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Thinking Outside of
the
Stump the Professor
Leah Smith
Elizabeth Vonderhaar
Jenny Lovegreen
History of Present Illness
17 year old female, G0
 Periumbilical abdominal pain x 12 hr
 Worsening (8/10), now in RLQ
 Nausea, decreased appetite, taking liquids well
 Denies fever/chills, vomiting, diarrhea,
constipation, hematochezia, melena, dysuria,
vaginal bleeding/discharge

History of Present Illness
LMP: unsure, irregular
 Denies sexual activity (mom in room)
 PMH/PSH/FH: negative
 Allergies: NKDA
 SH: student, lives with parents, denies
tobacco/ETOH/drugs

Physical Exam
VS: T 37.3 P 84 R 18 BP 99/56 O2 100%
 Gen: NAD, lying very still
 Abdominal: soft, nondistended, BS+

Tenderness to palpation periumbilical and
RLQ; involuntary guarding
 No rebound tenderness
 No mass palpated

Differential Diagnosis?
Clinical Work-Up?
Labs
HPD: WBC 16.9 (85% neuts, 5% bands,
6% lymphs)
 CMP: Alk Phos 147
 UA: WNL
 Urine HCG: negative

Imaging
Management?
Surgery
Operative Report
Procedure: Exploratory laparotomy with
resection of perforated Meckel's
diverticulum with primary anastomosis of
small bowel.
 Operative Findings: Perforated Meckel's
diverticulum approximately 45 cm proximal
to the ileocecal valve.

Meckel diverticulum
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Early in embryonic life, the fetal
midgut receives its nutrition from the
yolk sac via the vitelline duct
The duct then undergoes progressive
narrowing and usually disappears by 7
weeks' gestation
 When the duct fails to fully obliterate,
various vitelline duct anomalies
appear

Vitelline Duct Anomalies
Most common: 97%
Meckel diverticulum

May contain heterotopic mucosa

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50% contain gastric mucosa
5% contain pancreatic mucosa
True diverticulum = contains all layers of the
ileum
Found on the antimesenteric border of the
ileum
Usually 40-60 cm proximal to the ileocecal
valve
Epidemiology

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Most common congenital anomaly of the GI
tract
Found in 2-3% of individuals at autopsy
Prevalence of symptomatic Meckel
diverticula is estimated to be 4-35% of the
at-risk population
No racial biases have been reported
The male-to-female ratio is 3:1
Most patients with symptoms present <10
y/o
Presentation

Children = painless rectal bleeding

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Heterotopic gastric mucosa → acid
secretion → tissue damage/vessel
erosion → acute lower GI bleeding
Adults = intestinal obstruction and
inflammation

Most often due to volvulus or
intussusception
Diagnosis
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The diagnosis is notoriously difficult
Most patients are asymptomatic
All common imaging modalities are
nonspecific
The most sensitive technique is scintigraphy
Most Meckel diverticula are diagnosed
during surgery or autopsy, with imaging
playing a secondary role
References
Smoot, Rory, et al, “Meckel’s Diverticulum in
Adults – More Common Than You Think,”
www.residentandstaff.com. Dec 2005.
 eMedicine “Meckel Diverticulum”
