Gastrointestinal bleeding in infants and children: Meckel's diverticulum and intestinal duplication

Coexistence of cecal duplication cyst and Meckel's diverticulum presenting as intestinal obstruction: A case report

INTRODUCTION

Enteric duplication cysts (EDC) are rare anomalies of the gastrointestinal tract, with only 0.4 % occurring in the cecum. Meckel's diverticulum (MD) is a common congenital anomaly affecting up to 2 % of the population. The simultaneous occurrence of these two conditions is rare with no existing guideline on treatment.

CASE PRESENTATION

An 11-month-old boy presented with fever, vomiting, and abdominal distension. A contrast-enhanced computed tomography scan confirmed the diagnosis of an enteric duplication cyst causing intestinal obstruction. The patient underwent exploratory laparotomy, during which a cecal duplication cyst measuring 30 × 20 mm was found along with MD in the distal ileum. Right limited hemicolectomy was performed. Histopathological examination revealed features consistent with an enteric duplication cyst and the presence of gastric mucosal heterotopia.

CLINICAL DISCUSSION

Differentiating EDC from MD is a significant challenge, as both can present with similar symptoms and be positive on a Tc-99 m radionuclide scan. The final diagnosis of EDC and MD can only be made by correlating the imaging findings with the surgical findings and pathological features.

CONCLUSION

Cecal duplication cysts should be considered a differential diagnosis in infants who present with intestinal obstruction. Although their presentation may resemble that of Meckel's diverticulum, both conditions can coexist. Excision of duplication cysts in children is considered a safe and efficient treatment approach.

Meckel diverticulum scintigraphy: technique, findings and diagnostic pitfalls

Meckel diverticulum, the most common congenital anomaly of the gastrointestinal tract, results from the aberrant involution of the omphalomesenteric duct and accounts for more than 50% of unexplained lower gastrointestinal bleeding in the pediatric population. The most accurate imaging tool to identify a Meckel diverticulum containing ectopic gastric mucosa is the Technetium-99m pertechnetate Meckel scan, a scintigraphic study with a reported accuracy of 90% in the pediatric population. In addition to depicting a Meckel diverticulum with ectopic gastric mucosa, careful attention to the normal biodistribution of the radiotracer can lead to the identification of unexpected pathology with implications for patient management. This article serves to review the embryological origin and anatomical features of Meckel diverticulum, highlight the role of scintigraphy in evaluating Meckel diverticulum, and discuss the proper imaging technique when performing this test. We will focus on pitfalls that can lead to an erroneous diagnosis as well as incidental findings that can affect patient management.

[Surgical treatment of a patient with tubular colonic duplication complicated by perforation and peritonitis]

We present successful treatment of a patient with tubular colonic duplication complicated by fecal impaction, perforation and fecal peritonitis. This anomaly is usually detected in children younger 2 years old. In adulthood, this diagnosis is of a precedent-setting nature. If the diagnosis was not confirmed in early childhood, the absence of typical clinical picture, long-term course of disease and difficult interpretation of clinical data complicate subsequent verification of congenital anomaly. Only infectious complications and emergency surgery in adults can make a correct diagnosis.

Gastrointestinal Tract Duplications in Children: A Tertiary Referral Center Experience

Objective:

Methods:

Results:

Conclusions:

The diagnostic and treatment values of double-balloon enteroscopy in children's Meckel's diverticular bleeding

The diagnostic and treatment values and safety of preoperative double-balloon enteroscopy (DBE) for Meckel's diverticula (MD) bleeding in children by retrospective review and analyses.The clinical data were collected and analyzed from 10 cases of children with MD receiving preoperative DBE examination and postoperative pathological confirmation. The diagnostic and treatment values and safety were assessed through the comparison of the DBE results and intra-operative observations and subsequently postoperative pathological results.Total cases are 10, 7 males and 3 females. The male to female ratio is 2.3 to 1. The youngest patient is 3.3 years old and oldest 12.1, the average age is 7.4 ± 3.0. The lowest body weight is 12.6 kg and the average is 32.5 ± 18.9 kg. The hematochezia was the main clinical manifestation in all patients with anemia and moderate to severe anemia were common (9/10, 90%). All patients had and tolerated the DBE procedures via anal route with 100% success rate. There were no observable complications during the examinations and post operations. All patients were diagnosed with MD by DBE. Exploratory laparoscopy and surgical operations were subsequently performed. All surgical samples were confirmed by pathology as bleeding MD. The postoperative follow-ups up to April 2019 (from 3 to 12 months) do not show any bleeding sign. Pathological examinations found ectopic gastric mucosa in 9 patients (90%) and one case had both ectopic gastric mucosa pancreatic tissue (10%). The distance of MD to ileocecal valve was from 60 to 100 cm (average 81.0 ± 16.0 cm) by DBE examinations. Surgery showed similar findings from 30 to 100 cm (average 71.0 ± 18.5) consistently to DBE. There is no statistical significance between 2 methods (Ζ = 1.715, Ρ = .086).DBE examination proves to be a safe method for diagnosing children's MD disease and can reliably determine the bleeding lesions in children's MD, providing valuable guidance for surgical treatment of children's MD bleeding.

Non-variceal gastrointestinal bleed in children: surgical experience with emphasis on management challenges

PURPOSE

This exclusively surgical series on pediatric non-variceal gastrointestinal bleed (NVGIB) defines three levels of bleed site and describes etiology, bleed severity, diagnostic algorithm, and surgical management for each bleed site. Management challenges are detailed.

METHODS

Patients aged ≤ 18 years treated surgically for NVGIB were analysed.

RESULTS

Bleed site (n = 87) was classified as: upper gastrointestinal bleed (UGIB; n = 11); small bowel bleed (SBB: n = 52); and lower GIB (n = 24). Four etiology-based groups were identified: lesions with ectopic gastric mucosa (EGM; n = 33), tumours (n = 23), ulcers (n = 21), and vascular pathology (n = 8). Bleed severity spectrum was: acute severe bleed (n = 12); subacute overt bleed (n = 59); and occult GIB (n = 16). Preoperative diagnosis was obtained in all UGIB and LGIB lesions. Eighty-two percent of surgical SB lesions were diagnosed preoperatively on Tc^99m pertechnetate scan, computed tomography enterography-angiography, and capsule endoscopy; remaining 18% were diagnosed at laparotomy with intra-operative enteroscopy (IOE). Surgical management was tailored to bleed site, severity, and etiology. Indications of IOE and approach to management challenges are detailed.

CONCLUSIONS

The commonest site-specific bleed etiologies were duodenal ulcers for UGIB, EGM lesions for SBB, and tumours for LGIB. SBB presented diagnostic challenge. Diagnostic algorithm was tailored to bleed site, age-specific etiology, bleed severity, and associated abdominal/systemic symptoms. Management challenges were acute severe bleed, occult GIB, SBB, obscure GIB, and rare etiologies. IOE has a useful role in SBB management.

Congenital Segmental Intestinal Dilatation: A 25-Year Review with Long-Term Follow-up at the Medical University of Innsbruck, Austria

Background and Aim  Congenital segmental intestinal dilatation (CSID) is a neonatal condition with unclear etiology and pathogenesis. Typically, the newborn with CSID presents with a limited (circumscribed) bowel dilatation, an abrupt transition between normal and dilated segments, neither intrinsic nor extrinsic perilesional obstruction, and no aganglionosis or neuronal intestinal dysplasia. We aimed to review this disease and the long-term follow-up at the Children's Hospital of the Medical University of Innsbruck, Tyrol, Austria. Study Design  Retrospective 25-year review of medical charts, electronic files, and histopathology of neonates with CSID. Results  We identified four infants (three girls and one boy) with CSID. The affected areas included duodenum, ileum, ascending colon, and sigmoid colon. Noteworthy, all patients presented with a cardiovascular defect, of which two required multiple cardiac surgical interventions. Three out of the four patients recovered completely. To date, the three infants are alive. Conclusion  This is the first report of patients with CSID and cardiovascular defects. The clinical and surgical intervention for CSID also requires a thorough cardiologic evaluation in these patients. CSID remains an enigmatic entity pointing to the need for joint forces in identifying common loci for genetic investigations.

Simple diverticulectomy is adequate for management of bleeding Meckel diverticulum

PURPOSE

It is unclear whether simple diverticulectomy, rather than segmental bowel resection (SBR), is adequate treatment for gastrointestinal bleeding (GIB) secondary to Meckel diverticulum (MD). There is concern that ulcers in the adjacent bowel may continue to bleed if only the diverticulum is removed. This study seeks to determine if diverticulectomy is satisfactory treatment for bleeding MD.

METHODS

A multi-institution, retrospective review was performed for patients with a diagnosis of MD and GIB who underwent simple diverticulectomy or small bowel resection. Exclusion criteria were comorbid surgical conditions and other causes of GIB. The primary outcome was post-operative bleeding during the initial hospitalization. Secondary outcomes were bleeding after discharge, transfusion or additional procedure requirement, re-admission, and overall complications.

RESULTS

There were 59 patients who met study criteria (42 diverticulectomy, 17 SBR). One patient in the SBR group had early post-operative bleeding (p = 0.288). There was one re-admission (p = 0.288) and three total complications in the SBR group (p = 0.021). There were no cases of bleeding or other complications in the diverticulectomy group.

CONCLUSION

This study suggests that simple diverticulectomy is adequate for treatment of GIB caused by MD. Furthermore, diverticulectomy appears to have a lower overall complication rate.

Small intestinal diverticulum with bleeding: Case report and literature review

RATIONALE

Small intestinal diverticulum with bleeding is an important reason for obscure gastrointestinal bleeding (OGB) , in addition to tumor and vascular diseases. Small intestinal diverticulum with bleeding is difficult to detect by barium meal and angiographic methods and has been regarded as an important cause of obscure gastrointestinal tract bleeding in adolescents. Because of its complicated etiology and non-specific clinical manifestations, it is relatively difficult to detect small intestinal diverticulum with bleeding, especially in patients with a large amount of bleeding and hemodynamic instability.

PATIENT CONCERNS

This retrospective study collects clinical statistics of 19 patients admitted to our hospital from January 2010 to December 2016. Patients who had small intestinal diverticulum patients with bleeding were included in this study. Patients who were taking anticoagulants were excluded DIAGNOSES:: Small intestinal diverticulum patients with bleeding.

INTERVENTIONS

This retrospective study describes the clinical features of patients with small intestinal diverticulum whose main symptom was gastrointestinal bleeding and analyze the literature on this topic, with particular reference to the clinical characteristics, pathological features, and choice of examination methods.

LESSONS

Small intestinal diverticulum with bleeding is a common cause of obscure gastrointestinal bleeding, but it is difficult to detect using normal examination methods. For patients with repeated gastrointestinal bleeding and no positive results found on gastroscopy and colonoscopy, endoscopy of the small intestine and CTE with contrast can be considered as a diagnostic modality.

Etiology of gastrointestinal bleeding in children referred to pediatric wards of Mashhad hospitals, Iran

Background

Gastrointestinal (GI) bleeding, which has several clinical manifestation and origins, is known as one of the most life-threatening events in children. Several etiologies have been suggested for GI bleeding.

Objective

To determine the most important causes of GI bleeding in children referred to Ghaem Hospital and Dr. Sheikh Hospital, Mashhad, Iran.

Methods

In this cross-sectional study, after obtaining written informed consent of their parents, 113 patients aging from newborn infants to 18-year-old children with GI bleeding admitted to Ghaem Hospital and Dr. Sheikh hospital were enrolled in this study from June 2012 to June 2014. After performing routine diagnostic and therapeutic procedures, a checklist containing all necessary information including demographic data, clinical history of patients, endoscopy and pathology findings, clinical and preclinical information were collected. The data were then analyzed using Statistical Package for the Social Sciences (SPSS) version 16.

Results

Of a total 113 study children, 61 (54%) were male and 52 (46%) were female. The results of this study showed that the most important causes of bleeding in upper GI among all admitted patients were prolapse gastropathy (18.6%), esophagitis (15.9%) and esophageal varices, gastritis, and coagulopathy (7.1% for each). The main causes of lower GI bleeding were polyp (32.5%), chronic nonspecific colitis (20.7%), and proctitis (18.2%).

Conclusion

Findings of this study indicated that prolapse gastropathy and esophagitis are more prevalent causes of upper GI bleeding. Furthermore, esophageal varices were more common in children older than 13 years. Polyp, chronic nonspecific colitis and proctitis are the most prevalent causes of lower GI bleeding.

Use of diagnostic imaging in the evaluation of gastrointestinal tract duplications

Background

Gastrointestinal tract duplication is a rare malformation associated with the presence of additional segment of the fetal gut. The aim of this study was to retrospectively review clinical features and imaging findings in intraoperatively confirmed cases of gastrointestinal tract duplication in children.

Material/Methods

The analysis included own material from the years 2002–2012. The analyzed group included 14 children, among them 8 boys and 6 girls. The youngest patient was diagnosed at the age of three weeks, and the oldest at 12 years of age.

Results

The duplication cysts were identified in the esophagus (n=2), stomach (n=5), duodenum (n=1), terminal ileum (n=5), and rectum (n=1). In four cases, the duplication coexisted with other anomalies, such as patent urachus, Meckel’s diverticulum, mesenteric cyst, and accessory pancreas. Clinical manifestation of gastrointestinal duplication cysts was variable, and some of them were detected accidently. Thin- or thick-walled cystic structures adjacent to the wall of neighboring gastrointestinal segment were documented on diagnostic imaging.

Conclusions

Ultrasound and computed tomography are the methods of choice in the evaluation of gastrointestinal duplication cysts. Apart from the diagnosis of the duplication cyst, an important issue is the detection of concomitant developmental pathologies, including pancreatic heterotopy.

Antenatal ultrasonographic features associated with segmental small bowel dilatation: an unusual neonatal condition mimicking congenital small bowel obstruction

Segmental dilatation of the intestine (SDI) is an unusual condition presenting during the neonatal period, with symptoms of obstruction. Late diagnosed cases are also reported. The clinical polymorphism, and the lack of specificity of radiological investigations, make diagnosis difficult. Prenatal detection of abdominal cystic lesions or bowel dilatation has occasionally been reported to be associated with SDI. We herein report two cases of SDI, with a prenatal ultrasonographic suspicion of intestinal abnormality. In both infants, a dilatation of the ileum was found at surgery, without any evident site of obstruction or abnormal histology. SDI must be taken into consideration when a prenatal alert of possible bowel obstruction is not followed by postnatal clinical signs.

Disturbed balance between SOX2 and CDX2 in human vitelline duct anomalies and intestinal duplications

Congenital gastric-type heteroplasia is common in intestinal duplications and anomalies, which originate from incomplete resorption of the omphalomesenteric duct during development. Two transcription factors determine the proximodistal specification of the gastrointestinal tract, SOX2, expressed exclusively in the proximal part of the primitive gut, and CDX2, expressed solely in the distal part. Aberrant expression of these factors may result in abnormal development and congenital abnormalities. Therefore, we analyzed the expression of SOX2 and CDX2 in a number of pediatric intestinal anomalies. We investigated the expression pattern of SOX2 and CDX2 in three congenital intestinal anomalies in which ectopic gastric tissue may be present, Meckel's diverticulum (N = 8), persistent ductus omphalomesentericus (N = 14), and intestinal duplications (N = 8). CDX2, but not SOX2, was detected in intestinal epithelial cells in tissue lacking gastric heteroplasia. In gastric-type heteroplasia, a reciprocal expression pattern existed between SOX2 and CDX2 in the gastric and intestinal tissues, respectively. Interestingly, patches of CDX2-positive cells were present within the gastric mucosa in a subset of Meckel's diverticula and intestinal duplications, suggesting that it is not the absence of CDX2, but rather the ectopic expression of SOX2 that leads to gastric tissue in the prospective intestinal tissue. This is in concordance with our previous mouse studies. Collectively, our data indicate that a fine balance between SOX2 and CDX2 expression in the gastrointestinal tract is essential for proper development and that ectopic expression of SOX2 may lead to malformations of the gut.

Duodenal duplication cyst in a 52-year-old man: A challenging diagnosis and management

INTRODUCTION

Duodenal duplication is a rare congenital malformation. Although more frequent in childhood, it may rarely be observed in adulthood. Pre-operative diagnosis can be difficult.

PRESENTATION OF CASE

We report the case of a 52-year-old man with a duodenal duplication cyst, who was misdiagnosed even after a primary surgery. Definitive treatment needed an extensive diagnostic workup and a second delicate operation.

DISCUSSION

This article discusses the incidence of duodenal duplications, their types, their clinical presentations, the radiologic and diagnostic features along with different therapeutic options.

CONCLUSION

Duodenal duplication should always be one of the differential diagnoses proposed when approaching upper abdominal cystic formations.

Perforated Meckel's diverticulum presenting with combined bowel and urinary obstruction and mimicking Crohn's disease: a case report

INTRODUCTION

Meckel's diverticulum is a common congenital anomaly of the gastrointestinal tract, but is an uncommon cause of serious complications in adults. Although cases of patients with hemorrhage, bowel obstruction or perforation associated with Meckel's diverticulum have been reported, there have been no prior reports of patients with combined urinary and bowel obstruction due to abscess formation.

CASE PRESENTATION

We describe the case of a 21-year-old man with a history of recurrent papillary thyroid cancer, but no prior abdominal surgeries, who presented with a one-month history of rectal pain and new-onset obstipation with urinary retention. He reported night sweats and weight loss, and had a second-degree relative with known Crohn's disease. A digital rectal examination was notable and revealed marked tenderness with proximal induration. A computed tomography scan of the patient's abdomen revealed a large, complex, circumferential perirectal abscess compressing the rectal lumen and base of the urinary bladder, associated with terminal ileal thickening and an ileocecal fistula. A flexible sigmoidoscopy with an endorectal ultrasound scan displayed a complex abscess with extensive mucosal and surrounding inflammation. An exploratory laparotomy revealed a Meckel's diverticulum with a large perforation at its base, positioned near the ileocecal fistula and immediately superior to the perirectal abscess. The section of small bowel containing the Meckel's diverticulum, the terminal ileum, and the cecum, were all resected, and the abscess was debrided.

CONCLUSIONS

Pre-operative diagnosis of Meckel's diverticulum can be difficult. If the nature of the complication makes ultimate surgical management likely, an early laparoscopic or open exploration should be performed to prevent the morbidity and mortality associated with late complications.

Technetium-99m scan in the laparoscopic management of a misdiagnosed Meckel's diverticulum: a case report

Introduction

Although Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract and modern imaging techniques are available, its diagnosis remains problematic.

Case presentation

A technetium-99 scan was performed in an 18-year-old man with abdominal pain, vomiting and rectal bleeding to confirm the presence of a Meckel's diverticulum which was not diagnosed laparoscopically elsewhere. The technetium-99 scan was positive and a diagnostic laparoscopy was re-performed which revealed a Meckel's diverticulum that was subsequently resected.

Conclusion

We suggest that a technetium-99m scan should be performed before laparoscopy in children and adolescents with suspected Meckel's diverticulum. A positive technetium-99m scan may significantly contribute to the laparoscopic definitive diagnosis and treatment of a bleeding Meckel's diverticulum. However, diagnostic laparoscopy should only be performed by experienced surgeons.

Bleeding Meckel's diverticulum in a 4-month-old infant: Treatment with laparoscopic diverticulectomy. A case report and review of the literature

A bleeding Meckel’s diverticulum is presented in a 4-month-old African American infant. This event is rare at this age, and our patient is only the second 4-month-old infant reported in the English literature. The infant presented with painless frank rectal bleeding, the blood being maroon-colored, and clots were found in the diaper. There was also anemia, with an hemoglobin of less than 8 gm/dl. The color of the blood suggested a bleeding site in the ileo-cecal region, a Meckel’s diverticulum was suspected, which was then confirmed by an isotope scan. A typical Meckel’s diverticulum was found on laparoscopic surgery, was excised, and the infant made an uneventful recovery.

Rectal bleeding in children: endoscopic evaluation revisited

OBJECTIVES

Rectal bleeding is an alarming event both for the child and parents. It is hypothesized that colonoscopy instead of sigmoidoscopy and adding esophago-gastro-duodenoscopy in case of accompanying complaints, improves the diagnostic accuracy in children with prolonged rectal bleeding.

STUDY DESIGN

All pediatric patients undergoing colonoscopy because of prolonged rectal bleeding over an 8-year period at the Emma Children's Hospital/Academic Medical Centre were reviewed. Patient demographics, clinical features, number and extent of endoscopic examinations and the endoscopic and histopathological findings were assessed.

RESULTS

A total of 147 colonoscopies were performed in 137 pediatric patients (63 boys) because of prolonged rectal bleeding. Inflammatory bowel disease and polyp(s) were the most prevalent diagnoses. In 72% of patients diagnosed as Crohn's disease, focal, chronically active gastritis was seen on histology, giving support to the diagnosis Crohn's disease. In 22% of the cases polyps would have been missed in the case where only sigmoidoscopy was performed. No complications after endoscopic intervention were seen.

CONCLUSIONS

Colonoscopy is the investigation of choice in children with prolonged rectal bleeding. In patients presenting with accompanying complaints such as abdominal pain or diarrhea, it is advisable to perform ileocolonoscopy combined with esophago-gastro-duodenoscopy. This combines a high diagnostic yield with a safe procedure.

Segmental dilatation of the intestine

PURPOSE

The aim of this work is to discuss the pathogenesis of the segmental dilatation of the intestine (SDI) and to review its clinical presentation and the ways to confirm the diagnosis.

METHODS

Eight cases of pathologically proven SDI from 1987 to 2003 were reviewed and discussed. There were 7 newborns and a 1-year-old boy.

RESULTS

Our patients are 5 boys and 3 girls. In all cases, the diagnosis was not suspected before surgery. Two patients presented with a low neonatal bowel obstruction. Six patients were operated for omphalocele, which was the most frequent associated malformation. The SDI involved the ileum in all patients. The treatment consisted on a resection of the dilated segment with an end-to-end anastomosis. Histological examination demonstrated the presence of ganglion cells in all cases. The muscular layer was hypertrophied in two cases and very thin in one case. A heterotopic gastric mucosa was observed in one case. No anomalies were observed in 5 cases. The postoperative course was uneventful in 6 cases with a mean follow-up of 5 years.

CONCLUSIONS

Segmental intestinal dilatation is an exceptional pathology with an unknown etiology and a misleading clinical presentation. Several theories were proposed to explain this malformation; however, most authors are rather inclined to an embryological theory incriminating an extrinsic intrauterine intestinal compression. Most cases are neonatal discoveries. The clinical polymorphism and the lack of specificity of radiological investigations explain the difficulties to have a preoperative diagnosis. However, this difficulty is compensated by the favorable evolution after the resection of the dilated segment.

Giant T-shaped duplication of the transverse colon. A case report

A case of long diverticular colonic duplication producing acute abdominal pain in a 6-year-old girl is presented. Physical examination showed no signs of acute abdomen at the initial presentation. After a pain-free interval, there was a sudden onset of severe abdominal pain and a large tumor in the lower abdomen was observed. A plain x-ray showed an enormously dilated colonic pouch filled with gas. Excision of the T-shaped duplication and small part of the transverse colon was successful. Because of extensive fibrotic changes in the colon near the opening of duplication, a resection margin of at least 2 cm is recommended.

The role of laparoscopy in the diagnosis of intestinal vascular anomalies affecting two small infants

Two infants affected by intestinal vascular anomalies causing lower gastrointestinal hemorrhage are reported. Upper and lower gastrointestinal tract endoscopy and radionuclide scan were negative. The authors found laparoscopic exploration very useful in detecting the cause and the site of bleeding. Because the usual investigations for gastrointestinal bleeding have been proven to be time-consuming and often unreliable in small infants, the authors suggest considering laparoscopic exploration as a first-line diagnostic tool in this subset of patients. A new diagnostic algorithm for gastrointestinal bleeding in infants is proposed.

Laparoscopic management of Meckel's diverticulum in children

BACKGROUND

Rectal bleeding, recurrent abdominal pain, nausea, and vomiting in children could present a diagnostic as well as therapeutic challenge. Meckel's diverticulum (MD) is one of the causes. The objective of the current study was to evaluate the feasibility and outcome of laparoscopic management of MD.

METHODS

The clinical data of 33 children admitted with rectal bleeding and/or recurrent abdominal pain with no identifiable cause were reviewed over a period of 8 years. There were 23 boys and 10 girls with a mean age of 5.12 +/- 2 years (range, 3-12 years). In 21 cases, MD was an incidental finding on laparoscopic appendectomy and symptomatic in 12 cases. Patients with rectal bleeding were subjected to upper gastrointestinal endoscopy; colonoscopy, and technetium Tc 99m-labeled pertechnetate scan (MS). All patients were subjected to routine laboratory investigations and diagnostic laparoscopy.

RESULTS

Of the 1200 appendectomies, incidental MD was found in 21 (1.9%) patients and symptomatic in 12 cases. Upper gastrointestinal endoscopy and colonoscopy did not show a bleeding source in 7 patients presented with bleeding per rectum. Four cases showed a positive MS uptake. Of these, 3 were found on laparoscopy to have an MD. Three cases showed a negative scan. Of these, 2 had an MD. In 5 cases with recurrent abdominal pain nausea, vomiting, and abdominal distention, diagnostic laparoscopy revealed Meckel's diverticulitis in 3 cases and intussusception secondary to MD in 1 case. Laparoscopic Meckel's diverticulectomy and laparoscopic-assisted Meckel's diverticulectomy was done for 18 and 12 cases, respectively. Ectopic gastric mucosa was present in 13 cases (44%).

CONCLUSIONS

Laparoscopy is safe, cost-effective, and efficient for the diagnosis and definitive treatment of MD. Compared with conventional laparotomy, it has the advantage of precise operative diagnosis, less traumatic access, fewer intraoperative and postoperative complications, and shorter recovery period.

Duplicações do aparelho digestivo

OBJETIVO: Mostrar os aspectos fisiopatológicos e as várias formas de apresentação clínica e tratamento das duplicações do tubo digestivo, através da análise de seis casos operados pela equipe de Cirurgia Pediátrica do Hospital da Lagoa, no Rio de Janeiro. MÉTODO: Foram analisados a evolução clínica, os meios empregados no diagnóstico e a conduta terapêutica em seis pacientes portadores de duplicação, cada um deles se apresentando de forma diferente. Uma era duodenal, quatro jejuno-ileais e uma não era ligada ao tubo digestivo e sim ao pâncreas. RESULTADOS: Todos os casos foram operados, sendo que o cisto duodenal foi comunicado por meio de uma janela ao duodeno, os quatro jejuno-ileais foram ressecados juntamente com o intestino adjacente e o cisto que parecia se originar no pâncreas foi ressecado. Em dois casos houve complicações pós-operatória, mas não houve óbitos. CONCLUSÕES: As duplicações devem ser lembradas no diagnóstico diferencial dos tumores torácicos e abdominais, bem como nos quadros de obstrução intestinal e enterorragia. O conhecimento da existência e das características desta malformação possibilitará ao cirurgião agir da melhor forma possível no caso do seu encontro inesperado durante uma operação. É importante lembrar que podem haver anomalias associadas ou mais de uma duplicação. Se houver suspeita antes da operação, elas devem ser estudadas pelos meios semióticos apropriados, para se tomar a melhor conduta para o caso.

A fading Meckel's diverticulum: an unusual scintigraphic appearance in a child

We describe the case of a 13-month-old boy with significant rectal bleeding in which the (99m)Tc pertechnetate scan showed an initial focus of uptake in the left iliac fossa, which faded rapidly at 15 min. At surgery an ulcerated Meckel's diverticulum was found. We therefore highlight the need to consider a Meckel's diverticulum in cases where this atypical scintigraphic appearance is seen.

A Moving Meckel’s Diverticulum on Tc-99m Pertechnetate Imaging in a Patient With Lower Gastrointestinal Bleeding

Meckel's diverticulum is one of the most common causes of lower gastrointestinal hemorrhage in the young. We report a case of a 16-year-old youth who presented with a 3-day history of bright red bleeding per rectum. Clinical examination revealed pallor but nothing else of note. The patient had a hemoglobin of 9 G% on admission. Tc-99m pertechnetate scintigraphy was performed and demonstrated an abnormal focus in the pelvis on the right that changed in position during the course of imaging. A laparotomy was done and a 5 x 2-cm Meckel's diverticulum was removed from the ileum. Histopathologic examination revealed heterotopic gastric mucosa of the body type. The patient recovered fully after operation.

Diagnosis and treatment of foregut duplications

In its broadest sense, the term, foregut duplication encompasses the full spectrum of developmental aberrations of the embryonic foregut (bronchopulmonary and alimentary tract). Evidence is emerging that the notochord may have a pivotal role to play in foregut development through the Shh-GLi signalling pathway. The investigation and management of these lesions depends on the clinical presentation and the level of the foregut affected. The presentation of symptomatic foregut duplications also depends on any space-occupying effect they exert and where specific complications related to the malformation occur, such as when the mucosal lining contains acid-secreting cells. In a minority of cases, (eg, where they cause respiratory compromise or spinal cord compression) urgent intervention is required. In the remainder, precise diagnostic imaging according to the level and location of the foregut duplication provides the necessary information to plan surgical excision of the lesions. Magnetic resonance imaging best shows the relationships of complex bronchopulmonary foregut malformations and associated anomalies of the spine. eg, neurenteric canal. Most lesions can be excised with minimal morbidity. Minimal-access surgical techniques can be applied to the simpler cysts, particularly some bronchogenic cysts. Thoraco-abdominal duplications and neurenteric cysts require careful preoperative delineation and more complex surgery.

When to resect and when not to resect an asymptomatic Meckel's diverticulum: an ongoing challenge

To determine the morbidity and mortality of Meckel's diverticulum (MD) as a cause of acute abdominal disorders and to evaluate the relationship between patient age, MD complications, and postoperative complications. We reviewed 74 patients who underwent surgery between 1990 and 2000 for an acute abdominal syndrome with a MD diagnosed intraoperatively. Forty children were treated before 1995 and reviewed retrospectively, while the remaining 34 were reviewed prospectively. The average age was 4.8 years; the male/female ratio was 2.5/1; 34 (46%) were less than 2 years old, 32 were between 2 and 8 years, and 8 were older than 8 years. None of the symptoms was suggestive of the diagnosis of MD. Thirty-nine MDs were asymptomatic (21 intussusception, 18 volvulus), but all were the secondary cause of the acute abdomen. The remaining 35 children had a symptomatic MD (diverticulitis in 14, diverticular bleeding in 11, diverticular perforation in 10). The risk of complications due to a MD occurring in children under 2 years and between 2 and 8 years of age was significantly higher compared to children older than 8 years (P = 0.02). Postoperative complications occurred more commonly in children between 2 and 8 years of age compared to other patients. There is thus an increased risk of morbidity in a symptomatic MD in patients less than 2 and between 2 and 8 years of age, and there is no predictive factor for the development of diverticular complications. Resection of the MD is recommended in all children younger than 8 years, including asymptomatic ones, in the absence of absolute contraindications.

[Intestinal duplications. A survey of 18 cases]

OBJECTIVE

The present study analyses the experience of two centers in the management of intestinal duplications in children.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of a series of 18 children with intestinal duplication (January 1993 to December 1999). The median age was 11 months (range: 9 days to 12 years). The variables analysed were: clinical presentation, diagnosis, localization, anatomic type, treatment, and complications. The relationship between age and clinical presentation was also analysed.

RESULTS

Most cases were located in the ileum (n 14; 78 %) and presented with rectal bleeding (36 %) or intussusception (36 %). Most symptomatic cases in the first year of life presented with intussusception (n 5/6). All duplications, except one located in the ascending colon, were cystic. 99mTc-pertechnate abdominal scan was positive in three out of five patients. One case was diagnosed by prenatal ultrasonography. Diagnosis was confirmed by laparoscopy in three patients and by laparotomy in the remaining patients. In one patient, cystic esophageal duplication presented in the neonatal period as respiratory distress. Diagnosis as well as excision was performed by thoracoscopy. Of the two gastric duplications, one was diagnosed by prenatal ultrasonography and the other by laparotomy. Treatment consisted of segmental enterectomy (n 14) or excision of the lesion without enterectomy (n 4). No complications were found during a mean follow-up of 3 years.

CONCLUSIONS

The onset of intestinal duplication may be late. The lesions were most commonly located in the ileum and were cystic. Clinical presentation was related to age. Minimally invasive surgery plays an important role in the management of these lesions.

Perforated congenital diverticulum of the sigmoid colon

A case of perforation of a congenital sigmoid diverticulum producing diffuse peritonitis in a 4-year-old boy is presented. Physical examination showed an acute abdomen despite a normal computed tomography study. Successful surgical treatment was achieved by excision of the diverticulum, adjacent bowel, and an end-to-end anastomosis.

Lower gastrointestinal bleeding in children

Lower gastrointestinal bleeding is a common problem in the practice of general pediatrics. The differential diagnosis can be extensive and varies according to the age of the child. A specific diagnosis can usually be made with a thorough history, physical examination, simple laboratory investigations, and appropriate diagnostic studies. Treatment should be directed at the underlying cause. In most children, bleeding ceases spontaneously, and only supportive therapy is necessary. If there is evidence of hypovolemia, the patient must be hemodynamically stabilized, active bleeding stopped, and recurrent bleeding prevented.