What is the management approach for a patient with Meckel's diverticulum?

Management of Meckel's Diverticulum

All symptomatic Meckel's diverticula should be surgically removed with resection of a segment of ileum, while incidentally discovered diverticula in adults should generally be left alone unless they are easily amenable to stapled resection. 1

Symptomatic Meckel's Diverticulum: Surgical Resection Mandatory

When a Meckel's diverticulum causes symptoms, surgical removal is the definitive treatment. 1 The key presentations requiring intervention include:

Clinical Presentations Requiring Surgery

Gastrointestinal Bleeding:

• Most common in children and young adults (typically <40 years old), presenting as painless rectal bleeding or melena 2, 3
• Caused by ectopic gastric mucosa within the diverticulum that secretes acid, ulcerating adjacent ileal mucosa 4
• Technetium-99m pertechnetate scintigraphy (Meckel scan) is the diagnostic test of choice, with 89% sensitivity and 98% specificity in symptomatic patients 5, 2
• In one pediatric series, 78 of 99 bleeding patients underwent Meckel scan with 55 showing positive tracer uptake 4

Intestinal Obstruction:

• Can occur via volvulus around a fibrous band connecting the diverticulum to the umbilicus, entrapment of small bowel beneath a mesodiverticular band, or intussusception 2, 6
• More common presentation in adults 3
• CT scan with IV contrast is the most accurate imaging modality for identifying the cause of obstruction 6

Diverticulitis:

• Presents similarly to appendicitis with right lower quadrant pain 4, 7
• More common in adults over 40 years old 3
• CT scan of abdomen and pelvis with contrast is highly accurate for diagnosing diverticulitis or perforation 5
• Preoperative diagnosis is challenging—only 40% of adult cases are diagnosed preoperatively, with exploratory laparoscopy needed in 60% 3

Surgical Approach for Symptomatic Cases

Laparoscopy is the preferred surgical approach for both diagnosis and treatment of Meckel's diverticulum. 4, 7

• Laparoscopy was used in 62% of pediatric cases in one series, with conversion to open surgery in only 8 of 36 patients 7
• For symptomatic diverticula, segmental ileal resection including the diverticulum is recommended rather than simple diverticulectomy 1
• Intestinal resection was performed in 89% of adult cases versus diverticulectomy in only 11% 3

Rationale for segmental resection: The base of symptomatic diverticula often contains heterotopic tissue or pathology that extends into the adjacent ileum, making simple diverticulectomy inadequate. 1

Incidentally Discovered Meckel's Diverticulum: Selective Approach

The management of asymptomatic Meckel's diverticula found incidentally during surgery for other indications is more nuanced and depends on patient age, sex, and technical feasibility.

Evidence Against Routine Prophylactic Removal in Adults

In adults, particularly women, incidental removal of asymptomatic diverticula is not recommended. 8

• In a 10-year adult series, 74.5% of removed diverticula were incidental findings, but only 25.5% were symptomatic 8
• Female patients were significantly less likely to be symptomatic (13% vs 50% in males, p<0.05) 8
• Complications from prophylactic removal included wound infections and anastomotic leaks requiring reoperation (8.5% morbidity) 8
• The lifetime risk of an asymptomatic Meckel's diverticulum becoming symptomatic decreases with age, making prophylactic removal in adults less justified 1

When to Consider Removal of Incidental Diverticula

Remove incidentally found diverticula if they are easily amenable to stapled resection without technical difficulty. 1

• If the diverticulum easily fits in a stapling device, removal is reasonable given the low complication rate of stapling 1
• If the diverticulum is broad-based or short such that stapling cannot be done without difficulty, it should be left undisturbed as it is unlikely to become symptomatic 1

In the pediatric population, removal of incidentally found diverticula is more justified:

• Heterotopic tissue (gastric or pancreatic mucosa) is the main cause of complications and was found in 154 of 286 pediatric patients (54%) 4
• Significant differences in heterotopic tissue were observed between symptomatic and incidentally found groups, but the presence of ectopic tissue cannot be determined without removal 4
• Children have a longer lifetime risk period for developing complications 4

Diagnostic Pitfalls and Key Clinical Pearls

Maintain high suspicion in young patients with unexplained GI bleeding after negative upper endoscopy and colonoscopy. 5, 2

• Meckel's diverticulum is present in approximately 2% of the population but accounts for a disproportionate number of obscure GI bleeding cases in young patients 5
• The Meckel scan has a positive predictive value approaching 100% in anemic patients with GI bleeding 2

Preoperative diagnosis is notoriously difficult:

• Only 6 of 58 pediatric patients (10%) had MD recognized preoperatively despite an average of 2.3-3.2 diagnostic investigations per patient 7
• In adults, exploratory laparoscopy plays a central role when acute abdomen has uncertain diagnosis 3

Age-related presentation patterns:

• Patients under 40 are more likely to present with GI bleeding 3
• Patients over 40 are more likely to present with diverticulitis 3
• This age distribution was statistically significant (p=0.02) in one adult series 3

Postoperative Outcomes

Surgical treatment of Meckel's diverticulum has excellent outcomes when performed for appropriate indications. 4, 7

• In a large pediatric series of 286 patients, only one death occurred (from peritonitis and sepsis), with one anastomotic leak and one adhesive obstruction requiring reoperation 4
• In another pediatric series of 58 patients, only two complications occurred (Clavien-Dindo II and IIIb) 7
• Adult series showed similar low complication rates when surgery was performed for symptomatic disease 3, 8