1. Meckel’s diverticulum presenting as small bowel obstruction 振興醫院小兒科 Dr. 程美美

5. Clinical Course At ward At ward NG: coffee-ground with bile contain (160ml) NG: coffee-ground with bile contain (160ml) Low urine output with dropping BP: 86/42 despite NS challenge Low urine output with dropping BP: 86/42 despite NS challenge Use three combined antibiotics (Ampicillin, GM, Metronidazole) Use three combined antibiotics (Ampicillin, GM, Metronidazole) Follow Abdominal echo: persistent bowel distension, bowel wall thickening, no target sign, increase ascites amount Follow Abdominal echo: persistent bowel distension, bowel wall thickening, no target sign, increase ascites amount Consult Pediatric surgeon: suggest operation Consult Pediatric surgeon: suggest operation Sent to OR 12 hours later Sent to OR 12 hours later

6. OP Findings and pathological report Dilated distal half of small bowel Dilated distal half of small bowel Meckel’s diverticulum ( 5 x 3 x 1 cm ) which was 30cm away from ileocecal valve with fecal obstruction 5cm in length Meckel’s diverticulum ( 5 x 3 x 1 cm ) which was 30cm away from ileocecal valve with fecal obstruction 5cm in length Resection 15cm of ileum, Clear ascites: ±100ml Resection 15cm of ileum, Clear ascites: ±100ml 1. Diverticulum lined by small intestine mucosa with focal lymphocyte infiltration. 2. The muscular wall of diverticulum is thin. 3. No ectopic gastric or pancreatic tissue 4. Surrounding ileal mucosa is unremarkable

9. Discussion Intestinal obstruction Intestinal obstruction Meckel’s diverticulum

10. Cause of gastrointestinal obstruction–small intestine Nelson 17th Congenital Congenital 1. Duodenal atresia 2. Annular pancreas 3. Malrotation / volvulus 4. Malrotation / Ladd bands 5. Ileal atresia 6. Meconium ileus 7. Meckel’s diverticulum with volvulus or intussusception 8. Inguinal hernia 9. Intestinal duplication

11. Cause of gastrointestinal obstruction–small intestine Nelson 17th Acquired Acquired 1. Postsurgical adhesions 2. Crohn’s disease 3. Intussusception 4. Distal ileal obstruction syndrome ( cystic fibrosis ) 5. Duodenal hematoma 6. Superior mesenteric artery syndrome

12. Differentiation between simple and strangulating obstruction Signs of shock, acidosis, and peritonitis, and abdominal wall often doughy and erythematous Signs of shock, acidosis, and peritonitis, and abdominal wall often doughy and erythematous Fever, feculent vomiting, absent bowel sound, localized abdominal tenderness, and leukocytosis Fever, feculent vomiting, absent bowel sound, localized abdominal tenderness, and leukocytosis

13. Meckel’s diverticulum

15. Lifetime complication around 4 % including perforation, obstruction, inflammation, hemorrhage, herniation, neoplasm, umbilical fistula, ulceration Lifetime complication around 4 % including perforation, obstruction, inflammation, hemorrhage, herniation, neoplasm, umbilical fistula, ulceration Half of them occur before 2 years old Half of them occur before 2 years old Longer ( 4 cm ), broad base ( 2 cm ) Longer ( 4 cm ), broad base ( 2 cm )

16. Obstruction in Meckel’s diverticulum Meckel’s diverticulum may be associated with partial or complete bowel obstruction. Meckel’s diverticulum may be associated with partial or complete bowel obstruction. 1. Act as a lead point of an intussusception ( more common in older male children ) 2. Intraperitoneal bands connecting residual omphalomesenteric duct remnants to the ileum and umbilicus Nelson 17th edition Nelson 17th edition

17. Meckel’s diverticulum causing intestinal obstruction The American journal of gastroenterology December 2001 31 y/o man with recurrent vomiting and abdominal pain 31 y/o man with recurrent vomiting and abdominal pain The apex of the Meckel’s diverticulum adhesion to the mesentery, making an obstructing fold in the adjacent small bowel The apex of the Meckel’s diverticulum adhesion to the mesentery, making an obstructing fold in the adjacent small bowel Bowel loops proximal to the obstruction were dilated, adhesive band was lysed, unfolding the bowel and diverticulectomy was performed Bowel loops proximal to the obstruction were dilated, adhesive band was lysed, unfolding the bowel and diverticulectomy was performed

18. 10 different ways for Meckel’s diverticulum can cause bowel obstruction 1. Intussusception 2. Fibrous band persisting between the MD and the umbilicus causing a volvulus 3. Internal hernia caused by a loop of bowel trapped between the mesentery and the mesodiverticular band, mechanically compress the ileum 4. Litter’s hernia where MD obstructed in an external hernia 5. MD causing inflammatory reaction and adhesion with surrounding bowel cause obstruction

19. 10 different ways for Meckel’s diverticulum can cause bowel obstruction 6. Obstruction of the neck of MD enlargement and compress the bowel lumen 7. Obstruction by a large enterolith in the MD 8. Torsion of MD on its own axis 9. Extrusion of the ileum through a persistent omphalomesenteric duct out of the abdomen 10. True knot involving MD and another hollow viscus

20. Thank you for attention