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| CASE REPORT |
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| Year : 2014 | Volume
: 3
| Issue : 3 | Page : 166-167 |
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Mesenteric location of Meckel's diverticulum: Is it really uncommon?
Pankaj Kumar Mohanty1, Shasanka Shekhar Panda2, Rashmi Ranjan Das3, Saumyaranjan Mallick4
1 Department of Neonatology, Manipal Hospital, Bangalore, Karnataka, India
2 Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
3 Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
4 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| Date of Web Publication | 7-Oct-2014 |
Correspondence Address:
Rashmi Ranjan Das
Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2278-0521.142330
One child aged 16 months was admitted to hospital with history of bleeding per rectum and unremarkable physical examination findings. Technetium-99 m scintigraphy scan was positive for bleeding Meckel's diverticulum. Intra-operatively, diverticulum was detected on the mesenteric border of the ileum; the antimesenteric border of ileum being normal. Since the diverticulum was located at the base of the mesentery, resection and anastomosis was preferred instead of wedge resection. Histology revealed presence of antral type gastric mucosa showing chronic peptic ulceration apart from intestinal mucosa. Patient is doing well in follow-up. Keywords: Gastric mucosa, Meckel′s diverticulum, mesenteric location, resection and anastomosis
How to cite this article:
Mohanty PK, Panda SS, Das RR, Mallick S. Mesenteric location of Meckel's diverticulum: Is it really uncommon?. Saudi J Health Sci 2014;3:166-7 |
| Introduction | |  |
Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, seen in approximately 2% of the population. The common presentations during childhood are painless bleeding per rectum, obstruction, and diverticulitis. The anti-mesenteric location is emphasized as one of the cardinal findings in defining the Meckel's diverticulum. [1] A mesenteric location [2],[3],[4],[5],[6] as well as other uncommon pathology in the diverticulum [7] has been rarely described in the literature. We describe a case of Meckel's diverticulum located at the mesenteric border. The clinical presentation and management of the case has also been described.
| Case report | | |
One child aged 16 months was admitted to hospital with history of intermittent bleeding per rectum. There was no history of fever, pain abdomen, bowel problem or bleeding from any other site. Physical examination findings were grossly normal. Per abdominal and per rectal examinations could not identify any abnormality. Ultrasound abdomen showed multiple mesenteric lymph nodes. Technetium-99 m scintigraphy (Meckel scan) was positive for bleeding Meckel's diverticulum. In view of symptomatic diverticulum, elective surgery was planned. Intra-operatively, diverticulum was detected about 60 cm [Figure 1] from the ileocecal valve on the mesenteric border of the ileum; the anti-mesenteric border being normal. Since diverticulum was located at the base of the mesentery, resection and anastomosis was preferred instead of wedge resection. Gross pathological examination showed Meckel's diverticulum, the bases of which were at the mesenterolateral junction of the ileum with the anti-mesenteric border being free. Histology revealed presence of antral type gastric mucosa showing chronic peptic ulceration apart from intestinal mucosa. The post-operative course was uneventful and is currently doing well in follow-up. | Figure 1: Intra-operative view of Meckel's diverticulum wedged into the mesenteric border of the ileum
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| Discussion | | |
Anti-mesenteric border location is one of the characteristic features of Meckel's diverticulum. Mesenteric location is very rare, and only few cases have been described in the literature till now. [2],[3],[4],[5] Sarioglu-Buke et al., in their report on a 7-month-old child described that mesenteric Meckel's diverticulum is a distinct variant that is forgotten or underestimated. [2] According to them, it is possible that this entity is being accepted as an ileal duplication by many authors because it is not reported in large series. Segal et al., described another case in which they considered enterogenous cyst in the differential diagnosis, and favored Meckel's diverticulum as the primary diagnosis. [3] Similar were the descriptions by Walczak et al. and Seitun et al. [4],[5] All of them suggested that classification of the diverticulum into mesenteric location needs review. In another report by Kurzbart et al., a patent omphalo-mesenteric canal detected during the newborn period disappeared at 3 months of age, leaving a diverticulum adherent to the mesentery without a meso-diverticular band. [6]
In their case-series, Donellan et al., described that the etiology of the mesenteric location is due to congenital and inflammatory adhesions. [1] Other possibility considered by them was a meso-diverticular band (due to persistent short vitelline artery), which might have diverted the diverticulum away from the anti-mesenteric border during rapid growth. But, in our case, pathological examination neither revealed a meso-diverticular band nor a vitelline artery, and there were also no features of inflammation. This rule out the speculations mentioned above and supports the true mesenteric nature of the diverticulum.
Two types of wedging of the mesenteric side needs to be highlighted. First, the fate of vitello-intestinal duct itself, second, the detached vitello-intestinal duct getting attached to the mesentery and making the vessels to form a band that twist the former to the new mesentero-lateral position. Besides these, rarely, the true diverticulum on mesenteric side could be due to neurenteric canal theory. But there should have some vertebral anomalies as per the later theory. In case of acquired diverticulum, presence of ectopic gastric or pancreatic tissue can cause inflammation and adhesion that can again modify the position of the former. This later mechanism appears more plausible, as the reported cases have shown the diverticuli wedged on the superior (rather than inferior) leaf of the mesentery. The closest differential diagnosis of a mesenteric Meckel's diverticulum is ileal duplication. However, the later shares the wall and the blood supply from the ileum, and the former has its own arterial supply. But, in about 10% of the cases it might be difficult to differentiate both the conditions because of the presence of the vitelline artery. [8]
Though the treatment of a symptomatic Meckel's diverticulum is relatively straight forward, the proper management of an asymptomatic case is still controversial. [9] It is difficult to predict which patients in the asymptomatic group will become eventually symptomatic. Karaman et al., advocated prophylactic resection if the diverticulum has an umbilical connection, mesodiverticular band or is heterogenous on palpation, and there is no contraindication for diverticulectomy. [9] The location on mesenteric border is more alarming than a usual anti-mesenteric location because it may erode the mesentery and its vasculature during the inflammatory process (diverticulitis) causing devastating consequences. Therefore, it has been suggested that the surgical decision should be standard resection even if this lesion is incidentally detected during laparotomy. [2],[3]
| Conclusion | | |
Contrary to previous thinking, mesenteric location of Meckel's diverticulum is a true entity and might not be rare. Mesenteric location is more alarming because it may erode the mesentery and its vasculature during diverticulitis causing devastating consequences. Incidentally detected lesions during laparotomy should be resected/removed if possible.
| References | | |
| 1. | Donellan WL. Meckel′s diverticulum and related anomalies. In: Donellan WL, Burrington JD, Kimura K, Schafer JC, White JJ. editors. Abdominal surgery of infancy and childhood. Luxembourg: Harwood Academic Publishers; 2001. p. 41/1-41/12. 
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| 2. | Sarioglu-Buke A, Corduk N, Koltuksuz U, Karabul M, Savran B, Bagci S. An uncommon variant of Meckel′s diverticulum. Can J Surg 2008;51:E46-7.
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| 3. | Segal SD, Albrecht DS, Belland KM, Elster EA. Rare mesenteric location of Meckel′s diverticulum, a forgotten entity: A case study aboard USS Kitty Hawk. Am Surg 2004;70:985-8.
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| 4. | Walczak DA, Fa³ek W, Zakrzewski J. An uncommon location of Meckel′s diverticulum or small intestine duplication? Case report and literature review. Pol Przegl Chir 2011;83:457-60.
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| 5. | Seitun S, Vito LD, Rossi UG, Panetta M, Cabiddu F, Tedeschi U, et al. Perforated Meckel′s diverticulitis on the mesenteric side: MDCT findings. Abdom Imaging 2012;37:288-91.
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| 6. | Kurzbart E, Zeitlin M, Feigenbaum D, Zaritzky A, Cohen Z, Mares AJ. Rare spontaneous regression of patent omphalomesenteric duct after birth. Arch Dis Child Fetal Neonatal Ed 2002;86:F63.
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| 7. | Thomas RA, Gibson S, Paul M, McDonald SW. Jejunal diverticulum with ectopic pancreatic mucosa: Was it really a Meckel′s diverticulum? Clin Anat 2012;25:509-12.
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| 8. | Kusumoto H, Yoshida M, Takahashi I, Anai H, Maehara Y, Sugimachi K. Complications and diagnosis of Meckel′s diverticulum in 776 patients. Am J Surg 1992;164:382-3.
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| 9. | Karaman A, Karaman Ý, Çavuþoaðlu YH, Erdoaðan D, Aslan MK. Management of asymptomatic or incidental Meckels diverticulum. Indian Pediatr 2010;47:1055-7.
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[Figure 1]
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