Who was Hilidanus

A. Adegbesan,

Case 1

• 68 year old lady admitted with a 2 day history of diffuse abdominal pain and vomiting.• Acute onset intermittent sharp epigastric pain,

rated 7/10 with no aggravating or relieving factors.

• Bowel motion and flatus last passed 3 day previously

• Poor appetite.• No recent alcohol ingestion as per patient.

Case History• Past Medical History:

– PUD– Hiatus hernia– Chronic Kidney Disease– COPD

• Past Surgical History– Hysterectomy– Cholecystectomy– Appendectomy

Case History

• Family History– Nil significant

• Social History– Ex smoker

• ROS:– Nil significant

On Examination

• Vital Signs:– BP 111/74– HR 92– Temp 36.2– RR 16– O2 SATS 100% on RA

• Abdomen was not distended. Tenderness in epigastrium with mild guarding. No rebound. Bowel sounds exaggerated. Hernial orifices were intact.

Investigations

• WCC 7.4; Hb 13.3; Plts 433; CRP 17• Urea 42; Na 125; K 7.4; Creat 609 (baseline 60-

120)• ABG: pH 7.38, pCO2 4.57, pO2 12.4, HCO3 20• Amylase 160 • ECG: NSR; tachycardic; tented T waves• CXR: no free air under diaphragm.• PFA: prominent small bowel loops

Management

• Initially admitted medically with– Acute on chronic renal failure– Dehydration

• Upon surgical review:– Features of small bowel obstruction for

conservative management.

Management

• Day 1 post admission: – Abdomen now distended, non tender, BS

present. PFA showed progression - ? small bowel obstruction 2o to adhesions.

• Day 2 post admission:– Medical review re: acute renal failure, hyperkalaemia

and hyponatraemia.– Surgical team review– To continue conservative management– NG tube and urinary catheter placed

Management

• Day 5 post admission:– Renal failure indices resolved– Abdominal distension still persistent– Obstipated– PFA showed increasing bowel dilatation – NG tube active– Proceeded to laparotomy

Operative findings

• Small bowel volvolus with fulcrum around meckel’s diverticulum adherent to pelvic sidewall.

• Merckel’s diverticulum and adjacent small bowel were resected and sent for histology.

• Side to side anastomosis

Post Operative

• The post operative period was uneventful.

• Histology– Gastric body type mucosa– No helicobacter pylori– No evidence of malignancy

Case 2

• 31 year old gentleman admitted with:– 1/7 history of sudden onset non-radiating

colicky lower abdominal pain.– No associated nausea, vomiting or altered

bowel habit. – No previous medical/surgical hx.– ROS – nil significant

On Examination

• Vital Signs:• BP 115/68• HR 93

• O2 SATS 99% on RA

• Apyrexial 36.2oC

• On examination:• Tenderness and guarding in lower abdomen• Reduced bowel sounds.

Investigations

• Urinalysis– NAD

• Bloods– WCC 13.4 (neuts 10.58), Hb 13.4, CRP 49, Amylase

107– Sickle cell screen negative

• CXR– No air under the diaphragm

• PFA– Bowel gas pattern normal. No bowel distension or

obstruction. No free air.

Investigations

• CT Abdomen/Pelvis– Minor stranding of fat around a loop of small

bowel in right lower quadrant (differential included inflammatory change around a meckel’s diverticulum)

– Small nodes in the adjacent mesentery. – No evidence of large colonic diverticulitis and

normal appearance of the appendix.

CT Abdo/Pelvis

Management

• On admission:– IV fluids, co-amoxiclav and analgesia

• Day 2 post admission:– Proceeded to Laparoscopy:

• Operative findings:– Perforated merckel’s diverticulum which was resected at its

base using Endo GIA and sent for histology– Appendix long and injected but not acutely inflamed - most

likely not the cause of his symptoms but removed.

Histological Findings

• Ectopic gastric tissue at the fundus of the meckel’s diverticulum.

• The excised edge was free of ectopic gastric tissue

Introduction

• A true congenital diverticulum, a congenital bulge in the small intestine.

• It is a vestigial remnant of the omphalomesenteric duct

• is the most frequent malformation of the gastrointestinal tract

• It was first described by Fabricius Hildanus, German surgeon, in 1598

• Johann Friedrich Meckel, described the embryological origin of this type of diverticulum in 1809

Pathophysiology

• It is a vestigial remnant of the omphalomesenteric (vitellointestinal) duct

• Human embryos initially have convex umbilical loops of primitive gut that communicate freely with the yolk sac through the omphalomesenteric (vitellointestinal) duct

• As development proceeds, the duct normally becomes occluded and disappears entirely by weeks 8-10 of gestation

• Results from the failure of the vitelline duct to obliterate during the fifth week of fetal development

Pathophysiology

• The following anomalies are caused by the persistence

of the omphalomesenteric (vitellointestinal) duct

Epidemiology

• Autopsy records show an incidence of about 2% in the general population.

• For asymptomatic diverticula there is no gender predominance,.

• For symptomatic diverticula some studies give a 3:1 male to female ratio, while others have detected little difference.

• The risk of complications ranges from 4-25% in various studies.

Anatomic Considerations• Meckel's diverticulum is located in the

distal ileum, on its antimesenteric border. usually within about 60-100 cm of the ileocecal valve

• It can also be present as an indirect hernia, typically on the right side, where it is known as a "Hernia of Littre."

Anatomic considerationTopography of abdomen

Anatomic Considerations

• A memory aid is the rule of 2's:• 2% (of the population) • 2 feet (from the ileocecal valve) • 2 inches (in length) • 2% are symptomatic • 2 types of common ectopic tissue (gastric 80% ,

pancreatic, colonic and other tissues 20%),• The most common age at clinical presentation is

2, and • males are 2 times as likely

Clinical features

• Asymptomatic in majority of cases• Painless rectal bleeding, • Intestinal obstruction, • Volvulus and Intussusception. • Meckel's diverticulitis may present with all the

features of acute appendicitis. • Epigastric pain & Bloating• Neoplasm - lipoma, leiomyoma, neurofibroma

and angioma, leiomyosarcoma and carcinoid, which represent about 80% & adenocarcinoma and metastatic lesions

Diagnosis

• A technetium-99m (99mTc) pertechnetate scan is commonly used to diagnose Meckel's diverticulum – Gastric tissue.

• Abd CT• Barium studies to out rule enterocolitis and

intussuception• Laparoscopy• A bleeding scan.• Selective arteriography • Wireless capsule endoscopy • Abd USS

Treatment

• Surgical for symptomatic Merckel’s diverticulum• Incidental Meckel’s diverticulum in asymptomatic

patients remains controversial – Narrow vs wide• Excision is carried out by performing a wedge

resection of adjacent ileum and anastomosis • a primitive persistent right vitelline artery

originating from the mesentery has been found during operation - Bleeding

Histology

• Heterotropic gastric mucosa 62%

• pancreatic tissue  6%,

• Both pancreatic tissue and gastric mucosa were found in 5%,

• Jejunal mucosa was found in 2%,

• Brunner tissue was found in 2%, and

• Both gastric and duodenal mucosa were found in 2%

Take home message

• Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract.

• it is often difficult to diagnose

• It may remain asymptomatic

• it may mimic disorders such as Crohn's disease, appendicitis, peptic ulcer disease, obstruction and bleeding.

Thank you

• Who should take credit for this clinical entity

• Fabricius Hildanus,, in 1598

• Johann Friedrich Meckel, 1809