Case Presentation CC vomiting abdominal pain PI 49

Case Presentation CC: vomiting, abdominal pain PI: 49 y/o man who 36 hours prior to admission had the onset RUQ abdominal pain. Pain worsened, went to ER 4 hours later. CBC, SMA, LFT’s, amylase, lipase all normal. Abdominal sono normal. Some relief after GI cocktail, discharged.

Case Presentation Night prior to admission, pain recurred associated with vomiting. Next am, ER- repeat testing normal, discharged. Admitted PHD due to continuing pain and vomiting. No hematemesis or blood in stool, fever, diarrhea or constipation. No prior history of similar symptoms.

Case Presentation PMHx- no prior abdominal surgery, only history of GI problems is occasional GERD. History of seizure disorder and mild depression. Meds- Tegretol, Celexa, ASA 81 mg, Pepcid prn ETOH- avg 1 drink/ day

Case Presentation PE- 120/72, HR 66, T 98. 4 Normal exam except abdomen tender, voluntary guarding RUQ and periumbilical. No rebound. No hepatosplenomegaly, mass. BS’s reduced. Labs- normal abd. sono, LFT’s, amylase, lipase. Normal lytes. Bun/Cr= 11/1. 2. WBC 7. 2 K, Hgb 14. 6 Normal HIDA scan. Obstructive series- multiple air/ fluid levels seen throughout the small bowel consistent with partial small bowel obstruction

Case Presentation Working diagnosis: distal small bowel obstruction of uncertain etiology Initial course- NG tube placed, IV fluids, IV PPI. CT scan- distended small bowel consistent with distal partial small bowel obstruction. Appendix and colon normal. Surgery consult obtained.

Causes of Intestinal Obstruction 1. Intrinsic Bowel Lesions A. Congenital- atresia / stenosis, malrotation, duplications/cysts B. Inflammatory Diverticulitis, TB, actinomycosis Crohn’s disease Ischemia Radiation injury Chemical (e. g. , potassium chloride) Endometriosis Postanastomotic C. Intussusception D. Obturation Polypoid neoplasms Gallstones Foreign bodies Bezoars Feces E. Neoplastic stricture II. Extrinsic Bowel Lesions A. Congenital bands B. Adhesions (usually postoperative) C. Hernias (inguinal, femoral, ventral, umbilical, diaphragmatic) D. Volvulus/ torsion E. Carcinomatosis, extraintestinal neoplasm F. Intra-abdominal abscess

Case Presentation Next day- no improvement in x-ray findings, patient taken to surgery. Surgical findings: dilated prox sm. bowel with bruising and torsion of the small bowel due to a Meckel’s diverticulum as the lead point for the torsion. The Meckel’s diverticulum was resected.

Meckel’s Diverticulum Phillip M Aronoff, M. D.

Meckel’s Diverticulum • Most common congenital abnormality of the gastrointestinal tract • Remnant of the vitelline duct • antimesenteric border of the ileum • Often contain heterotropic tissue- gastric, occasionally pancreatic • Vast majority of Meckel’s diverticuli are clinically silent

Meckel’s Diverticulum Rule of 2’s • 2% of the population have one • 1/2 of symptomatic lesions usually present before the age of 2 years old, others most commonly in the first 2 decades of life • Diveriticuli in adult patients only become symptomatic in about 2% • 2 times more common in males than females • Usually found within 2 feet of the ileocecal valve • Usually are about 2 inches in length • 1/2 contain heterotrophic mucosa (usually gastric, occasionally pancreatic)

Meckel’s Diverticulum Clinical presentation Lower GI bleeding due to ulceration by heterotopic gastric mucosa Intestinal obstruction due to internal segmental volvulus or intussusception Local inflammation with or without perforation resembling appendicitis due to diverticulitis Rare presentations: Neoplasms

Meckel’s Diverticulum Lower GI bleeding due to ulceration by heterotrophic gastric mucosa • • • 25 -50% of symptomatic presentations Usually painless Episodic Hematochezia (usually maroon but may be tarry or bright red) Not infrequently massive bleeding- occult bleeding is rare Most common cause of small intestinal hemorrhage in patients under 30 y/o • Meckel’s scan is often positive patients

Meckel’s Diverticulum Intestinal obstruction due to internal segmental volvulus or intussusception • 20 -30% of symptomatic presentations • More common in older patients • Diverticulum acts as a lead point causing entero-entero or entero-colonic intussusception which often cannot be reduced hydrostatically. This may present with “currant jelly” like stool and a palpable mass may be present • If volvulus can be reduced hydrostatically, the patient should still have a surgical resection. • If diverticulum is connected to umbilicus by fibrous cord, this may act as a focal point for internal herniation of the small bowel or secondary volvulus. • Volvulus is acute and may result in strangulation of the bowel if not treated

Meckel’s Diverticulum Local inflammation with or without perforation due to Meckel’s diverticulitis • 10 -20% of symptomatic presentations • Usually adult patients • Usually due to ectopic acid producing gastric mucosa causing significant ulceration and possible perforation. This may occasionally be related to H. Pylori infection of the mucosa. • Rarely caused by perforation due to a foreign body in the diverticulum. • Usually these patients are thought to have appendicitis prior to surgery

Meckel’s Diverticulum Rare Presentations- neoplasms arising in the diverticulum • Benign- (most common) Leiomyomas Angiomas Lipomas • Malignant. Adenocarcinoma- usually from the gastric mucosa Sarcoma Carcinoid tumor

Meckel’s Diverticulum Diagnostic studies • Difficult diagnosis • Most accurate test, especially in children, is “Meckel’s scan”sodium 99 -Tc-pertechinetate, taken up by gastric mucosa (sensitivity 85%, specificity 95%, accuracy 90% in pediatric patients) • Less accurate in adults due to reduced prevalence of ectopic gastric mucosa in the diverticulum causing false negatives. Accuracy improved by giving pentagastrin (increases metabolism of mucus producing cells), glucagon or H 2 blockers (reduce peristalsis and secretions that may flush out the radionuclide) • In adults with a negative scan, abdominal CT scan is often helpful in cases of obstruction by showing a site of high grade partial bowel obstruction in the distal ileum. • If CT is negative barium studies should be performed which may show the diverticulum (do not do prior to Meckel’s scan as barium may interfere) • If bleeding with a negative scan, angiography may be helpful

Meckel’s Diverticulum Treatment • If symptomatic, prompt surgical intervention to resect the diverticulum or segment of ileum containing the diverticulum. If bleeding, the source of bleed is often in the segment of ileum adjacent to the diverticulum. • If not symptomatic and found incidentally at surgery in children under 2 y/o, resection is recommended. In asymptomatic adults, resection is controversial since only about 2% of these patient’s will become symptomatic and there is about a 2% incidence of short or long term complications (stenosis, adhesions) after prophylactic resection.

Meckel’s Diverticulum Phillip M Aronoff, M. D.