What are the potential complications and management strategies for a patient with Meckel's diverticulum?

Complications of Meckel's Diverticulum

Primary Complications by Age Group

Meckel's diverticulum complications vary significantly by age, with gastrointestinal bleeding predominating in children and obstruction or diverticulitis more common in adults. 1

Pediatric Presentations (Age <1 year)

• Gastrointestinal obstruction is the most prevalent complication in infants under one year of age 1
• Obstruction occurs through volvulus around a fibrous band connecting the diverticulum to the umbilicus or entrapment of small bowel beneath a mesodiverticular band 2

Childhood Presentations (Ages 1-18)

• Peptic ulceration with serious gastrointestinal bleeding dominates as the primary complication during childhood 1
• Painless rectal bleeding is the classic presentation, particularly in younger patients 2
• Most symptomatic Meckel diverticula with bleeding are found in children and young adults 2

Adult Presentations (Age >18)

• Various forms of gastrointestinal obstruction and diverticulitis are most prevalent in adults 1
• Perforation becomes a recognized complication in adult presentations 3, 4
• Rarely, neoplasms (including gastrointestinal stromal tumors) can develop within the diverticulum 3, 4

Overall Complication Risk

• The lifetime risk of developing complications from Meckel's diverticulum is 4-9% 1, 5
• The probability of complications decreases with age and approaches zero after age 70 1
• Meckel's diverticulum is present in approximately 2% of the general population 2, 1

Diagnostic Approach by Clinical Scenario

For Active Gastrointestinal Bleeding

• Meckel's scan (99mTc pertechnetate scintigraphy) is the diagnostic test of choice for suspected bleeding from Meckel's diverticulum, as it detects ectopic gastric mucosa 2
• Sensitivity is 80-92% in children but only 62-88% in adults 5
• Positive and negative predictive values approach 100% in anemic patients with GI bleeding 2
• Perform Meckel's scan in young patients with unexplained lower GI bleeding after negative upper endoscopy and colonoscopy 2

For Suspected Obstruction or Diverticulitis

• CT scan of abdomen and pelvis with contrast is highly accurate for diagnosing complications like diverticulitis or perforation 2
• CT enterography can help identify Meckel's diverticulum and exclude other etiologies when bleeding is not active 2

For Diagnostic Uncertainty

• Small bowel capsule endoscopy (SBCE) has a diagnostic yield of only up to 50% 5
• Device-assisted enteroscopy (DAE) has a sensitivity of 84-100% for Meckel's diverticulum but is invasive 5
• A multimodality combination of SBCE, Meckel's scan, CT, and DAE is often required for definitive diagnosis 5

Management Strategies

Symptomatic Meckel's Diverticulum

• Surgical resection is the definitive treatment for all symptomatic cases 1, 5, 6
• Resection followed by anastomosis is preferable to wedge resection or tangential mechanical stapling to avoid leaving behind abnormal heterotopic mucosa 6
• Morbidity after resection of symptomatic Meckel's diverticulum is 11.1-17.6% with 6.0-7.5% mortality 1

Incidentally Discovered Meckel's Diverticulum

For patients younger than 40 years: routine resection is recommended 1, 6

For patients 40 years and older: resection should be performed only if risk factors are present: 1, 6

• Male gender 6
• Diverticulum longer than 2 centimeters 6
• Palpable stigmata of heterotopic tissue 1
• Macroscopically visible mucosal alteration noted at surgery 6
• Presence of omphaloenteric or omphalodiverticular bands 1

The morbidity rate for resection of incidentally discovered diverticulum is only 1.2-8.9%, significantly lower than for symptomatic cases 1

Critical Anatomical Features

• Meckel's diverticulum is a true diverticulum containing all layers of the intestinal wall including muscularis propria 2, 3
• Located on the antimesenteric border of the distal ileum, approximately 45-60 cm proximal to the ileocecal valve 3, 4
• Identified as a saccular, blind-ending structure 3

Common Pitfalls to Avoid

• Do not dismiss Meckel's diverticulum in adults simply because complications are more common in children—serious complications including perforation and neoplasms can occur 4, 6
• Do not rely solely on Meckel's scan in adults, as sensitivity drops to 62-88% compared to 80-92% in children 5
• Do not perform wedge resection or tangential stapling when resecting Meckel's diverticulum, as this risks leaving behind heterotopic mucosa 6
• Do not routinely resect incidentally discovered Meckel's diverticulum in patients over 40 unless specific risk factors are present, as complication risk approaches zero after age 70 1, 6