Meckel’s diverticulum on third-generation video capsule endoscopy: intradiverticular ulcer, ectopic gastric mucosa, and active bleeding

A 29-year-old man presented with acute rectal bleeding causing hemorrhagic shock. The patient had presented with a similar episode of digestive bleeding 4 years previously, with no diagnosis being found. His physical examination did not reveal any clinical abnormalities. Gastroscopy, colonoscopy, and abdominal computed tomography angiography (CTA) were normal. Small-bowel video capsule endoscopy revealed an ileal diverticular orifice, with the double-lumen sign. After passage of the capsule into the diverticulum, an ulcer with a visible vessel (Forrest IIa) was observed at the bottom of the diverticulum, located next to a patch of heterotopic gastric mucosa. During this examination, active bleeding was seen from this area of ulceration ([Fig. 1]; [Video 1]).

Fig. 1 Images obtained during small-bowel video capsule endoscopy showing: a an ileal diverticular orifice with the double-lumen sign. b ulceration with a visible vessel (Forrest IIa); c ectopic gastric mucosa (black arrows); d the presence of intradiverticular bleeding (red arrow, diverticular orifice; green arrow, ileum).

Video 1 Appearances of a Meckel’s diverticulum on third-generation video capsule endoscopy.

A Meckel’s diverticulum was suspected. A ^99 mTc pertechnetate scintigraphy scan was performed, which confirmed the presence of ectopic gastric mucosa, corresponding to a probable Meckel’s diverticulum ([Fig. 2]). Surgery allowed the excision of a diverticulum of 6 × 2 × 1 cm that was found 70 cm above the ileocecal valve. Histological examination confirmed the presence of ectopic fundal mucosa within the diverticulum ([Fig. 3]). The patient left hospital 3 days after the surgery and has not re-presented with any further recurrence of bleeding.

Fig. 2 ^99 mTc pertechnetate scintigraphy (Meckel’s scan) showing ectopically located gastric mucosa.

Fig. 3 Histological appearance on hematoxylin, eosin, and saffron (HES) staining showing ectopic fundal mucosa.

Meckel’s diverticulum is a vestigial remnant of the omphalomesenteric duct, located on the antimesenteric border of the ileum, within 100 cm above the Bauhin’s valve. About 50 % of symptomatic Meckel’s diverticula have been found to contain ectopic tissue, especially gastric mucosa (35 % – 45 %), which can cause ulceration and hemorrhage; 75 % of hemorrhagic Meckel’s diverticula contain gastric ectopic mucosa [1]. Abdominal CT is an insensitive test for detection, especially in adults. In patients with obscure gastrointestinal bleeding, small-bowel video capsule endoscopy is a potentially interesting test for the diagnosis of Meckel’s diverticulum, with a positive predictive value up to 85 % [2]. ^99 mTc pertechnetate scintigraphy (Meckel’s scan), which specifically detects gastric mucosa, is more sensitive in a pediatric population (85 % – 90 %) than in adult patients (60 %). This test is particularly effective when there are symptoms related to the ectopic gastric mucosa, such as bleeding [3].

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• References

• 1 Park JJ, Wolff BG, Tollefson MK. et al. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950 – 2002). Ann Surg 2005; 241: 529-533
• 2 Krstic SN, Martinov JB, Sokic-Milutinovic AD. et al. Capsule endoscopy is useful diagnostic tool for diagnosing Meckel’s diverticulum. Eur J Gastroenterol Hepatol 2016; 28: 702-707
• 3 Elsayes KM, Menias CO, Harvin HJ. et al. Imaging manifestations of Meckel’s diverticulum. AJR Am J Roentgenol 2007; 189: 81-88