What is the management of Meckel diverticulum?

Management of Meckel Diverticulum

Surgical intervention is the definitive treatment for symptomatic Meckel diverticulum, with the specific approach determined by the diverticulum characteristics and presenting complications.

Overview of Meckel Diverticulum

Meckel diverticulum is a congenital diverticulum of the small intestine, representing a remnant of the omphalomesenteric duct. It is typically located within 100 cm of the ileocecal valve on the antimesenteric border of the ileum.

Key characteristics:

• Follows the "rule of 2s":
  • Present in approximately 2% of the population
  • Located within 2 feet of the ileocecal valve
  • Typically 2 inches in length
  • Often contains 2 types of heterotopic tissue (gastric and pancreatic)
  • Most commonly symptomatic before age 2 years

Diagnostic Approach

Clinical Presentation

• Asymptomatic: Often an incidental finding during surgery for other conditions
• Symptomatic presentations:
  • Gastrointestinal bleeding (most common in children)
  • Diverticulitis
  • Intestinal obstruction
  • Perforation
  • Volvulus

Diagnostic Methods

1. Meckel scan (technetium-99m pertechnetate): 85% sensitivity in pediatric patients for detecting ectopic gastric mucosa 1
2. CT enterography: Less specific than nuclear medicine scans 1
3. Diagnostic laparoscopy: Most sensitive test when other investigations are inconclusive 1

Management Algorithm

1. Symptomatic Meckel Diverticulum

All symptomatic Meckel diverticula require surgical intervention 1, 2

Surgical approach based on presentation:

• Simple diverticulitis:

  • Long diverticulum (height-to-diameter ratio >2): Diverticulectomy
  • Short diverticulum: Wedge resection 2

• Complicated diverticulitis with perforated base:

  • Wedge or segmental resection 2

• Intestinal obstruction:

  • Wedge or segmental resection 2

• Gastrointestinal bleeding:

  • Wedge or segmental resection (preferred) 2
  • Must ensure removal of all ectopic gastric tissue

2. Incidentally Discovered Meckel Diverticulum

Risk factors for future complications (if present, consider resection):

1. Age younger than 50 years 3, 2
2. Male sex 2
3. Diverticulum length >2 cm 2, 4
4. Presence of ectopic tissue or abnormal features 2

In patients with risk factors:

• Long diverticulum: Diverticulectomy
• Short diverticulum: Wedge resection 2

Surgical Techniques

1. Diverticulectomy

• Appropriate for narrow-based diverticula without inflammation at the base 1
• Simple transverse resection at the base with closure

2. Wedge Resection

• Indicated for wide-based diverticula or when ectopic tissue is suspected at the base 1, 2
• Removes diverticulum and adjacent ileal wall

3. Segmental Resection with Anastomosis

• Required for:
  • Extensive inflammation
  • Perforation
  • Tumor
  • Bleeding that cannot be controlled by simpler techniques 1

Special Considerations

Age-Related Management

• Patients under 50 years have a significantly higher risk of developing symptoms (70% vs 10% in those over 50) 3
• Younger patients are more likely to present with gastrointestinal bleeding 5
• Older patients (>40 years) more commonly present with diverticulitis 5

Ectopic Tissue

• Present in approximately 16-33% of cases 6, 5
• Distribution based on diverticulum morphology:
  • Long diverticula: Ectopic tissue typically at body and tip
  • Short diverticula: Wide distribution including the base 2
• Gastric mucosa is most common, but pancreatic tissue may also be present 6

Gender Considerations

• Males are more likely to be symptomatic (50% of males vs 13% of females in one study) 6

Postoperative Management

• Antibiotic therapy for 4-7 days in cases of diverticulitis or perforation 1
• Monitor for potential complications:
  • Wound infections
  • Anastomotic leaks (rare but serious)

By following this evidence-based approach to the management of Meckel diverticulum, clinicians can optimize outcomes while minimizing unnecessary interventions in low-risk patients.