Wireless Capsule Endoscopy Detects Meckel's Diverticulum in a Child with Unexplained Intestinal Blood Loss

Diagnosis of Inverted Meckel's diverticulum by double-balloon enteroscopy: a case report

Background

Meckel's diverticulum (MD) is the most common congenital defect of the gastrointestinal tract, occurring in about 1% to 2% of population. Most MD are rarely symptomatic, with presenting symptoms including diverticulitis, digestive tract hemorrhage and intestinal obstruction. The semblance of symptoms to enteritis and appendicitis makes preoperative diagnosis challenging. Current diagnosis of MD includes technetium-99m pertechnate scan, laparoscopic or intraoperative findings and examining surgical specimens. Here, we report that a double-balloon enteroscopy (DBE) improves the diagnosis accuracy of MD and presents high clinical application value.

Case Description

A 12-year-old male patient was admitted to our hospital due to recurrent abdominal pain and black stools for more than half a year, recurrence for 2 days, accompanied by vomiting. The boy had anemic appearance, with periumbilical tenderness, and no mass was detected upon palpations. Past medical records revealed recurrent abdominal pain episodes thrice. Pre-surgery 99TcmO4-single-photon emission computed tomography/computed tomography (SPECT/CT) imaging was performed but did not reach the condition for diagnosis of MD. DBE was then performed and identified an upper ileum mass. After surgery, it was confirmed that the patient was an inverted MD, and the pathology showed gastric mucosa and pancreatic tissue. The patient recovered well after surgery and was discharged.

Conclusions

DBE is not widely used in the diagnosis of MD, but its accuracy is higher than that of radionuclide scanning imaging. In addition, several advantages such as hemostasis treatment, direct detection and observation of the diverticulum, and demarcation of the site and scope of the lesion prior to surgery brings high clinical application value.

INTESTINAL OBSTRUCTION FROM MECKEL'S DIVERTICULUM IN AN ADULT; UNSUSPECTED BUT FOUND- A CASE REPORT

Introduction

Most cases of Meckel's Diverticulum (MD) are asymptomatic and when symptomatic, preoperative diagnosis of MD maybe a dilemma. Intestinal obstruction is a major complication in the adult population.

Case presentation

We report a case of a 24-year-old female presenting with intestinal obstruction from Meckels Diverticulum.

Conclusion

MD is largely asymptomatic in adults, however may be present and should be included in our array of differential diagnoses.

Small-bowel capsule endoscopy in patients with Meckel's diverticulum: clinical features, diagnostic workup, and findings. A European multicenter I-CARE study

BACKGROUND AND AIMS

Meckel's diverticulum (MD) may remain silent or be associated with adverse events such as GI bleeding. The main aim of this study was to evaluate indicative small-bowel capsule endoscopy (SBCE) findings, and the secondary aim was to describe clinical presentation in patients with MD.

METHODS

This retrospective European multicenter study included patients with MD undergoing SBCE from 2001 until July 2021.

RESULTS

Sixty-nine patients with a confirmed MD were included. Median age was 32 years with a male-to-female ratio of approximately 3:1. GI bleeding or iron-deficiency anemia was present in nearly all patients. Mean hemoglobin was 7.63 ± 1.8 g/dL with a transfusion requirement of 52.2%. Typical capsule endoscopy (CE) findings were double lumen (n = 49 [71%]), visible entrance into the MD (n = 49 [71%]), mucosal webs (n = 30 [43.5%]), and bulges (n = 19 [27.5%]). Two or more of these findings were seen in 48 patients (69.6%). Ulcers were detected in 52.2% of patients (n = 36). In 63.8% of patients (n = 44), a combination of double lumen and visible entrance into the MD was evident, additionally revealing ulcers in 39.1% (n = 27). Mean percent SB transit time for the first indicative image of MD was 57% of the total SB transit time.

CONCLUSIONS

Diagnosis of MD is rare and sometimes challenging, and a preoperative criterion standard does not exist. In SBCE, the most frequent findings were double-lumen sign and visible diverticular entrance, sometimes together with ulcers.

Bleeding Meckel's Diverticulum in a 33-Year-Old Female Diagnosed with Video Capsule Endoscopy and a Technetium-99 m Pertechnetate Scan with a Favorable Response to H2 Blocker and PPI

Meckel's diverticulum is a true diverticulum consisting of all three layers of the small intestine resulting from incomplete regression of the vitelline duct. While it is often benign, it can present with serious complications such as intussusception, ulceration, torsion, hemorrhage, obstruction, inflammation, and fistula formation. Although it typically presents in infancy and early childhood, it can also manifest much later into adulthood. We report a case of Meckel's diverticulum complicated by significant bleeding in a 33-year-old female patient. Diagnosis was accomplished with video capsule endoscopy and a technetium-99 m pertechnetate scan. The patient responded well to acid suppression, initially with an H₂ blocker and later with a PPI (proton pump inhibitor), and remained asymptomatic for nearly four months in the interim to definitive surgical treatment. Microscopic examination of the resected diverticulum confirmed the presence of ectopic gastric mucosa. A PubMed literature search revealed several similar cases of Meckel's diverticulum complicated by hemorrhage with a favorable response to H₂ blockers and PPIs. While surgical resection remains the mainstay of definitive treatment, medications aimed at acid suppression can delay the need for urgent surgery, allow for diagnostic assessment, and optimize conditions for elective surgical treatment.

A Rare and Severe Presentation of Henoch-Schönlein Purpura in an Adolescent With Crescentic Glomerulonephritis, Arrhythmia, Acute Gastrointestinal Bleed, and Neurological Complications

Henoch-Schönlein purpura (HSP) is a childhood vasculitis disorder that involves the skin, joints, gastrointestinal (GI) tract, and kidneys. It is related to immunoglobulin A (IgA) antibody deposition in small blood vessels. HSP is a self-limiting disorder, but its morbidity is primarily associated with renal involvement. GI pathologies like intussusception, gastritis, duodenitis, ileitis, or ulcer have been reported to be associated with this disease. However, cardiac and neurological complications are rarely reported.

We present the case of a 16-year-old, previously healthy male who was diagnosed with HSP after presenting with a non-blanching purpuric rash in the lower extremities. The patient also had joint and abdominal pain, and swelling in the extremities. There was renal dysfunction at presentation with blood urea nitrogen (BUN) of 67 mg/dL and serum creatinine of 1.9 mg/dL. The serum albumin was low at 2 g/dL, and the patient had nephrotic range proteinuria. Urine microscopy showed red blood cell casts. A renal biopsy was performed, which showed IgA deposition in glomeruli. He was started on intravenous (IV) pulse methylprednisolone and was later prescribed oral steroids. Four weeks after the treatment initiation, he presented with syncope and acute anemia (hemoglobin of 3.5 g/dL). The fecal occult blood was positive. Esophagogastroduodenoscopy (EGD) was not suggestive of gastritis, duodenitis, or ulcer. The pill-cam capsule endoscopy revealed GI bleeding from the terminal ileum near Meckel’s diverticulum. He subsequently required blood transfusions, and the bleeding eventually improved with symptomatic management. Six weeks after treatment initiation, he presented with dizziness and palpitations. The EKG showed the presence of atrial fibrillation, and he had an episode of non-sustained ventricular tachycardia on telemetry. Arrhythmia was diagnosed secondary to HSP cardiac vasculitis, and we initiated treatment with metoprolol and amiodarone. Seven weeks after the initial treatment, he had neurological clinical findings of proximal muscle weakness, tremors, and upper and lower extremity clonus. A second renal biopsy was then performed due to the presence of persistently elevated serum creatinine, which showed 75% of glomeruli with cellular crescents. He was treated with IV cyclophosphamide. Subsequently, the renal function improved. There were no other GI, cardiac, or neurological complications after six months of follow-up.

The presentation of HSP can be more severe in adolescents, and they need to be closely monitored for GI, cardiac, renal, and neurological complications after the disease occurrence. Bleeding from Meckel’s diverticulum or an episode of non-sustained ventricular tachycardia with HSP has not been previously reported to our knowledge. Arrhythmia is an exceptionally unusual occurrence in HSP, and it is usually treated with anti-arrhythmic drugs and intensification of the immunosuppressive regimen.

The diagnostic value of video capsule endoscopy for Meckel's diverticulum in children

BACKGROUND

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and is also an important cause of bloody stool and anemia in children. However, there are few data about video capsule endoscopy (VCE) for MD in children. This study aimed to evaluate the diagnostic value of VCE for MD in children.

MATERIALS AND METHODS

children who underwent VCE for obscure gastrointestinal bleeding from October 1st 2015 to August 31st 2019 at the Children's Hospital of Fudan University were included in this retrospective study. Medical data, VCE data and Meckel's scans, etc. were collected for each patient.

RESULTS

sixteen patients were diagnosed with MD by VCE, including 13 males and 3 females. The age of the patients ranged from 4 years to 13 years, with an average of 7.8 ± 2.7 years. Lower gastrointestinal tract bleeding was the main symptom for patients with MD, including hematochezia (75 %) and melena (25 %). Of the VCE findings, 14 patients had double lumen signs and 2 showed protruding lesions. Among the 16 patients diagnosed with MD by VCE, 14 patients were diagnosed with MD by Meckel's scan, 3 with MD by abdominal enhanced CT and 14 patients were diagnosed with MD by surgery. During the follow-up, bleeding occurred sporadically in patient 12 and the reason is still unknown.

CONCLUSIONS

VCE is useful for the diagnosis of MD and should be used as a valuable and less invasive examination to confirm or establish a diagnosis.

Capsule endoscopy as a diagnostic test for Meckel's diverticulum

OBJECTIVE

We described a case series of patients diagnosed with Meckel's diverticulum using capsule endoscopy (CE), reviewed the literature, and aimed to reveal the common CE characteristics of Meckel's diverticulum.

MATERIALS AND METHODS

We reviewed a case series of Meckel's diverticulum in the Department of Gastroenterology, Beijing Shijitan Hospital Affliated to the Capital Medical University. In each case, primary upper endoscopy and colonoscopy failed to reveal a reason to explain the complaints (hematochezia in three cases and abdominal pain in one). CE (Pillcam SB2, Given Imaging, Yoqneam, Israel) was chosen as the next diagnostic test of choice and Meckel's diverticulum was detected by CE. Then, endoscopic characteristics and follow-up of Meckel's diverticulum were analyzed.

RESULTS

4 patients were enrolled. CE revealed Meckel's diverticulum in patients with different features. In case 1, CE revealed a typically double lumen sign and diaphragm sign, with visible blood. In case 2 and case 3, CE revealed a protruding lesion with/without erosion. In case 4, CE revealed multiple caved lesions, double lumen sign and capsule retention in an abnormal blind end for over 2 hours.

CONCLUSION

Except double lumen sign, partial disappearance of normal mucosa and capsule retention, other CE findings could be used for the diagnosis of Meckel's diverticulum, such as protruding lesion, caved lesion, solitary polyp and stenosing lesion.

Meckel’s diverticulum diagnosis by video capsule endoscopy: A case report and review of literature

BACKGROUND

Meckel’s diverticulum (MD) occurs predominantly in children and adolescents. It is rarely diagnosed in adults. Preoperative diagnosis is difficult due to low sensitivity of the radiological imaging studies. The role of video capsule endoscopy (VCE) in the diagnosis of MD is unknown, and the endoscopic patterns are not defined. We will describe four of our cases of MD evaluated with VCE and make a review of the literature focusing on the endoscopic characteristics.

CASE SUMMARY

We present four cases of MD confirmed by surgery. They were all adult males with ages going from 18 to 50 years, referred to our service from 2004 to 2018, due to obscure gastrointestinal bleeding (OGIB). They had a history of 1 mo to 10 years of overt and occult bleeding episodes. Laboratory blood test showed an iron-deficiency anemia from 4 to 9 g/dL of hemoglobin that required multiple hospitalizations and blood transfusions in all cases. Repeated upper digestive endoscopies and colonoscopies were negative. Small bowel was examined with VCE, which revealed double lumen images in all cases, one with polyps and three with circumferential ulcers in the diverticulum. However, based on VCE findings, preoperative diagnosis of MD was suggested only in two patients. Capsule was retained in one patient, which was recovered with surgery. The anatomopathological report revealed ulcerated ectopic gastric mucosa in all cases.

CONCLUSION

VCE is useful for the diagnosis of MD. However, endoscopic characteristics must be recognized in order to establish preoperative diagnosis.

[When and how should small-bowel capsule endoscopy be used in children?]

Small-bowel capsule endoscopy (CE) has recently been used in children. During the past few years, an intense research activity has defined the advantages and limitations of CE. Its uses have been established in several small-bowel pathologies such as obvious or obscure digestive bleeding, Crohn disease, and hereditary polyposis. Although the absence of biopsy reduces the specificity of CE findings, small-bowel exploration using CE achieves better accuracy in detecting lesions than most radiological examinations. In children, swallowing problems and the risk of retention due to stenosis are the main concerns when using CE: these problems can be solved using endoscopic delivery of the capsule and luminal diameter calibration, respectively. This review focuses on the evidence making CE indispensable to small-bowel exploration.

Small Bowel Congenital Anomalies: a Review and Update

The small intestine is a complex organ system that is vital to the life of the individual. There are a number of congenital anomalies that occur and present most commonly in infancy; however, some may not present until adulthood. Most congenital anomalies of the small intestine will present with obstructive symptoms while some may present with vomiting, abdominal pain, and/or gastrointestinal bleeding. Various radiologic procedures can aid in the diagnosis of these lesions that vary depending on the particular anomaly. Definitive therapy for these congenial anomalies is surgical, and in some cases, surgery needs to be performed urgently. The overall prognosis of congenital anomalies of the small intestine is very good and has improved with improved medical management and the advent of newer surgical modalities. The congenital anomalies of the small intestine reviewed in this article include malrotation, Meckel's diverticulum, duodenal web, duodenal atresia, jejunoileal atresia, and duplications.