Melena and fresh Cimetidine 100 mg orally every 6 h Perforated ofter therapy, surgery blood rectally for 3 months

J1agno~1s of Meckel\ J1vcruculum ( l 2-15). The barium miccteJ under prcs,ure h1ghlighb any constricung lesion anJ the regulatory cffr:crs of the gastric mJ pyloric area, arc bypa,,cJ readily hy the enteroclysis carheter.

99Technetium pcrtL·chncrate h,ls an affinity for mucu,-producmg and parietal cells, and the tracer 1s cnncent rateJ hy the ectopic gastric mucosa. C1meridine does nor interfere wnh upr,1ke hut reduces lummal excret 1011 tourfolJ in the Jog moJel. It 1, optimally delivered 24 h before imaging ( 16). Another 11gent used co increase the sen-11t1v1ty of a Meckel\ scan is pcnta-

ACKNOWLEDGEMENTS: Thl' .iuthnr Kknowlcdge, rhl' excl'llc111 ,ccrcrnnal ,i,,1, ranee of Mrs Cec ile I lumphrcy.

REFERENCES Fabncul H. AmmaJv Var Argum Med Hclmst.Jan 1750. (Edit)

2. Meckel JF, Uhcrd1e 0 1ver11kcl am Darmkanal. Archd1e Physiology 1809;9:421 -53.

l Soltero MJ, Rill Al I. Thc natural his· tory of Mee kc l's d1vcmculum and its relation to mc1dental rcmnval. Am J Surg 1976;132:168-72.

4. Leijonmarck CE, 8nnmon-Sondclin K, Frisell J, Raf L, Meckel's <l1verticulum in the adul t. Br J Surg 1986;73;146-9.

5. K1rkpamck PA. Cimetidmc and Meckel\ d1vcrt1culum. Ann Intern Met! I 978;83:846-7.

6 Selkcr HP. Cimeridmc and cryptic 'Dy,pepsia Meckel,'. JAMA 1983; 249:1266. Collins JC. Hemorrhage from a

gaMrin. In mice, a 65% 111cn:,1sc in uptake is nmeJ with pcncaga,t rin, and some rad11)logists prefer the increase m scan ,en,iuv1ty despite a theoreucal rbk nf increased hleedmg ( 17). In a large series of 954 cases, of which 700 werL' children, ,ens1uv1ry for ectopic gastric mucosa wa, 85'\,. In adults wi th surgically confirmed Meckel\ d1vert1-Clil um a ,ensitiv 11 y nf 62.5% was repmtl'd ( 18). ll hleeding 1, present, ang1ograrhy warrant~ se ri<lUS cnns1dt·ramm ( 19). A prudent cour,e would involve more than one modality heing used heforl' exclusion of che diagno~1~.

Meckel\ d1vcniculum One cn,e w11h hercrotop1c gast nc muco,a rrc,nc<l w1rh cimetidml'. Arch Surg 1980;115:83-4.

8. Munchom PE, Wheeler WI I, Siherr JR. C1mctidmc anJ pcpuc ulccratinn m Meckcl's dl\·crriculum. Arch Dis Child 1980;55.Hl -5.

9. Manning RJ. Failure nf Hz blocker ther.ipy m a C.1'C of hemnrrhagc from ;1

Meckel\ Jiverucul um. J Clm Gm,tmenteml 1987;9:242.

10. Artigas V, Calhv1g R, 8adrn F. Meckel\ d1verr iculum. Value of ec-topic msue. Am J Surg 1986; I 51:63 1-4.

11. Dmmon<l T, Rus.,ell CFJ. Meckel\ Jiverticulum in the adult. Br J Surg I 985;72:480-2

12. Sutton D. A Textbook nf R,id1ology and Imaging, Vol I , 4th edn. Chicago: Churchi ll & Livmg,ton, 1987.

ll Dixon M, Nolan OJ. The <l iagnosis of Meckel', divemculum a concmumg challenge. Clm Radllll 1987;38:615-9.

14. Schwartz MJ, Lewis J. Meckel\ diver-t1culu111 P1tfalb m scmt1grnph1c detec-

CAN J GA~TROENTERl1L VOL 4 No 4 MA Y/JLNI: 1990

In conclus1on, awareness of of high risk groups, the various modes of presentation and the differences between pediatr ic and adult prc~entaunn are important in diagnn~ing symrwmatic Meckcl's Jivemculum. Use of an Hz hlocker may offer a hclpfu I diagnostic clue but data Jo not support its role in treatment. A small howcl enema and a 99 technetium Meckel's sc.1n are of significant value in rreopcrntive diagnosis. Finally, h1stologic 111format1on has deepened the underwrnding of this mo~t frequent congenital anoma ly o f the intestinal tract.

rnm m the ac.lult. Am J Ga,trocntewl 1984; 79:611-8.

15. Maglinte [), I lall R, Miller R, Chcnni h S. Detcu1on of surgical lesion, by small howcl enreroclys1s. AmJ Surg 1984: 147:225-9.

16. Baum S. Pcrtcchnctate imaging fo llow-mg cnnetidme admin1smuion in Mcckel's <l1vcrticulum of the ileum. Am J Gamoenceml 1981;76:464-5.

17. Treves S, Grand RJ , Erakles A. Penta-gastrm stimulauon of techncnum-99m uptake by ectopic gastric mucosa m a Mcckcl's diverticulum. Radiology 1978;129:71 t -2.

18. Sfak 1anak1s GN, Conway JJ. Oetemon of ectopic gastric mucosa in Mcckcl's d1vert1culum and m the ohservannn, hy scmtign1phy: Pathophysiology anJ IO years clm1cal experience. J Nucl Med 1981;22:647-54.

19. Maglintc D, Jordan L, Van Hove E, ct al. Chronic gastmintemna! hlecdmg from Meckel's divcrticulum -Rad1olog1cal con"dera11ons. J (. ' Im Gastroencerol 1981;3:47-52.

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Dyspepsia Meckeli · 2020. 1. 13. · Dyspepsia Meckell TABLE 1 Clinical features of six cases of...

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