Meckel\u27s diverticulum is usually asymptomatic and found in almost 2% of the population. Haemorrhage from a Meckel\u27s diverticulum is common in children but rare in adults. Here we report a case of 20 years old male with recurrent gastrointestinal bleeding. Meckel\u27s diverticulum was diagnosed due to abnormal vascularity on mesenteric angiography and embolization was performed. Diagnosis was correlated with other radiological imaging and later elective resection was performed. This case is reported to emphasize the potential role of mesenteric angiography in the detection and management of bleeding Meckel\u27s diverticulum and correlation with other radiological imaging

Ali, Muhammad

Azeemuddin, Muhammad

Khan, Rizwan

Sayani, Raza

Tanveer-ul-Haq,

English

eCommons@AKU

eCommons@AKUDepartment of Radiology Medical College, PakistanOctober 2013An unsuspected bleeding Meckel's diverticulum inan adult detected on mesenteric angiographyMuhammad AliAga Khan UniversityRaza SayaniAga Khan University, raza.sayani@aku.eduMuhammad AzeemuddinAga Khan University, muhammad.azeemuddin@aku.eduTanveer-ul-HaqAga Khan University, tanveer.haq@aku.eduRizwan KhanAga Khan University, khan.rizwan@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended CitationAli, M., Sayani, R., Azeemuddin, M., Tanveer-ul-Haq, ., Khan, R. (2013). An unsuspected bleeding Meckel's diverticulum in an adultdetected on mesenteric angiography. Journal of the College of Physicians and Surgeons Pakistan, 23(10), 759-760.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/151INTRODUCTIONMeckel's diverticulum was first described by JohannFriedrich Meckel in 1809 and is the most commoncongenital anomaly of the gastrointestinal tract.1 It is atrue diverticulum with all layers of the intestinal wallpresent, and usually arises from the antimesentericborder.2 It has its own blood supply from a terminalbranch of the superior mesenteric artery known asvitello-intestinal artery.3 It is usually asymptomatic withoccasional complications of bleeding, obstruction,diverticulitis and neoplasm.4 Because most symptomaticdiverticula contain ectopic gastric tissue, radionuclideimaging with Technetium (Tc) 99m pertechnetate isconsidered to be the method of choice for theirdetection.5 However, a bleeding Meckel's diverticulummay not be detected on radionuclide imaging inspite ofthe presence of ectopic gastric mucosa.5 In these cases,mesenteric angiography is an alternative procedure fordetecting Meckel's diverticulum.6This case is reported to emphasize the potential role ofmesenteric angiography in the detection and manage-ment of bleeding Meckel's diverticulum and correlationwith other radiological imaging.CASE REPORTA 20 years old male presented to ER with the complaintof painless rectal bleeding for last 6 days. He had asimilar episode 6 months back when extensive investi-gation was performed including upper GI endoscopy,colonoscopy and mesenteric angiogram, but all cameout to be negative.On admission, the patient's blood pressure was 100/60mm Hg, haemoglobin level was 8.9 g/dl and hematocritwas 21%. On examination, he had painless per rectalbleeding. Episodes of bleeding continued over next 3days of admission and a total of 8 units of packed redcells were administered. He bled profusely on the thirdday and was shifted to the special care unit. His urgentRBC-tagged radionuclide scan was performed whichshowed abnormal focus of bleeding in the pelvis(Figure 1a). His mesenteric angiogram was performedwhich showed profuse active extravasation of contrastfrom an abnormal end artery arising from ileocolicbranch of superior mesenteric artery. The bleedingvessel was successfully embolized with micro-coils.Due to the abnormal location and course of the vessel,it appeared to be vitello-intestinal artery and suspicion ofMeckel's diverticulum was raised (Figure 1b). Hissubsequent CT scan showed a blind ending intestinalpouch with enhancing walls in the lower mid abdomen(Figure 2a). Later on radionuclide Meckel's diverticulumscintigraphy was performed with 200 MBq Tc 99mpertechnetate, which demonstrated tracer deposition inJournal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (10): 759-760 759CASE REPORTAn Unsuspected Bleeding Meckel's Diverticulum in an AdultDetected on Mesenteric AngiographyMuhammad Ali1, Raza Sayani1, Muhammad Azeemuddin1, Tanveer-ul-Haq1 and Rizwan Khan2ABSTRACTMeckel's diverticulum is usually asymptomatic and found in almost 2% of the population. Haemorrhage from a Meckel'sdiverticulum is common in children but rare in adults. Here we report a case of 20 years old male with recurrentgastrointestinal bleeding. Meckel's diverticulum was diagnosed due to abnormal vascularity on mesenteric angiographyand embolization was performed. Diagnosis was correlated with other radiological imaging and later elective resection wasperformed. This case is reported to emphasize the potential role of mesenteric angiography in the detection andmanagement of bleeding Meckel's diverticulum and correlation with other radiological imaging.Key Words: Meckel's diverticulum.   Mesenteric angiography.   Recurrent gastrointestinal haemorrhage.Department of Radiology1 / Surgery2, The Aga Khan UniversityHospital, Karachi.Correspondence: Dr. Muhammad Azeemuddin, II-A-6/24,Nazimabad, Karachi-74600.E-mail: muhammad.azeemuddin@aku.eduReceived: December 23, 2011;   Accepted: January 19, 2013.Figure 1: (a) Selective angiogram of ileocolic artery demonstrated profusebleeding from an aberrant branch of SMA. (b) The vessel was superselectively cannulated and embolised with two pushable platinum coils.the hypogastric region (Figure 2b). Findings confirmedthe presence of heterotopic gastric mucosa due toMeckel's diverticulum.After that, an open Meckel diverticulectomy wasperformed. Meckel's diverticulum was found around 2cm from ileocecal junction on the anti-mesenteric border.Patient recovered well from surgery and was dischargedon the third day. There have been no further episodes ofgastrointestinal bleeding on follow-up till 2 months aftersurgery.DISCUSSIONThere are many causes of obscured gastrointestinalhaemorrhage in young adults including angiodysplasia,diverticulitis, tumours, Crohn's disease, and NSAID-induced ulcers.2 However, haemorrhage from a Meckel'sdiverticulum is very rare in the adult age group and isusually overlooked as the possible cause of occult lowergastrointestinal bleed.7 Angiographic detection of vitello-intestinal artery plays a pivotal role in detection ofMeckel's diverticuli. The vitello-intestinal artery hasbeen seen to arise as fifth, sixth or seventh ileal branchand appears as a long branch with few or no branch.Groebli et al. found haemorrhage in 15% of symptomaticdiverticula in 52 adults.8 Mackey and colleaguesreviewed 402 patients with Meckel's diverticulum inwhich only 16.9% of the patients were symptomaticand only one quarter of them had gastrointestinalhaemorrhage.9 Haemorrhage is caused by pepticulceration produced by secretion of acid and pepsin fromectopic gastric mucosa as it was found in this case anddescribed by several authors.2,6 The traditionaldiagnostic test of choice has been the Meckel's scan, inwhich technetium-99 is taken-up by ectopic gastricmucosa but it cannot be performed in emergencysetup.10 Other options include enteroclysis, CT scan,magnetic resonance imaging, ultrasound and capsuleendoscopy.6Angiography plays a dominant role, because it canshow the bleeding site and, at the same time, provideeffective treatment of haemorrhage by transcatheterembolization.2,4 In patients with intermittent bleeding,demonstration of an abnormal embryonic arteryindicates the high probability of Meckel's diverticulum;even without active extravasation of contrast. Previousreports have also identified this abnormal arterysupplying the Meckel's diverticulum.8In this case, there was a history of recurrent lowergastrointestinal haemorrhage but there was no clinicalsuspicion of Meckel's diverticulum. Angiographic detec-tion and later confirmation by other modalities andsurgery, as in this case, is infrequent. By using micro-catheter, this artery was super selectively catheterizedand successfully embolized the bleeding vessel withlimited risk to the adjacent bowel.In conclusion, possibility of Meckel's diverticulum shouldbe suspected in adult patients with occult gastro-intestinal haemorrhage and finding of abnormal vitello-intestinal artery on mesenteric angiography.REFERENCES1. Levy AD, Hobbs CM. From the archives of the AFIP. Meckel’sdiverticulum: radiologic features with pathologic correlation.Radiographics 2004; 24:565-87.2. Lee JS, Moon W, Park SJ, Park MI, Kim KJ, Lee SH, et al.Haemorrhagic Meckel's diverticulum in an older womandiagnosed by repeated angiographies. Turk J Gastroenterol2009; 20:282-6.3. Stone PA, Hofeldt MJ, Lohan JA, Kessel JW, Flaherty SK.A rare case of massive gastrointestinal haemorrhage causedby Meckel's diverticulum in a 53-year-old man. WV Med J2005; 101:64-6.4. Mitchell AW, Spencer J, Allison DJ, Jackson JE. Meckel'sdiverticulum: angiographic findings in 16 patients. AJR Am JRoentgenol 1998; 170:1329-33.5. Geelhoed GW, Druy EM, Steinberg WM. Recurrent bleed-ing from Meckel's diverticulum in an adult: angiographicdemonstration after normal scans. South Med J 1986; 79:65-8.6. Munroe CA, Copland A, Pai R, Friedland S, Triadafilopoulos G.Meckel's diverticulum with gastrointestinal bleeding: role ofcomputed tomography in diagnosis. Dig Dis Sci 2010; 55:242-4.7. Kopácová M, Vykouril L, Vacek Z, Tycová V, Bártová J, RejchrtS, et al. Inverted Meckel's diverticulum with ectopic pancreatictissue as a source of severe gastrointestinal bleeding.J Gastrointest Surg 2010; 14:578-81. 8. Groebli Y, Bertin D, Morel P. Meckel's diverticulum in adults:retrospective analysis of 119 cases and historical review.Eur J Surg 2001; 167:518-24.9. Mackey WC, Dineen P. A fifty year experience with Meckel'sdiverticulum. Surg Gynecol Obstet 1983; 156:56-64.10. Huang MC, Huang FC, Cheng YF, Shieh CS. The value ofangiography in diagnosis of Meckel's diverticulum: case report.Chang Gung Med J 2000; 23:716-9.Muhammad Ali, Raza Sayani, Muhammad Azeemuddin, Tanveer-ul-Haq and Rizwan Khan760 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (10): 759-760Figure 2: (a) Coronal reformatted image of contrast enhanced CT scandemonstrated abnormal blind ended bowel loop in hypogastric region withenhancing walls. (b) Subsequent pertechnetate scan showed abnormaltracer accumulation in the hypogastric region.

An unsuspected bleeding Meckel\u27s diverticulum in an adult detected on mesenteric angiography

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An unsuspected bleeding Meckel\u27s diverticulum in an adult detected on mesenteric angiography

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