Clinical use and toxicity of intravenous lidocaine. A report from the Boston Collaborative Drug Surveillance Program

To determine the natural history of Meckel's diverticulum, 202 case records of proved disease of Meckel's diverticulum were retrieved, covering a fifteen year period, from all the hospitals of King County, Washington (population, 1,143,800). Using the figure of 2 per cent incidence of Meckel's diverticulum, we calculated that a Meckel's diverticulum has a 4.2 per cent likelihood of causing disease during a lifetime, decreasing to zero with old age. Using previously published mortality and morbidity figures, we calculated that to save one patient's life from the complications of Meckel's diverticulum, it would be necessary to remove approximately 800 asymptomatic Meckel's diverticula. This would be likely to incur a significant amount of postoperative morbidity from postoperative intestinal obstruction and infection. We suggest that the prophylactic removal of Meckel's diverticulum is rarely, if ever, justified.     

Unusual disclosure of giant Meckel's diverticulum

At discovery of diabetes mellitus, complementary explorations revealed a superinfection of a giant Meckel's diverticulum. We present this clinical situation in one case and suggest possible nosologies. The epidemiology and clinical approach to Meckel's diverticulum are discussed.     

Laparoscopy as a cause of a false-positive Meckel's scan

A new cause of a false-positive result of a Meckel's scan is reported. An 11-year-old girl had a 3-week history of constant right lower quadrant pain that was initially managed by laparoscopic appendectomy. A repeated laparoscopy for persistent pain was nondiagnostic. A missed Meckel's diverticulum was considered as the cause of this pain, which prompted a Meckel scan. This scan revealed a periumbilical focus of activity that was interpreted as a Meckel's diverticulum attached to the anterior abdominal wall by a band. The laparotomy showed no Meckel's diverticulum. The false-positive result of the Meckel scan may be the result of inflammation from the periumbilical laparoscopic port site.     

Evaluation of a smoking cessation program implemented in the workplace

BACKGROUND: Acute abdominal pain due to complicated Meckel's diverticulum is an unusual event. Even the presence of biliary enterolithiasis at the onset of inflamed congenital diverticulum has rarely been reported previously. RESULTS: Despite this unusual presentation, an episode of gallstone passage through the biliary tract has not yet been described. CONCLUSIONS: Whether the stones were primarily formed in the diverticulum as enterolithiasis, or secondary to gallstone passage is discussed. The complications of Meckel's diverticulum requiring surgical treatment are reviewed, focusing on the unusual finding of biliary stones in Meckel's diverticulum and the etiogenic mechanism of enterolithiasis.     

Laparoscopic diagnosis and excision of Meckel's diverticulum

Meckel's diverticulum is one of the primary concerns in the differential diagnosis of the pediatric patient with massive, acute gastrointestinal bleeding, intussusception, or abdominal pain of uncertain cause. The hospital course of two children with Meckel's diverticulum, successfully treated by laparoscopic excision, is presented, along with details of the operative procedure. Both patients recovered from the procedure without incident and were discharged at 24 and 48 hours after surgery. The authors believe a laparoscopic approach is safe and effective in the diagnosis and treatment of Meckel's diverticulum.     

Meckel's diverticulum in adults. A 3-decade experience

OBJECTIVE: To review the prevalence, clinic manifestations and characteristics of the adult Meckel's diverticulum in the Hospital Espa?ol de México. BACKGROUND: The Meckel's diverticulum is the most frequent congenital malformation of the gastrointestinal tract. However, only in seldom occasions produces manifestations in adults. METHODS: Retrospective review of 31 years. RESULTS: Meckel's diverticulum was found in only 13 cases. The most common clinical manifestation was pain in the right lower abdominal quadrant; there was not a single case of bleeding. A correct pre surgical diagnosis was done in only one patients. Post surgical course was satisfactory in all patients. CONCLUSION: In adults, the Meckel's diverticulum complications are uncommon, being the most frequent clinical manifestation the pain in the right lower abdominal quadrant and intestinal obstruction.     

Intestinal obstruction due to Meckel's diverticulum. Description of three cases

Among 588 small bowel mechanical obstructions operated since January 1982 until December 1996 at the Flajani Surgery Department and Emergency Department of the San Camillo Hospital in Rome, 3 male patients were operated for intestinal obstruction due to Meckel's diverticulum. In one case, obstruction was caused by a small bowel volvulus rolling on a Meckel's diverticulum, whose gangrenous extremity was "blocked" on caecum. In the other two cases, intestinal loops were incarcerated into an internal hernial ring constituted by the same diverticulum whose inflamed extremity was fixed to corresponding mesentery. We examined embryologic and clinical aspects of the pathology here considered, particularly its complications, obstruction being the most common in adult age. Diagnosis is often misunderstood, since a complicated Meckel's diverticulum simulates many other abdominal pathologies. A straight radiography and an ultrasonography of the abdomen may be useful to reach the correct diagnosis. We performed diverticulectomy, using a linear stapler and we underline the opportunity of this method. In young age laparoscopy resection is considered the gold treatment of this pathology by some authors. We didn't observe any mortality, although one of our patients was in a severe septic condition. It is necessary to examine the last ileal 100 centimetres when a suspected acute appendicitis is not initially found by operation. The opportunity of a promptly performed operation is underlined to prevent that such a benign pathology may induce also exitus.     

Massive gastrointestinal bleeding from Meckel''s diverticulum in a 91-year-old man

Although Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal (GI) tract, complications in adults are rare, especially in the elderly. Intestinal obstruction is the most common complication in the adult, and inflammation mimicking acute appendicitis may also occur. Lower GI bleeding as a result of Meckel's diverticulum with ectopic gastric mucosa is distinctly unusual among the elderly, with most previous case reports involving patients under the age of 40. The case we report involved a 91-year-old man with massive lower GI hemorrhage found to be due to a Meckel's diverticulum with ectopic gastric mucosa.     

Meckel's diverticulum. Internal hernia and adhesions without gastrointestinal bleeding--ultrasound and scintigraphic findings

The results from an ultrasound study performed on an 11-year-old boy, who had several weeks of intermittent abdominal pain, showed a nonperistaltic loop of bowel near the umbilicus, which suggested either an internal hernia or a diverticulum. Tc-99m pertechnetate imaging showed a focal collection near the umbilicus, which was consistent with a Meckel's diverticulum. No evidence was found of gastrointestinal bleeding. Exploratory laparotomy showed a Meckel's diverticulum near the terminal ileum and attached to the anterior abdominal wall close to the umbilicus. Small bowel had herniated through the loop formed by the terminal ileum and the diverticulum.     

Meckel's diverticulum in childhood. The authors' own experience

Meckel's diverticulum occurs in approximately 2 percent of the population and may present at any age. Although Meckel's diverticulum may produce an intestinal obstruction or perforation, simulating an appendicitis, hemorrhage is its most important clinical presentation. From 1989 to 1994, Meckel's diverticulum was discovered in ten children at laparotomy. Three cases were asymptomatic, representing an incidental finding at laparotomy. Of the seven symptomatic patients, four presented with bowel obstruction (intussusception), three had rectal bleeding one of whom had diverticulitis. Contrast studies--in gastrointestinal hemorrhage--were not helpful in establishing the diagnosis; colonoscopy and gastroscopy ruled out other causes of bleeding. Five of seven symptomatic patients had an intestinal resection while two a diverticulectomy after assessment that the ulcer did not require resection. No postoperative morbidity and mortality is reported in either groups. A Meckel's diverticulum found incidentally at laparotomy should be always resected as the risk of complication is high and that of resection low.     

Acute Meckel's diverticulum in a senior patient

Meckel's diverticulum is the most common congenital abnormality of the intestinal tract, occurring in 2% of autoptic studies. The case of an 85-year-old man referred to the Emergency Surgery Unit for intestinal obstruction and lower gastrointestinal tract bleeding is reported. Surgical exploration revealed a complicated Meckel's diverticulum full of coproliths, immersed in pus and blood. Examination of the resected diverticulum showed necrotic diverticulitis in the absence of ectopic gastric or pancreatic tissues.     

Bronchogastric fistula, pulmonary sequestration, malrotation of the intestine, and Meckel's diverticulum--a new association

Two female children, each who had a bronchogastric fistula and pulmonary sequestration (communicating bronchopulmonary foregut malformation, CBPFM) and associated malrotation of the intestine and Meckel's diverticulum are presented. Each child also presented with severe gastroesophageal reflux. The association of malrotation of the intestine and Meckel's diverticulum with a CBPFM never has been reported as a distinct entity. The concept of association of anomalies is discussed briefly.     

Meckel''s diverticulum presenting as gastric outlet obstruction: case report

We report a case of gastric outlet obstruction simulating gastric antral neoplasm resulting from a perforated Meckel's diverticulum. Presentation of this nature has not been previously reported.     

Meckel's diverticulum: angiographic findings in 16 patients

OBJECTIVE: The purpose of this study was to assess the sensitivity of angiography in revealing the vitellointestinal artery or other arteriographic abnormalities in patients in whom surgery subsequently proved Meckel's diverticulum. MATERIALS AND METHODS: From the 36 patients who had undergone a Meckel's diverticulectomy between 1980 and 1997 at Hammersmith Hospital or a referring hospital, we selected 18 who had undergone preoperative angiography at our institution. Case notes and angiograms of these 18 patients were reviewed for the presence of a persistent vitellointestinal artery or other angiographic evidence of a Meckel's diverticulum. RESULTS: Angiograms of 16 of 18 patients were available for review. A striking male preponderance existed (male:female = 13:3). Mean age was 28 years (range, 12-65 years). In 11 (69%) of the 16 patients, a persistent vitellointestinal artery was seen that had been noted at the time of the study and reported before surgery for nine patients. Other angiographic abnormalities at the site of the Meckel's diverticulum were present in four patients and included a vascular blush, early venous return, and arterial irregularity. CONCLUSION: Angiography will show a persistent vitellointestinal artery in most individuals with a Meckel's diverticulum who present with chronic gastrointestinal bleeding. However, the recognition of a persistent vitellointestinal artery may be difficult because of overlying vessels, and superselective catheterization of distal ileal arteries may be necessary.     

The role of the mts1 gene in the metastatic process

The operation notes and pathology records of 294 consecutive patients who had right hemicolectomy for Crohn's disease were reviewed. A Meckel's diverticulum was found in 17 (5.8%) of these patients, 2-3 times the expected rate in the general population. At least 50% of diverticula in the normal population contain heterotopic mucosa, but none was found in those diverticula that were examined from this group. The increased prevalence of Meckel's diverticulum in patients with Crohn's disease confirms previous anecdotal reports, but the cause for the increased frequency remains unexplained. The significance of this finding is discussed.     

Perforated leiomyosarcoma of Meckel's diverticulum

Two cases of perforated leiomyosarcoma of Meckel's diverticulum are presented. There are only 59 cases reported in current literature, including 4 perforations. Although the condition is rare, leiomyosarcoma is the commonest tumour of Meckel's diverticulum. Its clinical presentation include abdominal pain, intestinal bleeding, abdominal mass, intestinal obstruction and less commonly, acute perforations. Both our cases presented with perforations which is unusual. Despite this late presentations both were resectable and both had no distant or local metastasis. One of our patients was 89 years old at presentation and has been disease-free 3 years after resection. The other patient was 69 years old and has also been disease-free.     

Small bowel causes of per rectum haemorrhage

The majority of cases of per rectal haemorrhage (PRH) are due to colorectal causes within the diagnostic reach of the colonoscope. However a few cases are from the small bowel which may pose difficulty and delay in diagnosis. We reviewed 1489 patients with PRH from 1989 to 1993 and identified 10 cases of bleeding originating from the small bowel (0.7%). These were diagnosed when both the colonoscopy and upper gastrointestinal endoscopy were negative or by observing blood coming through the ileo-caecal valve. The causes were Meckel's diverticulum (4), leiomyoma (1), intussusception (1), lymphoma (1), carcinoma (1), Crohn's disease (1) and vasculitis (1). Six cases presented with active bleeding and haemodynamic instability; 4 had chronic bleeding associated with anaemia. Bleeding from Meckel's diverticulum could be differentiated by age, mid-20s or younger compared with mid-40s or older of non-Meckel's cases. Small bowel causes need to be considered in PR bleeding unexplained on colonoscopy and oesophagogastroduodenoscopy findings. A 99mtechnetium isotope scan is most likely to be of help in the young adult but from mid-life onwards, however, other techniques such as small bowel barium studies are required.     

Meckel''s diverticulum: demonstration of heterotopic gastric mucosa with technetium-99m-pertechnetate SPECT

Demonstration of functioning heterotopic gastric mucosa with 99mTc-pertechnetate SPECT is reported. Abnormal tracer uptake was shown conclusively with SPECT but not with planar imaging. When a Meckel's diverticulum is suspected, we suggest SPECT be performed if the results of planar scintigraphy are equivocal and that it be considered if there is a high clinical suspicion and planar imaging is normal.     

The emerging role of hospitalists--will family physicians continue to practice hospital medicine?

Adult intussusception is rare and is usually caused by a tumor serving as a lead point. Surgery is necessary to treat obstruction and rule out malignancy. However, if a benign cause (lipoma, fibroma, or Meckel's diverticulum) is suspected preoperatively, a minimally invasive surgical approach should be considered. This case illustrates the laparoscopic management of benign small bowel intussusception due to lipoma.     

Heterotopic gastric mucosa in the ileum with perforated ulcer

Heterotopic gastric mucosa (HGM) in the small bowel, other than in the Meckel's diverticulum or other congenitally anomalous bowel, is exceedingly rare. A patient with HGM of the small intestine with perforation of the ileum due to ulceration of the adjacent mucosa is presented. The authors remark the importance of the histological criteria to differentiate between true HGM from metaplastic changes, two entities with different behavior and prognostic implications.