Management of Meckel's Diverticulitis
Symptomatic Meckel's diverticulitis requires surgical resection, specifically segmental ileal resection including the diverticulum, as the definitive treatment. 1, 2
Immediate Assessment and Diagnosis
When Meckel's diverticulitis is suspected, obtain CT imaging with IV contrast to confirm the diagnosis, though recognize that definitive diagnosis is typically made intraoperatively. 3, 4 The clinical presentation mimics other acute abdominal conditions—look specifically for:
- Acute abdominal pain with peritoneal signs 4
- Leukocytosis with neutrophilia 4
- CT findings showing inflammation at the antimesenteric border of the distal ileum 3
The diagnosis is challenging because Meckel's diverticulitis often masquerades as appendicitis or other causes of acute abdomen, making a high index of suspicion critical. 5
Surgical Management Algorithm
For Symptomatic/Complicated Meckel's Diverticulitis:
Perform segmental ileal resection that includes the diverticulum and a margin of normal bowel. 1, 2 This is non-negotiable for:
- Active diverticulitis with inflammation or perforation 4, 5
- Gastrointestinal bleeding 1, 5
- Intestinal obstruction 1, 5
Use stapling devices for the resection when feasible, as they offer ease of use and low complication rates. 2 Simple diverticulectomy alone is inadequate because the base often contains heterotopic tissue. 2
For Incidentally Discovered Meckel's Diverticulum:
The decision tree depends on age and anatomical features:
In patients younger than 40 years: Remove all incidentally discovered Meckel's diverticula. 1 The lifetime risk of complications (4.2%) and declining risk with age justifies prophylactic resection in younger patients. 1
In patients 40 years and older: Resection is selective, reserved for diverticula with: 1
- Palpable heterotopic tissue (ectopic gastric or pancreatic mucosa)
- Significant length (>2 cm)
- Presence of omphalomesenteric or omphalomesenteric bands
If the diverticulum is broad-based or very short and cannot be easily stapled, leave it undisturbed—it is unlikely to become symptomatic. 2
Perioperative Antibiotic Management
For complicated Meckel's diverticulitis with perforation or peritonitis, follow the same principles as other intra-abdominal infections:
- Initiate broad-spectrum antibiotics with gram-negative and anaerobic coverage immediately 6
- Continue for 4 days in immunocompetent patients if adequate source control is achieved 7
- Extend to 7 days in immunocompromised or critically ill patients 7
Critical Pitfalls to Avoid
Do not attempt simple diverticulectomy for inflamed or perforated Meckel's diverticulum—always perform segmental resection. 2 The base is often indurated and contains heterotopic mucosa that predisposes to complications.
Do not dismiss Meckel's diverticulitis in adults over 40. While risk decreases with age and approaches zero after 70, adults most commonly present with diverticulitis or obstruction rather than bleeding. 1
Recognize that morbidity for symptomatic Meckel's resection (11-18%) significantly exceeds that of incidental resection (1-9%), reinforcing the value of prophylactic removal in appropriate candidates. 1
Special Populations
In immunocompromised patients presenting with suspected Meckel's diverticulitis, maintain a lower threshold for imaging and surgical consultation, as these patients may present with milder symptoms despite severe disease. 6 Extend antibiotic duration to 10-14 days in this population. 6