Pediatr Gastroenterol Hepatol Nutr.  2019 Jan;22(1):98-104. 10.5223/pghn.2019.22.1.98.

Meckel's Diverticulum Diagnosed in a Child with Suspected Small Bowel Crohn's Disease

Affiliations
  • 1Department of Pediatrics, Jeju National University School of Medicine, Jeju, Korea. kskang@jejunu.ac.kr
  • 2Department of Radiology, Jeju National University School of Medicine, Jeju, Korea.
  • 3Department of Pathology, Jeju National University School of Medicine, Jeju, Korea.
  • 4Department of Surgery, Jeju National University School of Medicine, Jeju, Korea.

Abstract

We report a rare case of Meckel's diverticulum in a boy who initially presented with chronic iron deficiency anemia (IDA) without any history of gastrointestinal (GI) bleeding at 8 years-old. Isolated small bowel Crohn's disease was suspected based on findings of small bowel ulcers on capsule endoscopy. At four years from initial presentation, he developed massive GI bleeding. Abdominal computed tomographic angiography and small bowel series revealed findings suggestive of Meckel's diverticulum. Meckel's diverticulum should be suspected in children with unexplained chronic IDA even in the absence of prominent GI bleeding and negative findings on repetitive Meckel's scans. Moreover, Meckel's diverticulum should be included in the differential diagnosis of isolated small bowel Crohn's disease when the disease is limited to a short segment of the distal small bowel, as ulcers and inflammation may result as a consequence of acid secreted from adjacent heterotopic gastric mucosa constituting the Meckel's diverticulum.

Keyword

Meckel diverticulum; Iron deficiency anemia; Crohn disease

MeSH Terms

Anemia, Iron-Deficiency
Angiography
Capsule Endoscopy
Child*
Crohn Disease*
Diagnosis, Differential
Gastric Mucosa
Hemorrhage
Humans
Inflammation
Male
Meckel Diverticulum*
Ulcer

Figure

  • Fig. 1 Technetium-99m pertechnetate (Meckel's) scan at initial presentation (A) and 4 years later (B). Meckel's scan results were both negative at initial presentation with pallor (A) and 4 years later when presenting with massive melena and syncope (B). ANT: anterior.

  • Fig. 2 Abdominal computed tomography image at initial presentation (A) and 4 years later (B). Initial findings reveal wall thickening of the terminal ileum (arrow) but no other remarkable findings (A), while a prominent enhancing tubular structure (arrowheads) connected to the distal ileum with a blind end (B) were noted 4 years later.

  • Fig. 3 Capsule endoscopy image at initial presnetation demonstrating diffuse erythematous mucosa and multiple aphthous ulcers in the distal ileum.

  • Fig. 4 Small bowel barium study performed 4 years later showing a contrast-filling structure (9.7 cm) outside and inferior to the terminal ileum, suspicious of Meckel's diverticulum (arrowheads).

  • Fig. 5 Diverticulectomy specimen (A) and histology (B). The specimen shows a segment of the ileum with a Meckel's diverticulum (arrowheads) of approximately 9-cm length (arrows) (A). Light microscopy image shows a low-power view with a mixture of gastric (yellow arrows) and intestinal epithelia (red arrows) within the Meckel's diverticulum (H&E, ×100) (B).


Reference

1. Yahchouchy EK, Marano AF, Etienne JC, Fingerhut AL. Meckel's diverticulum. J Am Coll Surg. 2001; 192:658–662.
Article
2. Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg. 2005; 241:529–533.
3. Huang CC, Lai MW, Hwang FM, Yeh YC, Chen SY, Kong MS, et al. Diverse presentations in pediatric Meckel's diverticulum: a review of 100 cases. Pediatr Neonatol. 2014; 55:369–375.
Article
4. Bani-Hani KE, Shatnawi NJ. Meckel's diverticulum: comparison of incidental and symptomatic cases. World J Surg. 2004; 28:917–920.
Article
5. Al-Onaizi I, Al-Awadi F, Al-Dawood AL. Iron deficiency anaemia: an unusual complication of Meckel's diverticulum. Med Princ Pract. 2002; 11:214–217.
Article
6. Goodwin B, Smith M. Meckel's diverticulum as a cause of persistent anaemia. ANZ J Surg. 2018; 88:112–113.
Article
7. Baumgart DC, Sandborn WJ. Inflammatory bowel disease: clinical aspects and established and evolving therapies. Lancet. 2007; 369:1641–1657.
Article
8. Rosen MJ, Dhawan A, Saeed SA. Inflammatory bowel disease in children and adolescents. JAMA Pediatr. 2015; 169:1053–1060.
Article
9. Kang B, Choi SY, Kim HS, Kim K, Lee YM, Choe YH. Mucosal healing in paediatric patients with moderate-to-severe luminal Crohn's disease under combined immunosuppression: escalation versus early treatment. J Crohns Colitis. 2016; 10:1279–1286.
Article
10. Kang B, Choe YH. Early biologic treatment in pediatric Crohn's disease: catching the therapeutic window of opportunity in early disease by treat-to-target. Pediatr Gastroenterol Hepatol Nutr. 2018; 21:1–11.
Article
11. Murawska N, Fabisiak A, Fichna J. Anemia of Chronic disease and iron deficiency anemia in inflammatory bowel diseases: pathophysiology, diagnosis, and treatment. Inflamm Bowel Dis. 2016; 22:1198–1208.
Article
12. Gasche C, Lomer MC, Cavill I, Weiss G. Iron, anaemia, and inflammatory bowel diseases. Gut. 2004; 53:1190–1197.
Article
13. Aljomah G, Baker SS, Schmidt K, Alkhouri R, Kozielski R, Zhu L, et al. Anemia in pediatric inflammatory bowel disease. J Pediatr Gastroenterol Nutr. 2018; 67:351–355.
Article
14. Hall B, Holleran G, McNamara D. Small bowel Crohn's disease: an emerging disease phenotype? Dig Dis. 2015; 33:42–51.
Article
15. de Bie CI, Paerregaard A, Kolacek S, Ruemmele FM, Koletzko S, Fell JM, et al. Disease phenotype at diagnosis in pediatric Crohn's disease: 5-year analyses of the EUROKIDS Registry. Inflamm Bowel Dis. 2013; 19:378–385.
16. Yen HH, Chang CW, Chou JW, Wei SC. Balloon-assisted enteroscopy and capsule endoscopy in suspected small bowel Crohn's disease. Clin Endosc. 2017; 50:417–423.
Article
17. Enns RA, Hookey L, Armstrong D, Bernstein CN, Heitman SJ, Teshima C, et al. Clinical practice guidelines for the use of video capsule endoscopy. Gastroenterology. 2017; 152:497–514.
Article
18. Glick SN, Maglinte DD, Herlinger H. Association of Meckel's diverticulum and Crohn's disease. Gastrointest Radiol. 1988; 13:67–71.
Article
19. Andreyev HJ, Owen RA, Thompson I, Forbes A. Association between Meckel's diverticulum and Crohn's disease: a retrospective review. Gut. 1994; 35:788–790.
Article
20. Freeman HJ. Meckel's diverticulum in Crohn's disease. Can J Gastroenterol. 2001; 15:308–311.
Article
21. Hamilton CM, Arnason T. Ileitis associated with Meckel's diverticulum. Histopathology. 2015; 67:783–791.
Article
22. Lim WC, Wang Y, MacDonald JK, Hanauer S. Aminosalicylates for induction of remission or response in Crohn's disease. Cochrane Database Syst Rev. 2016; 7:CD008870.
Article
23. Kong MS, Chen CY, Tzen KY, Huang MJ, Wang KL, Lin JN. Technetium-99m pertechnetate scan for ectopic gastric mucosa in children with gastrointestinal bleeding. J Formos Med Assoc. 1993; 92:717–720.
24. Sinha CK, Pallewatte A, Easty M, De Coppi P, Pierro A, Misra D, et al. Meckel's scan in children: a review of 183 cases referred to two paediatric surgery specialist centres over 18 years. Pediatr Surg Int. 2013; 29:511–517.
Article
25. Suh M, Lee HY, Jung K, Kim SE. Diagnostic accuracy of Meckel scan with initial hemoglobin level to detect symptomatic Meckel diverticulum. Eur J Pediatr Surg. 2015; 25:449–453.
Article
26. Sagar J, Kumar V, Shah DK. Meckel's diverticulum: a systematic review. J R Soc Med. 2006; 99:501–505.
Article
27. Qualia CM, Drugas GT, Jones LT. Meckel's diverticulum on small-bowel follow-through series and computerized tomography scan in a 7-year-old boy with anemia. Clin Gastroenterol Hepatol. 2007; 5:e42–e43.
Article
Full Text Links
  • PGHN
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr