Who was Hilidanus A. Adegbesan,. Case 1 68 year old lady admitted with a 2 day history of diffuse...
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Transcript of Who was Hilidanus A. Adegbesan,. Case 1 68 year old lady admitted with a 2 day history of diffuse...
Who was Hilidanus
A. Adegbesan,
Case 1
• 68 year old lady admitted with a 2 day history of diffuse abdominal pain and vomiting.• Acute onset intermittent sharp epigastric pain,
rated 7/10 with no aggravating or relieving factors.
• Bowel motion and flatus last passed 3 day previously
• Poor appetite.• No recent alcohol ingestion as per patient.
Case History• Past Medical History:
– PUD– Hiatus hernia– Chronic Kidney Disease– COPD
• Past Surgical History– Hysterectomy– Cholecystectomy– Appendectomy
Case History
• Family History– Nil significant
• Social History– Ex smoker
• ROS:– Nil significant
On Examination
• Vital Signs:– BP 111/74– HR 92– Temp 36.2– RR 16– O2 SATS 100% on RA
• Abdomen was not distended. Tenderness in epigastrium with mild guarding. No rebound. Bowel sounds exaggerated. Hernial orifices were intact.
Investigations
• WCC 7.4; Hb 13.3; Plts 433; CRP 17• Urea 42; Na 125; K 7.4; Creat 609 (baseline 60-
120)• ABG: pH 7.38, pCO2 4.57, pO2 12.4, HCO3 20• Amylase 160 • ECG: NSR; tachycardic; tented T waves• CXR: no free air under diaphragm.• PFA: prominent small bowel loops
Management
• Initially admitted medically with– Acute on chronic renal failure– Dehydration
• Upon surgical review:– Features of small bowel obstruction for
conservative management.
Management
• Day 1 post admission: – Abdomen now distended, non tender, BS
present. PFA showed progression - ? small bowel obstruction 2o to adhesions.
• Day 2 post admission:– Medical review re: acute renal failure, hyperkalaemia
and hyponatraemia.– Surgical team review– To continue conservative management– NG tube and urinary catheter placed
Management
• Day 5 post admission:– Renal failure indices resolved– Abdominal distension still persistent– Obstipated– PFA showed increasing bowel dilatation – NG tube active– Proceeded to laparotomy
Operative findings
• Small bowel volvolus with fulcrum around meckel’s diverticulum adherent to pelvic sidewall.
• Merckel’s diverticulum and adjacent small bowel were resected and sent for histology.
• Side to side anastomosis
Post Operative
• The post operative period was uneventful.
• Histology– Gastric body type mucosa– No helicobacter pylori– No evidence of malignancy
Case 2
• 31 year old gentleman admitted with:– 1/7 history of sudden onset non-radiating
colicky lower abdominal pain.– No associated nausea, vomiting or altered
bowel habit. – No previous medical/surgical hx.– ROS – nil significant
On Examination
• Vital Signs:• BP 115/68• HR 93
• O2 SATS 99% on RA
• Apyrexial 36.2oC
• On examination:• Tenderness and guarding in lower abdomen• Reduced bowel sounds.
Investigations
• Urinalysis– NAD
• Bloods– WCC 13.4 (neuts 10.58), Hb 13.4, CRP 49, Amylase
107– Sickle cell screen negative
• CXR– No air under the diaphragm
• PFA– Bowel gas pattern normal. No bowel distension or
obstruction. No free air.
Investigations
• CT Abdomen/Pelvis– Minor stranding of fat around a loop of small
bowel in right lower quadrant (differential included inflammatory change around a meckel’s diverticulum)
– Small nodes in the adjacent mesentery. – No evidence of large colonic diverticulitis and
normal appearance of the appendix.
CT Abdo/Pelvis
Management
• On admission:– IV fluids, co-amoxiclav and analgesia
• Day 2 post admission:– Proceeded to Laparoscopy:
• Operative findings:– Perforated merckel’s diverticulum which was resected at its
base using Endo GIA and sent for histology– Appendix long and injected but not acutely inflamed - most
likely not the cause of his symptoms but removed.
Histological Findings
• Ectopic gastric tissue at the fundus of the meckel’s diverticulum.
• The excised edge was free of ectopic gastric tissue
Introduction
• A true congenital diverticulum, a congenital bulge in the small intestine.
• It is a vestigial remnant of the omphalomesenteric duct
• is the most frequent malformation of the gastrointestinal tract
• It was first described by Fabricius Hildanus, German surgeon, in 1598
• Johann Friedrich Meckel, described the embryological origin of this type of diverticulum in 1809
Pathophysiology
• It is a vestigial remnant of the omphalomesenteric (vitellointestinal) duct
• Human embryos initially have convex umbilical loops of primitive gut that communicate freely with the yolk sac through the omphalomesenteric (vitellointestinal) duct
• As development proceeds, the duct normally becomes occluded and disappears entirely by weeks 8-10 of gestation
• Results from the failure of the vitelline duct to obliterate during the fifth week of fetal development
Pathophysiology
• The following anomalies are caused by the persistence
of the omphalomesenteric (vitellointestinal) duct
Epidemiology
• Autopsy records show an incidence of about 2% in the general population.
• For asymptomatic diverticula there is no gender predominance,.
• For symptomatic diverticula some studies give a 3:1 male to female ratio, while others have detected little difference.
• The risk of complications ranges from 4-25% in various studies.
Anatomic Considerations• Meckel's diverticulum is located in the
distal ileum, on its antimesenteric border. usually within about 60-100 cm of the ileocecal valve
• It can also be present as an indirect hernia, typically on the right side, where it is known as a "Hernia of Littre."
Anatomic considerationTopography of abdomen
Anatomic Considerations
• A memory aid is the rule of 2's:• 2% (of the population) • 2 feet (from the ileocecal valve) • 2 inches (in length) • 2% are symptomatic • 2 types of common ectopic tissue (gastric 80% ,
pancreatic, colonic and other tissues 20%),• The most common age at clinical presentation is
2, and • males are 2 times as likely
Clinical features
• Asymptomatic in majority of cases• Painless rectal bleeding, • Intestinal obstruction, • Volvulus and Intussusception. • Meckel's diverticulitis may present with all the
features of acute appendicitis. • Epigastric pain & Bloating• Neoplasm - lipoma, leiomyoma, neurofibroma
and angioma, leiomyosarcoma and carcinoid, which represent about 80% & adenocarcinoma and metastatic lesions
Diagnosis
• A technetium-99m (99mTc) pertechnetate scan is commonly used to diagnose Meckel's diverticulum – Gastric tissue.
• Abd CT• Barium studies to out rule enterocolitis and
intussuception• Laparoscopy• A bleeding scan.• Selective arteriography • Wireless capsule endoscopy • Abd USS
Treatment
• Surgical for symptomatic Merckel’s diverticulum• Incidental Meckel’s diverticulum in asymptomatic
patients remains controversial – Narrow vs wide• Excision is carried out by performing a wedge
resection of adjacent ileum and anastomosis • a primitive persistent right vitelline artery
originating from the mesentery has been found during operation - Bleeding
Histology
• Heterotropic gastric mucosa 62%
• pancreatic tissue 6%,
• Both pancreatic tissue and gastric mucosa were found in 5%,
• Jejunal mucosa was found in 2%,
• Brunner tissue was found in 2%, and
• Both gastric and duodenal mucosa were found in 2%
Take home message
• Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract.
• it is often difficult to diagnose
• It may remain asymptomatic
• it may mimic disorders such as Crohn's disease, appendicitis, peptic ulcer disease, obstruction and bleeding.
Thank you
• Who should take credit for this clinical entity
• Fabricius Hildanus,, in 1598
• Johann Friedrich Meckel, 1809