What is the management and treatment of Meckel's diverticulum?

Management and Treatment of Meckel's Diverticulum

Surgical resection with segmental small bowel resection and primary anastomosis is the definitive treatment for symptomatic Meckel's diverticulum, while prophylactic resection of incidentally discovered asymptomatic Meckel's diverticulum should be strongly considered in patients under 50 years of age. 1

Symptomatic Meckel's Diverticulum

Surgical Management

• Open or laparoscopic small bowel segmental resection with primary anastomosis is the treatment of choice for symptomatic Meckel's diverticulum presenting with complications 2
• Surgical options include either segmental resection (removing the affected ileal segment containing the diverticulum) or simple diverticulectomy, with segmental resection preferred when complications are present 1, 3
• Laparoscopic approach can be utilized in selected cases when technically feasible 1

Common Presentations Requiring Surgery

Obstruction:

• Volvulus around a fibrous band connecting the diverticulum to the umbilicus requires emergency surgical intervention 4, 5
• Entrapment of small bowel beneath a mesodiverticular band necessitates surgical release and resection 4, 5
• Internal hernias twisted around the diverticulum, though rare, require emergent laparotomy and segmental resection 3, 6

Bleeding:

• Painless rectal bleeding, particularly in younger patients, is a classic presentation requiring surgical resection after diagnosis 4
• Most symptomatic bleeding occurs in children and young adults 4
• Meckel scan (99mTc pertechnetate scintigraphy) is the diagnostic test of choice for suspected bleeding, as it detects ectopic gastric mucosa 4

Diverticulitis/Perforation:

• CT scan with contrast is highly accurate for diagnosing these complications 4
• Surgical resection is required for perforation or inflammation 7

Asymptomatic Meckel's Diverticulum (Incidental Finding)

Age-Based Approach

• Prophylactic resection should be performed in patients under 50 years of age due to 70% likelihood of developing symptoms in this age group 1
• Patients over 50 years of age have only a 10% risk of becoming symptomatic and are less likely to benefit from prophylactic resection 1

Risk Factors Favoring Prophylactic Resection

• Presence of heterotopic tissue (gastric or pancreatic mucosa) increases complication risk, though this is typically only identified on pathology 1
• Heterotopic tissue was found in 33% of symptomatic patients versus 0% in asymptomatic resected patients 1
• Male patients have slightly higher incidence (M:F ratio 1.23:1) 1

Diagnostic Workup

Imaging Strategy

• CT scan of abdomen and pelvis with contrast is the primary imaging modality for suspected complications 4
• CT enterography can identify Meckel's diverticulum when bleeding is not active and helps exclude other etiologies 4
• Meckel scan (99mTc pertechnetate scintigraphy) is appropriate in young patients with unexplained lower GI bleeding after negative upper endoscopy and colonoscopy 4

Clinical Pearls

• Meckel's diverticulum should be considered in young patients presenting with small bowel obstruction, especially when accompanied by GI bleeding 5
• Preoperative diagnosis is challenging and achieved in only 4% of cases 6
• The diverticulum is a true diverticulum containing all intestinal wall layers located on the antimesenteric border of the distal ileum 4, 8

Surgical Outcomes

• Complication rates are similar between segmental resection and diverticulectomy approaches 1
• Both open and laparoscopic approaches have comparable outcomes when appropriately selected 1
• Postoperative course is typically uneventful with appropriate surgical technique 3, 6

Common Pitfalls to Avoid

• Do not delay surgical intervention in patients presenting with obstruction or perforation, as these are surgical emergencies 2, 7
• Do not dismiss the diagnosis in patients over 50 years, though less common, complications still occur 1
• Do not rely solely on CT imaging for diagnosis, as it may not identify the underlying cause in many cases 3, 6