Bleeding Meckel’s Diverticulum in a 33-Year-Old Female Diagnosed with Video Capsule Endoscopy and a Technetium-99 m Pertechnetate Scan with a Favorable Response to H2 Blocker and PPI

Meckel’s diverticulum is a true diverticulum consisting of all three layers of the small intestine resulting from incomplete regression of the vitelline duct. While it is often benign, it can present with serious complications such as intussusception, ulceration, torsion, hemorrhage, obstruction, inflammation, and fistula formation. Although it typically presents in infancy and early childhood, it can also manifest much later into adulthood. We report a case of Meckel’s diverticulum complicated by significant bleeding in a 33-year-old female patient. Diagnosis was accomplished with video capsule endoscopy and a technetium-99 m pertechnetate scan. The patient responded well to acid suppression, initially with an H2 blocker and later with a PPI (proton pump inhibitor), and remained asymptomatic for nearly four months in the interim to definitive surgical treatment. Microscopic examination of the resected diverticulum confirmed the presence of ectopic gastric mucosa. A PubMed literature search revealed several similar cases of Meckel’s diverticulum complicated by hemorrhage with a favorable response to H2 blockers and PPIs. While surgical resection remains the mainstay of definitive treatment, medications aimed at acid suppression can delay the need for urgent surgery, allow for diagnostic assessment, and optimize conditions for elective surgical treatment.

Meckel’s diverticulum with intraperitoneal hemorrhage in a child detected with screening laparoscopy: a case report

Background The most common presentation of symptomatic Meckel’s diverticulum (MD) are intestinal obstruction, gastrointestinal hemorrhage, and inflammation of the MD with or without perforation. Intraperitoneal hemorrhage because of MD is extremely rare. We report a case of MD with intraperitoneal hemorrhage in a child detected with screening laparoscopy. Case presentation An 11-year-old girl presented to another hospital with lower abdominal pain and vomiting that lasted for 2 days. Acute appendicitis was suspected, and she was referred to our department. Abdominal enhanced computed tomography showed an abscess in the lower abdomen with ascites in the pelvis. She was diagnosed with a localized intra-abdominal abscess and the decision was made to treat with antibiotics. However, her abdominal pain worsened, with abdominal distension, tenderness and guarding. She was diagnosed with panperitonitis and the decision was made for surgery 5 h after admission. During surgery, laparoscopic observation from the umbilical region revealed 200 ml of fresh blood throughout the peritoneal cavity, originating from the mesentery of the ileum. MD was observed with bleeding from the surrounding mesentery. Small bowel resection was performed, and the patient was discharged on the 5th postoperative day. Pathological findings revealed an MD containing ectopic gastric mucosa and small intestinal ulcer perforation at the base of the MD. Conclusions We report an extremely rare case of an MD with intraperitoneal hemorrhage in a child. In pediatric cases, it is possible that perforation with ectopic gastric mucosa may cause massive bleeding because of rupture of the surrounding mesenteric blood vessels.

Gastric antral duplication cyst: A case report

Alimentary tract duplications may be symptomatic or may be discovered incidentally. They are named for the organ with which they are associated.1 Congenital gastrointestinal (GI) tract duplication cysts are commonly located in the ileum (53%), mediastinum (18%), colon (13%), stomach (7%), duodenum (6%), rectum (4%), or oesophagus (2%)2. A single theory is insufficient to explain all types of duplications.3 Children may present with symptoms like vomiting, abdominal pain, lumps, or weight loss.4 The presence of ectopic gastric mucosa and the potential for malignancy remain matters of concern.2 Surgical management is essential for these rare cysts.5 We encountered a Bangladeshi boy with a gastric duplication cyst (GDC) that was pre-operatively diagnosed as a pancreatic cyst. A variety of imaging modalities failed to indicate GDC before the operation. Here we present the clinical course of the case and discuss the difficulties and problems in diagnosing GDC.

CA19-9-producing esophageal adenocarcinoma originating from the esophageal cardia of the mid-thoracic esophagus: a case report

Background Although there are many studies on primary esophageal adenocarcinoma arising from Barrett's esophagus or ectopic gastric mucosa, reports on adenocarcinoma arising from esophageal cardiac glands are extremely rare. Herein, we report a case of mid-thoracic cancer antigen 19-9 (CA 19-9)-producing primary esophageal adenocarcinoma, which presumably originated from the cardiac glands. Case presentation A 74-year-old man was referred to our department with advanced esophageal cancer, which initially presented with dyspepsia. Serum levels of cancer antigen 19-9 (CA 19-9) were elevated (724.89 U/ml). Upper gastrointestinal endoscopy revealed a type 2 tumor on the posterior wall of the mid-thoracic esophagus approximately 29–32 cm from the incisor. Mucosal biopsy was consistent with a diagnosis of adenocarcinoma. Contrast-enhanced computed tomography showed a circumferential wall thickening in the mid-thoracic esophagus without enlarged lymph nodes or distant metastasis. Positron emission tomography–computed tomography showed accumulation in the primary tumor, but no evidence of lymph node or distant metastasis. According to these findings, the adenocarcinoma was staged as cT3N0M0, thereby, requiring subtotal esophagectomy with lymph node dissection. Postoperative course was uneventful. Histopathologic analysis revealed a 50 × 40 mm moderately differentiated adenocarcinoma with invasion to the thoracic duct and lymph node metastasis at #108(1/4), #109R(1/3), and #109L(1/3). After surgery, the stage was revised to moderately differentiated pT4apN2pM0 (pStage III). Immunostaining revealed expression of CA19-9 and suggested esophageal cardiac gland origin of the tumor. Three months after the surgery, the patient showed no recurrence and is undergoing outpatient observation. Conclusions We experienced a case of mid-thoracic CA19-9-producing primary esophageal adenocarcinoma, which was presumed to have originated in the esophageal cardiac glands. Due to the scarcity of studies regarding this condition, specific management needs to be further clarified.

Practical advantage of SPECT/CT image co-registration for accurate bleeding Meckel’s diverticulum localization in pediatrics: A case report

Planar scintigraphy with 99mTc-pertechnetate or Meckel scan is the gold standard in the diagnosis of a bleeding Meckel’s diverticulum (MD) for pediatrics. However, several setbacks may occur during the interpretation of a scintigram, especially in cases of an atypical MD presentation. In this report, we highlight the importance of functional and anatomical image co-registration using a hybrid SPECT/CT scanner to precisely localize a MD lesion. An 18-month-old boy presented with severe hematochezia over 4 days with declining hemoglobin levels. He underwent a conventional 60-min dynamic planar imaging of the Meckel scan. Upon review of the Meckel scan, a suspicious increase in the 99mTc-pertechnetate uptake was observed at the right upper quadrant of the abdomen. Due to its atypical location at the right kidney, we could not differentiate between a physiological uptake of the right kidney or an ectopic gastric mucosa. The patient was imaged again using single-photon emission computed tomography (SPECT) and low-dose CT protocol with a hybrid SPECT/CT scanner, and the co-registration of both SPECT and CT images was able to confirm the MD, which was located anterior to the right kidney at the right hepatic flexure region. An exploratory laparotomy was then ensued to remove the bleeding MD. The patient was discharged after 3 days with no complications. In summary, this case illustrates that hybrid imaging modality and co-registration allow for a more definitive diagnosis, as well as a more precise localization of MD.

The Clinical Manifestation Variety and Management Choice of Meckel’s Diverticulum with Complication: A Single Center Experience

Background. The study was to analyze the clinical manifestation variety and management choices of symptomatic Meckel’s diverticulum in children. Methods. From July 2008 to October 2018, 28 cases of Meckel’s diverticulum with a variety of complications were admitted to our hospital. The clinical data included age, gender, symptoms and signs, investigations, intraoperative and pathological findings, and outcome. Results. The ratio of males to females was 2.5 : 1. The diagnoses were made by 99mTc-pertechnetate scan (in 5 cases) and by exploratory laparotomy (in 2 cases). The initial diagnosis in the other cases includes intussusception (in 4 cases), acute appendicitis (in 5 cases), intestinal obstruction (unknown origin), peritonitis, and even shock in 12 cases. Laparoscopic surgery was performed in 8 cases; 18 cases underwent open surgery. Excision of partial bowel segment with diverticulum and primary anastomosis was done in 22 cases and wedge resection of diverticulum in 4 cases. Two other cases received nonoperative therapy and went to other hospitals to receive surgical management. Ectopic gastric mucosa in the diverticulum was found in 9 cases, including 6 cases with lower gastrointestinal bleeding. Conclusion. The clinical characteristics of Meckel’s diverticulum varied. Children with hematochezia, peritonitis, and intestinal obstruction without history of prior abdominal operation should be suspected with this disease until proven otherwise. Hematochezia is often associated with ectopic gastric mucosa in the diverticulum. Laparoscopic surgery should be one of the choices for the diagnosis and treatment of Meckel’s diverticulum with complications.

Intussusception caused by a small intestinal lipoma with ectopic gastric mucosa containing gastric cystica profunda component cells within the inverted Meckel’s diverticulum: a case report

Background Lipomas are the most common cause of intussusception in adults. To our knowledge, however, no cases of lipoma and ectopic gastric mucosa with gastritis cystica profunda (GCP) have been reported. We report a case of intussusception caused by a small intestinal lipoma with ectopic gastric mucosa containing GCP-component cells within the inverted Meckel’s diverticulum. Case presentation A female in her 40s underwent computed tomography for postoperative follow-up of left breast cancer. A tumor, suspected to be a lipoma, was found in the ileum. Since there were no symptoms, the patient underwent regular follow-up. However, gradual enlargement was observed, and surgery was recommended due to the risk of intussusception. After reduction via the Hutchinson technique, laparoscopically assisted partial resection of the small intestine was performed due to suspicion that the tumor was causing intussusception starting from the ileum. Histopathologic examinations revealed proliferation of mature adipose tissue in the subserosal layer, which was diagnosed as lipoma. Furthermore, adipose tissue was found in the stem area and accordingly, we diagnosed lipoma associated with the inverted Meckel’s diverticulum. Moreover, gastric mucosa-like crypt epithelium and proper glandular tissue were identified in the mucosal membrane at the area of onset, and signs of gastric pit dilatation over the submucosa and crypt epithelium hyperplasia were observed. Diagnosis was ectopic gastric mucosa containing GCP component tissue. Conclusions Intussusception in the small intestine complicated with lipoma and ectopic gastric mucosa with GCP within the Meckel’s diverticulum has not been reported, demonstrating the rarity of our case.