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In this section we will feature outstanding photographs of clinical materials. These will be selected for their educational value, message, or possibly rarity. The images will be accompanied by brief case reports (limit 2 typed pages, 3 references). Our readers are invited to submit items for consideration.
Most sources of gastrointestinal blood loss can be diagnosed with upper or lower intestinal endoscopy, but 5% of gastrointestinal bleeding episodes are occult and caused by a variety of lesions within the jejunum or ileum. We present a rare case of chronic, gastrointestinal bleeding caused by an inverted Meckel's diverticulum.
Case report
A 60-year-old man came to his physician with fatigue, weakness, and dyspnea on exertion. He had a 3-year history of chronic gastrointestinal bleeding and a hematocrit of 17% at the time of initial evaluation. He received 4 units of packed red blood cells, and his hematocrit increased to 32%. Esophagogastroduodenoscopy and colonoscopy were unrevealing. On referral to our clinic, the patient's hematocrit had fallen 7% despite oral iron therapy. Physical examination was unremarkable. Enteroclysis demonstrated a 6-cm tubular filling defect in the distal ileum consistent with an inverted Meckel's diverticulum (Fig 1).
Fig. 1Enteroclysis radiograph demonstrating a 6-cm tubular filling defect in the terminal ileum.
At celiotomy, a punctate lesion overlying an intraluminal mass was identified in the terminal ileum. Probe placement into the mural invagination confirmed the preoperative suspicion of an inverted Meckel's diverticulum. Six centimeters of small bowel were resected, and intestinal continuity restored. Inspection of the specimen demonstrated a 4.5-cm inverted diverticulum with apical ulceration (Fig 2).
Fig. 2Intraoperative photographs showing the opened specimen with an inverted (A) Meckel's diverticulum which was everted (B).
Recovery was unremarkable, and his hematocrit has been stable. Histologic examination of the diverticulum showed normal small bowel mucosa without ectopic tissue.
Discussion
Symptomatic presentation of Meckel's diverticula occurs in 4% to 30% of patients, generally by 2 years of age. When symptomatic, adult presentation is hematochezia, small bowel obstruction (including intussusception), diverticulitis, or perforation. Chronic bleeding from a Meckel's diverticulum is uncommon.
The mechanisms of bleeding from a Meckel's diverticulum are multiple. First, the diverticulum may contain heterotopic gastric tissue with acid production and subsequent ulceration of the adjacent ileum. Second, repeated intussusception may cause trauma that produces chronic inflammation with mucosal erosion and bleeding. Additionally, an inverted Meckel's diverticulum may have mucosal irritation with chronic blood loss from repeated intraluminal mechanical trauma. Irrespective of the mechanism of bleeding, the treatment for bleeding Meckel's diverticula is segmental resection; diverticulectomy alone removes only the source of ulceration (when ectopic gastric mucosa is present) and not the source of bleeding.
An inverted Meckel's diverticulum is distinctly uncommon. The radiologic features of inverted Meckel's diverticulum on an intestinal contrast series include an oblong filling defect with smooth margins. The mass is often mobile, pedunculated, and may serve as a lead point for an intussusception. Enteroclysis may be the intestinal contrast procedure of choice because it causes more luminal distension and is more sensitive than a small bowel follow through.
References
Boldero BM
Inverted Meckel's diverticulum as a cause of anaemia and continuing blood loss.
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