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□ CASE REPORT □

Meckel’s Diverticulum Preoperatively Diagnosed byDouble-balloon Endoscopy

Keisuke Taniuchi 1,2, Hajime Tanaka 1, Shinichi Iwamura 4 and Itsumi Mori 3

Abstract

Symptomatic Meckel’s diverticulum is an uncommon diagnosis in adults, and bleeding Meckel’s diverticu-

lum after childhood is even more infrequent. We present herein the case of a 22-year-old man with gastroin-

testinal hemorrhage secondary to Meckel’s diverticulum containing ectopic gastric mucosa. As the source of

bleeding could not be identified by upper and lower gastrointestinal endoscopy and visceral selective angiog-

raphy, the new methods of capsule endoscopy and double-balloon endoscopy were used. Capsule endoscopy

showed oozing hemorrhage in the ileum, and double-balloon endoscopy demonstrated a large diverticulum in

the distal part of the ileum. Tc-99m pertechnetate Meckel’s scan revealed an abnormal focus of uptake in the

right lower abdomen. The diverticulum was resected laparoscopically. The postoperative course was unevent-

ful, and the patient remains in complete remission as of this writing. Detecting Meckel’s diverticulum endo-

scopically is difficult prior to surgery, but a combination of capsule endoscopy and double-balloon endoscopy

facilitates examination of the entire small intestine, making precise diagnosis of Meckel’s diverticulum possi-

ble.

Key words: Meckel’s diverticulum, lower gastrointestinal hemorrhage, capsule endoscopy, double-balloon

endoscopy, laparotomy

(Intern Med 51: 1023-1026, 2012)(DOI: 10.2169/internalmedicine.51.6594)

Introduction

Meckel’s diverticulum is the most common congenital

anomaly of the gastrointestinal tract, with an incidence on

autopsy of 0.3-4% (1, 2). This condition derives from in-

complete obliteration of the yolk stalk (omphalo-mesenteric

duct). Meckel’s diverticulum is a true diverticulum, with all

of the layers of the intestinal wall present. The diverticulum

is located on the antimesenteric border of the ileum, about

40-130 cm proximal to the ileocecal valve, and it is usually

3-5 cm long (3). Since cells lining the vitelline duct are plu-

ripotent, heterotopic gastric mucosa (50%), pancreatic mu-

cosa (5%), and, less commonly, colonic mucosa, endometri-

osis, and hepatobiliary tissue, may be present, and these are

responsible for other complications like hemorrhage, chronic

peptic ulceration and perforation (4-6).

An individual with Meckel’s diverticulum has a 4-6%

lifetime risk of developing a complication (7). The most

common clinical presentation is gastrointestinal bleeding,

which occurs in 25-50% of patients showing complica-

tions (8). Colonoscopy cannot usually diagnose the bleeding

from Meckel’s diverticulum, as the colonoscope cannot typi-

cally reach the part of the small intestine in which the diver-

ticulum is located. Recent advances in diagnostic methods,

including capsule endoscopy (CE) (9) and double-balloon

endoscopy (DBE) (10), have enabled observation of the

source of small-bowel bleeding. CE has proved to be of di-

agnostic value in some cases of bleeding Meckel’s diverticu-

lum, but reports have been very few and no conclusive

statement regarding the diagnostic value of this method can

be made at this time (11). DBE enables examination of the

entire small intestine (12). Although Tc-99m pertechnetate

scintigraphy is useful, particularly in patients with ectopic

gastric tissue, sensitivity was reported as�60% in a study

of 235 patients with Meckel’s diverticulum and anemia (13).

１Department of Internal Medicine, Tosa Municipal Hospital, Japan, ２Department of Gastroenterology and Hepatology, Kochi University Medical

School, Japan, ３Department of Surgery, Tosa Municipal Hospital, Japan and ４Department of Gastroenterology, Kochi Red Cross Hospital, Japan

Received for publication September 21, 2011; Accepted for publication December 19, 2011

Correspondence to Dr. Keisuke Taniuchi, jm-ktaniuchi@kochi-u.ac.jp

Intern Med 51: 1023-1026, 2012 DOI: 10.2169/internalmedicine.51.6594

1024

Figure　1.　Capsule endoscopy shows oozing hemorrhage in the ileum.

Preoperative diagnosis of a complicated Meckel’s diverticu-

lum may be challenging, because the clinical and imaging

features overlap with those of other causes of acute abdo-

men (14). We were able to identify small bowel bleeding us-

ing CE and visualize Meckel’s diverticulum of the ileum us-

ing DBE. These procedures may thus prove useful in the

preoperative diagnosis of bleeding Meckel’s diverticulum.

Case Report

A 22-year-old man presented to the emergency room with

a 2-day history of massive melena. At 15, 19 and 21 years

old, he had experienced similar episodes of bloody diarrhea

that resolved immediately. Upper gastrointestinal endoscopy

demonstrated no bleeding, while colonoscopy revealed blood

clots but no source of bleeding was seen with the episode of

bloody diarrhea at 21 years old. His family history was non-

contributory. On admission, physical examination did not re-

veal pallor or severe hypotension, and he was anicteric with

normoactive bowel sounds and a soft, flat abdomen without

evidence of tenderness or masses. Hematological analysis on

admission showed a red blood cell count of 320×104/μl, a

hemoglobin level of 8.6 g/dl and a hematocrit level of

25.9%. Platelet count, coagulation studies, and liver and re-

nal function tests were all normal. Emergent upper gastroin-

testinal endoscopy and colonoscopy were performed, reveal-

ing blood clots in the colon. Colonoscopy likewise revealed

that the bleeding was proximal, but did not identify a

source. Abdominal contrast-enhanced computed tomography

(CT) and angiography also failed to detect the source of

bleeding. The patient continued to have massive melena, re-

quiring transfusion of 8 units of packed red blood cells for

correction of anemia. Further investigation with CE on hos-

pital day 4 showed oozing hemorrhage in the ileum (Fig. 1).

CE was able to detect small bowel bleeding with a rough re-

gion of origin. A secondary procedure was therefore consid-

ered necessary according to CE findings. DBE was per-

formed on hospital day 5, revealing a large diverticulum in

the distal part of the ileum (Fig. 2A, arrows). The oozing

hemorrhage was already stopped, and no ulcers were appar-

ent in the diverticulum. On urografin-contrast radiography of

the small intestine from the endoscopy, the ileal diverticu-

lum was evident (Fig. 2B, arrowheads). Tc-99m pertechne-

tate was helpful in determining the existence of Meckel’s di-

verticulum because of its reactivity with the gastric mucosa.

On hospital day 8, a Tc-99m pertechnetate Meckel’s scan

showed an abnormal focus of uptake in the right lower ab-

domen (Fig. 3).

The patient was taken to the operating room with a pre-

sumptive diagnosis of bleeding Meckel’s diverticulum. Lap-

arotomy confirmed the findings of the DBE and Meckel’s

scan, showing a 5-cm long, 2-cm wide Meckel’s diverticu-

lum located approximately 90 cm proximal to the ileocecal

valve (Fig. 4A). Resection of a short segment of the small

bowel, including the diverticulum, with primary anastomosis

was performed (Fig. 4B). The patient experienced no further

hemorrhage and no postoperative complications, and was

discharged 1 week postoperatively with complete resolution

of symptoms. The pathological specimen revealed an area of

ectopic gastric mucosa within the diverticulum (Fig. 4C).

Discussion

Meckel’s diverticulum is difficult to detect nonsurgically.

We preoperatively detected the Meckel’s diverticulum in this

case using DBE. When bleeding is massive and cannot be

controlled using conservative methods, this represents an

emergency situation that needs to be promptly resolved us-

ing surgical resection of Meckel’s diverticulum after initial

resuscitation of the patient with blood transfusion. Making a

precise diagnosis as soon as possible is thus important. In

the present case, even though the patient continued to expe-

rience massive melena, CE was performed on hospital day

4. In retrospect, we should have performed CE and DBE

earlier to determine the exact cause of the bleeding.

The new methods of CE and DBE have revolutionized the

diagnostic approach to small intestinal bleeding in recent

years. CE is a noninvasive technique that allows visualiza-

tion of the entire alimentary tract (9). In the present case,

CE was able to detect the source of bleeding in the ileum,

but did not allow precise diagnosis. It is notable that DBE

enabled preoperative diagnosis in this case. DBE can visual-

ize the entire small intestine, allows detailed examination of

specific areas of interest, and is quicker and less painful

Intern Med 51: 1023-1026, 2012 DOI: 10.2169/internalmedicine.51.6594

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Figure　2.　Views from double-balloon endoscopy. (A) Endoscopy shows a large diverticulum (ar-rows) in the distal part of the ileum. (B) Urografin-contrast radiography of the small intestine from the endoscopy shows the diverticulum, approximately 5 cm in size, in the ileum (arrowheads).

Figure　3.　Image of the anterior lower abdomen after intra-venous administration of Tc-99m pertechnetate (Meckel’s scan). The diverticulum is clearly visible (arrow).

than previous endoscopic techniques (15). These results in-

dicate that CE and DBE can play complementary roles in

the preoperative diagnosis of bleeding Meckel’s diverticu-

lum. Overall detection rates of abnormalities in the small

bowel of CE (65%) and DBE (53%) are not significantly

different, nor are overall diagnostic yields of CE (50%) and

DBE (53%) (16). Since positive results on Tc-99m pertech-

netate scintigraphy do not always indicate that Meckel’s di-

verticulum is responsible for the bleeding, if the source of

small intestinal bleeding cannot be determined, subsequent

DBE examination should increase the detection rate of

Meckel’s diverticulum.

The diverticulum in the present patient contained ectopic

gastric mucosa without ulcers or visible vessels. Shinozaki

et al. investigated five cases of Meckel’s diverticulum and

concluded that endoscopic observation of ulcers in Meckel’s

diverticulum provides important evidence of bleeding (17).

However, if no adherent blood clots or vessels are visible in

ulcers within the Meckel’s diverticulum, confirming the ul-

cer as a bleeding source is difficult. The mechanisms of

hemorrhage from Meckel’s diverticulum remain unclear; this

report indicates that Meckel’s diverticulum without ulcera-

tion can cause bleeding. We conclude that DBE enables pre-

cise preoperative diagnosis and reasonable treatment of

bleeding Meckel’s diverticulum.

The authors state that they have no Conflict of Interest (COI).

Intern Med 51: 1023-1026, 2012 DOI: 10.2169/internalmedicine.51.6594

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Figure　4.　Extraction of Meckel’s diverticulum. (A) A Meckel’s diverticulum measuring 5 cm in length was found approximately 70 cm proximal to the ileocecal junction at laparoscopy. (B) Resec-tion of the intestine containing the diverticulum. Arrows, the Meckel’s diverticulum. (C) Microscop-ic section of the pathological specimen. Arrows, ectopic gastric glands. The glands to the right repre-sent normal intestinal glands.

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