Omphalomesenteric Duct Fistula: A Rare Manifestation of Omphalomesenteric Duct Anomalies

Omphalomesenteric duct (OMD) anomalies occur as a result of resorption failure during gestation. Various forms of OMD anomalies are documented depending upon the degree of resorption (complete or partial) including Meckels diverticulum, fistulas, fibrous bands, and cysts to umbilical polyps. Among these, Meckels diverticulum is the most common of these anomalies, and omphalomesenteric duct fistula (OMF) is the most rare. Complete persistence of OMD in neonates results in OMF, which has a male predominance. OMF is documented in less than 0.1% of the population. Differentials include urachal remnants and umbilical granuloma. We report a rare case of a 10-day male neonate who presented with umbilical swelling and discharge. This case is presented to highlight the occurrence of this extremely rare phenotype to raise a high index of suspicion and awareness among healthcare providers. Key Words: Omphalomesenteric duct fistula, Umbilical swelling, Sinogram.

Synchronous tumor duplicity of a neuroendocrine tumor of Meckels diverticulum with liver metastases and colorectal carcinoma

INTRODUCTION

Meckels diverticulum (MD) is a developmental abnormality and a true diverticulum of the small intestine which can give rise to a malignant tumor. Neuroendocrine tumors (NETs) are the most common tumors arising in MD, but due to the prevalence of MD and its malignancy rate, there is no uniform guideline regarding these tumors. Recent knowledge shows that their biological behavior is aggressive and unrelated to size. Their behavior resembles that of an ileal NET.

CASE REPORT

A 62-year-old male was examined for enterorrhagia, and an adenocarcinoma of the ascending colon was diagnosed along with multiple liver lesions that resembled metastases. Needle biopsy of a liver lesion was performed and showed the lesions to be NET metastases of unknown origin. Treatment with somatostatin analogs was commenced, and because of the patients anemization a right hemicolectomy was indicated, during which a normal Meckels diverticulum was found and resected. Histological evaluation of MD confirmed a moderately differentiated NET.

CONCLUSION

Surgery is the primary modality for treating MD, including cases in which MD is asymptomatic and found incidentally during surgery for other causes. In the case of NET of MD, a radical surgical treatment is needed because of the risk of early metastatic dissemination. When liver metastases are present, an aggressive approach combining surgical and systemic treatment is recommended to improve the prognosis of the disease.

Ileal duplication cyst with giant polypoidal gastric heterotropia

Enteric duplication cysts (EDCs) are congenital malformations of the gastrointestinal tract. EDCs can present as tubular or spherical cystic lesions of the abdomen. The tubular variant of EDC arises as an outpouching from the bowel wall, whereas the spherical variant rarely shows bowel communication. EDCs are known to harbour heterotopic pancreatic parenchyma or gastric mucosa. We present a case of EDC of the ileum (tubular type) with heterotopic gastric mucosa in a 7-year-old child who came with malena and abdominal discomfort. CT revealed focal abnormal dilatation of the ileal loop with polypoidal mucosal thickening. Differential diagnosis of lymphoma, bowel polyps and Meckel's diverticula with gastric heterotopia (GH) were considered. Subsequent surgery followed by histopathology revealed it to be EDC with GH. We discuss this case to familiarise radiologists with the atypical imaging features of EDC, to prevent misdiagnosis and initiate prompt treatment in appropriate clinical settings.

Perforated Ileal GIST Associated with Meckel Diverticulum - A Rare Pathological Entity of Surgical Acute Abdomen

Introduction: The GIST tumors are very rare entities ( 1% of all tumors). They originate in the Cajal interstitial cells, which are part of the autonomic nervous system of the intestine. Their most common location is the stomach, followed by the small intestine. The aim of this paper is to present a very rare case of perforated ileal GIST, associated with Meckel diverticulum. Case report: A 71 years old patient with comorbidities is admitted in emergency for symptoms and signs of acute surgical abdomen. The exploratory laparotomy reveals generalized acute peritonitis due to perforated ileal tumor and Meckel's diverticulum. A segmental enterectomy is performed, with favorable postoperative evolution. The histological examination of the resection piece shows the appearance of GIST, confirmed immunohistochemically. Conclusions: The GIST tumors of the small intestine are unusual tumors and the spontaneous perforation and life-threatening hemorrhage are a rarity. The main treatment for this form of GIST is the resection, with a favorable clinical outcome.

Neuroendocrine tumours within a Meckel's diverticulum

A Meckel's diverticulum is a common anomaly of the gastrointestinal tract. Although the majority of patients do not have any symptoms, malignancies can develop inside these diverticula, with neuroendocrine tumours being the most common. Diverticulectomy is the best option for complicated diverticula but prophylactic resection of asymptomatic diverticula in adults remains controversial. We present a case series of three patients with a neuroendocrine tumour found in a Meckel's diverticulum. Given the number of asymptomatic diverticula not resected, it seems likely that incidental neuroendocrine tumours are more prevalent than thought previously. With the minimally invasive techniques now available and the low complication rate for incidental diverticulectomy, we believe that the benefits of resection of this high risk area for cancer outweigh the risks of surgery.

[Adenocarcinoma in a Meckel's diverticulum with multiple liver metastases and gastrointestinal hemorrhage: a case report]

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, affecting approximately 2% of the population. It is a true diverticulum occurring on the anti-mesenteric border of the distalileum, typically within 100 cm of the ileo-caecal valve. Neoplasms arising in Meckel's diverticula are uncommon, and those reported in the literature are mainly carcinoid tumors, followed by gastrointestinal stromal tumors (GIST) and benign leiomyomas. Adenocarcinomas are extremely rare. Tumors in Meckel's present non-specifically with gastrointestinal complaints, such as bleeding, obstruction, inflammation or perforation. The suspicion of a Meckel's tumor is often not thought of at the initial. In this article we describe a 57-year-old woman who presented with massive rectal bleeding and severe anemia, later found to be caused by a adenocarcinoma arising from Meckel's diverticulum. The tumor was unfortunately highly aggressive. Multiple liver metastases had already existed when we discovered the primary mass. Later we performed a partial resection of the ileumto cease the bleeding. Meckel's diverticulum and the tumor were resected simultaneously. The pathological diagnosis confirmed adenocarcinoma arising from the Meckel's diverticulum. The final stage was pT4NxM1, stage IV according to the Union for International Cancer Control (UICC) classification. After operation we gave the patient first-line, mFOLFOX6 chemotherapy, but it turned out to be not effective. Rapid progress of the liver metastases and suspicion of multiple lung metastasis in short time after therapy indicated a bad outcome. We believe this is the first case of adenocarcinoma in a Meckel's diverticulum to be reported in domestic literature. The diagnosis of Meckel's tumor should be considered as inpatients'acute gastrointestinal complaints; when found incidentally at laparotomy, it should be carefully examined for any gross abnormality and resection should be considered.

Meckel's diverticulum perforated by a fishbone. An unusual presentation

Finding a Meckel's diverticulum during a laparotomy is rare, operating on a patient for a complication of diverticulum is rare, but if this complication is the result of a perforation of the diverticulum by a foreign body, then we are in the presence of a medical curiosity.

OBJECTIVE

To present the following case because despite being known, the etiological agent that caused the perforation is very unusual.

METHOD

male 53 years old with a history of emergency surgically underwent surgery for acute appendicitis 10 years where he underwent an appendectomy and a non-complicated Meckel's diverticulum was identified. For the record, the clinical picture and complementary examinations Meckel diverticulitis was diagnosed and we decided to intervene with surgically emergency. During surgery a Meckel's diverticulum perforated by a fishbone was identified. Segmental bowel resection and an ileo-ileoanastomosis performed manually.

CONCLUSIONS

Meckel's diverticulum perforated by fishbone is extremely rare. Its diagnosis is challenging because of their variable clinical presentation.

Highlighted Steps of the Management Algorithm in Acute Lower Gastrointestinal Bleeding - Case Reports and Literature Review

Acute lower gastrointestinal bleeding is a major problem worldwide, being a rare and life threatening condition, with a mortality rate situated between 2 and 4%. Acute lower gastrointestinal bleeding is solvent for 1 - 2% of the entire hospital emergencies, 15% presenting as massive bleeding and up to 5% requiring surgery. Lower gastrointestinal bleeding can be classified depending on their location in the small or large intestine. The small bowel is the rarest site of lower gastrointestinal bleeding, at the same time being the commonest cause of obscure bleeding. 5% of total lower GI bleeding appears in the small bowel. When endoscopic therapy associated with medical treatment are insufficient, endovascular intervention can be lifesaving. Unfortunately in some rare cases of acute lower gastrointestinal bleeding with hemo-dynamic instability and the angiography performed being unable to locate the source of bleeding, the last therapeutic resource remains surgery. In the following we exemplify two cases of acute lower gastrointestinal bleeding which were resolved in different ways, followed by a thorough description of the different types of available treatment and finally, in the conclusions, we systematize the most important stages of the management algorithm in acute lower gastrointestinal bleeding.

Ruptured Meckel's mesodiverticulum and Meckel's diverticulum following blunt abdominal trauma

OBJECTIVES

To present a case of simultaneous rupture of Meckel's diverticulum and mesodiverticulum with abdominal pain following a blunt trauma to the abdomen, sustained during an automobile accident.

CLINICAL PRESENTATION

Following a head-on automobile collision a 36-year-old man was referred to the emergency room with abdominal pain, guarding and rigidity and was taken to the operating theater with a preoperative impression of peritonitis due to rupture of a hollow viscus. Upon abdominal exploration, ruptured Meckel's diverticulum (from the base) and ileum with active bleeding from mesodiverticulum was found.

INTERVENTION

The ileum was repaired in two layers: a segmental bowel resection including Meckel's diverticulum and the gastrointestinal tube anastomosed without any tension. The patient has a normal postoperative course.

CONCLUSION

This case shows that a blunt abdominal trauma can tear the mesodiverticulum and rupture the Meckel's diverticular base simultaneously, resulting in hemoperitoneum and chemical peritonitis. Diagnosis and management of this type of injury are basically the same as those of acute surgical abdomen following trauma.

Ruptured Meckel diverticulum mimicking mucositis in a patient receiving induction therapy for high-risk acute lymphoblastic leukemia

A Meckel diverticulum is an embryonic remnant of the vitellointestinal duct. It is present in approximately 2% of the population and is estimated to cause symptoms<5% of the time. It generally results in painless bleeding or abdominal pain. Rarely, it can rupture, resulting in peritonitis and gram-negative sepsis. We present the case of a 17-year-old male who ruptured his Meckel diverticulum 23 days after the beginning of induction chemotherapy for high-risk acute lymphoblastic leukemia. We postulate that gastritis caused by dexamethasone, mucositis caused by doxorubicin, and the unique anatomic nature of a Meckel diverticulum may have contributed to this extremely unlikely and previously unreported event.

[Small bowel stromal tumors in a "meckelian" location. About a clinical observation]

The Meckels divetriculum has a prevalence of the 0.3-3%. It is surgically removed only when arise a complication or a neoplasia. The Meckels diverticulum tumors are unfrequent and observed in only the 0.5-3.2% of the Meckels diverticula. The 12% of these tumors are a GIST. We report a case of a gastrointestinal stromal tumor with neural immunophenotype, observed in a patient presenting a deep venous thrombosis perhaps with a paraneoplastic origin. We also report some observations about the state of the art about the GIST management and particularly of all of them arising in a Meckels diverticulum.

The arterial supply of Meckel's diverticulum in geese (Anser anser domesticus)

This study was carried out to describe the arterial supply of Meckel's diverticulum (MD) in geese, using 36 adult healthy geese of both sexes, 50 to 52 weeks of age. The arterial supply of MD was classified into three types, In the first type, MD was supplied by a very distinct branch from the cranial mesenteric artery in 21 geese. In the second type, it was supplied by one terminal branch from the cranial mesenteric artery in 9 geese. In the third type, it was supplied both by one branch from the jejunal artery and by terminal branch from the cranial mesenteric artery in 6 geese. Based on the these types, we found significant differences (p < or = 0.01) in the length of MD between type I and II. The blood supply of the third type was observed more frequently in the male than in the female. Results from this study may contribute to the anatomical knowledge of arterial supply of MD in the geese.

[Carcinoid of Meckel's diverticulum: presentation of a clinical case]

Clinical findings and surgical treatment of a 68 years old man with carcinoid tumor of Meckel's diverticulum are reported. Carcinoids in Meckel's diverticula are rare tumors, commonly discovered incidentally during surgical procedures for different indications. Symptoms are frequently expression of a metastatic disease. Specific diagnostic and therapeutic tools are discussed.

Further characterization of M cells in gut-associated lymphoid tissues of the chicken

M cells are considered to be the most effective cells for the transport of antigens from the intestinal lumen into the gut-associated lymphoid tissue. M cells are characterized by their ultrastructural appearance, the selective uptake of antigens, the binding of lectins, and the presence of underlying lymphocytes. Little attention has been paid to the interaction of intra-epithelial leucocytes and M cells in chickens; therefore, we have investigated both cell types separately and using double immunocytochemical staining in cecal tonsils and Meckel's diverticulum. In the follicle-associated epithelium (FAE), cells were present that differ from their neighbors by short, irregular microvilli. Ferritin was absorbed by these putative M cells, but also by other epithelial cells. The lectins of Triticum vulgaris (WGA) and Glycine max (SBA) showed a patchy staining of the FAE. The numbers of intra-epithelial leucocytes (IEL) increased rapidly after hatch, reaching innumerable at 6 wk of age. Most IEL were T lymphocytes expressing CD8 and only about 30% of them were B lymphocytes. Nevertheless, double staining of M cells (WGA/SBA) and IEL showed that M cells were much fewer than IEL. These results indicate that M cells are not solely induced by the intra-epithelial localization of leucocytes. Because the phenotype of IEL reflected the content of the adjacent underlying lamina propria, IEL immigrate the FAE locally and do not migrate along with the epithelial cells from the crypts. In conclusion, M cells exist in the chicken, but their phenotype and function are less well demarcated from neighbor epithelial cells than is seen in mammals.

Helicobacter pylori in ectopic gastric mucosa in Meckel's diverticulum

We report a case of a 25-year-old man who presented with a large rectal bleed and positive Meckel's scan followed by surgical excision of a Meckel's diverticulum. The diverticulum was lined by gastric body type mucosa showing evidence of active chronic gastritis associated with the presence of Helicobacter pylori organisms, these being identified immunohistochemically with a specific polyclonal antibody. We have reviewed another 21 cases of Meckel's diverticula removed at St Vincent's Hospital between 1984 and 1997: in nine of these cases the diverticulum was lined by ectopic gastric body type mucosa and in one of these there was an active chronic gastritis associated with Helicobacter pylori. There has been considerable controversy regarding both the presence and significance of Helicobacter organisms in Meckel's diverticula. This is the first study to use immunohistochemistry specifically to identify Helicobacter pylori within two cases of Meckel's diverticula. Both cases demonstrated an active chronic gastritis present within the gastric body type mucosa, thus suggesting that the organisms play a pathogenic role.