Complications of Meckel's diverticulum in children. Meckel's diverticulum

– a congenital anomaly of the ileum, resulting from a violation of obliteration of the proximal part of the vitelline duct. Meckel's diverticulum in children is dangerous due to its complications: bleeding, intestinal obstruction, inflammation, perforation, strangulation, and tumor processes. To diagnose Meckel's diverticulum in children, radiography of the small intestine with a barium suspension, scintigraphy, ultrasound and CT of the abdominal organs, and laparoscopy are performed. Complicated cases of Meckel's diverticulum in children require surgical tactics - resection of the diverticulum or section of the intestine.

General information

Meckel's diverticulum in children is a malformation of the small intestine, which is a pathological pouch-like protrusion in the lower third of the ileum. Meckel's diverticulum is one of the most common congenital anomalies of the gastrointestinal tract, detected in 2-3% of children, more often in boys. In half of the cases, the manifestation of clinical manifestations develops in children under 10 years of age, in the rest - under the age of 30 years. Meckel's diverticulum in children is a rather insidious pathology: it is difficult to diagnose, can have an asymptomatic course throughout life, or manifest itself as an acute abdomen in early childhood. Improving diagnostic and treatment algorithms for Meckel's diverticulum in children is an urgent task in pediatric abdominal surgery and pediatrics in general.

Causes of Meckel's diverticulum in children

Meckel's diverticulum in children is an embryonic defect, that is, it is formed during intrauterine development.

In the first months of fetal development, the embryonic vitelline duct, which is part of the umbilical cord and connects the terminal part of the ileum with the yolk sac, functions. At 3-5 months of embryonic development, obliteration of the vitelline duct and its atrophy normally occur. In the case of incomplete obliteration and preservation of the bile duct at the time of birth of the child in one form or another, the following types of anomalies are distinguished: incomplete and complete umbilical fistulas, enterocystoma, Meckel's diverticulum.

In most cases, Meckel's diverticulum in children is formed in the lower third of the ileum at a distance of 60-80 cm from the ileocecal (ileo-cecal) angle. Typically, a diverticulum is about 3-4 cm long, shaped like a cone or cylinder, and is located on the wall of the ileum opposite the mesentery. Meckel's diverticulum in children is a true diverticulum, since its wall completely repeats the morphological structure of the ileal wall. However, the diverticulum wall often contains ectopic gastric mucosa, capable of producing hydrochloric acid, or pancreatic tissue. The presence of ectopic glandular epithelium of the stomach in Meckel's diverticulum in children causes ulceration of its wall and gastrointestinal bleeding.

Meckel's diverticulum in children is often combined with esophageal atresia, anal and rectal atresia, omphalocele, and Crohn's disease.

Symptoms of Meckel's diverticulum in children

Uncomplicated Meckel's diverticulum in children is asymptomatic and may be an incidental finding during laparotomy for another disease or may not be recognized. The clinical manifestation of Meckel's diverticulum in children is usually associated with the development of complications: intestinal bleeding, inflammation (diverticulitis), intestinal obstruction (intussusception, strangulation), tumors.

Bleeding from a peptic ulcer, as the most common complication of Meckel's diverticulum in children, can be acute, profuse or chronic, hidden. A sign of intestinal bleeding with Meckel's diverticulum in children is tarry, black stool. Bleeding is accompanied by general weakness, dizziness, tachycardia, pallor, and clinical and laboratory signs of posthemorrhagic anemia. Unlike bleeding from esophageal varices or gastric and duodenal ulcers, children with complicated Meckel's diverticulum never experience "coffee-ground" vomiting.

Intestinal obstruction caused by Meckel's diverticulum in children is accompanied by nausea, vomiting, cramping abdominal pain, and increasing intoxication. Obstruction can be caused by intussusception, torsion of ileal loops around a diverticulum, or strangulation of intestinal loops.

Sometimes in children, Meckel's diverticulum becomes strangulated in the hernial sac of an inguinal or femoral hernia (Litre's hernia). If a hernia is strangulated, there is a sharp pain, tension and uncontrollability of the hernial protrusion, and the absence of a symptom of a cough impulse.

Less often than other complications, tumors of Meckel's diverticulum, both benign (hamartomas, fibroids, lipomas) and malignant (adenocarcinomas, carcinoids), occur in children. Clinical manifestations of Meckel's diverticulum tumors in children may be associated with intestinal obstruction, wall perforation, and bleeding.

Diagnosis of Meckel's diverticulum in children

Preoperative diagnosis of Meckel's diverticulum in children is established in less than 10% of cases. A physical examination usually reveals signs of muscle tension, local soreness, and peritoneal irritation. Of the laboratory tests, the most important are clinical and biochemical blood tests, feces for occult blood.

If intestinal obstruction is suspected, a plain radiography of the abdominal cavity, excision of the diverticulum of the small intestine (diverticulectomy) or segmental resection of the small intestine with end-to-end enteroenteroanastomosis is performed. In pediatric surgery, preference is given to endoscopic resection of the small intestine.

The method of choice for treating diverticulitis in children is conservative drug therapy: antibiotic infusions, injections of anti-inflammatory drugs. With the recurrent nature of inflammation of Meckel's diverticulum in children, the issue of resection of the diverticulum is resolved.

With the development of peritonitis, in addition to resection of the small intestine, it is necessary to carry out drainage and sanitation of the abdominal cavity, prescribe massive antibiotic therapy, infusion and detoxification therapy.

Prognosis of Meckel's diverticulum in children

In 95% of cases, Meckel's diverticulum remains asymptomatic throughout life; complications of Meckel's diverticulum develop in only 4-5% of children.

In case of complicated Meckel's diverticulum in children, the outcome of the disease is influenced by the timeliness of hospitalization and surgical treatment. The risk of surgical complications is low, but sometimes postoperative complications may develop.

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Meckel's diverticulum is a congenital pathological condition characterized by a pouch-like protrusion of the ileum. The length of such a blind protrusion reaches 4-6 cm, while the diameter varies within a wider range. The disease was first described by Meckel Johann Friedrich. Signs of Meckel's diverticulum directly depend on complications, but the first signal that the body gives is the presence of bright blood in the stool.

Signs of pathology and its localization

A sac-like protrusion of the ileum is formed during intrauterine development in the process of incomplete fusion of the umbilical intestinal duct (sometimes the bile duct), which should be completed by the third month of embryonic development.

The pathology is several times more common in males and is usually detected in the first years of life. In the case when such an anomaly is not detected in time in a child, in adult life the person lives with it, not even knowing about the intestinal pathology. But the asymptomatic course of the disease continues only until the necessary conditions for the development of complications are created in the body.

First manifestations of the disease:

difficulty with bowel movements;
bleeding from the anus (often blood is present in the stool);
anemia (pale skin);
nausea (sometimes with vomiting);
fever and chills (indicate the development of inflammation);
cramping pain in the lower abdomen (one of the signs of intestinal obstruction);
intoxication.

Many who are faced with a similar problem for the first time are wondering where Meckel’s diverticulum is localized. During a diagnostic study, it was revealed that the pouch-like protrusion is located between the navel and the intestine, or more precisely, on the ileum, about 60 cm from the bauginian valve (the fold at the junction of the small and large intestines).

Surgery

Surgery for Meckel's diverticulum is indicated for all patients when large protrusions are detected. Emergency surgery is necessary in the following cases:

heavy bleeding;
diverticulum size more than 2 cm;
acute inflammatory process;
twisting of the base of the saccular protrusion;
inflammation of the umbilical vessels;
fibrous cords in the abdominal cavity;
intestinal obstruction;
the ileum has thin walls;
perforation of the diverticulum wall.

Features of the operation

The purpose of the operation will be to remove the protrusion and normalize intestinal function. In most cases, the procedure consists only of excision of the diverticulum, after which the intestine is sutured in a transverse direction. In cases where the pathology has affected areas of the intestine and caused dystrophic changes in the structure, resection of this area will still be required.

In some clinics, surgeons use a special device for stitching, during which the doctor is finally convinced that the bleeding appeared precisely in the sac-like protrusion.

In cases where bleeding occurs from the intestine itself, specialists resort to segmental resection along with the diverticulum. This operation gives good results, and recurrent bleeding is practically excluded. Internal hernias or torsions of the base formed during the development of pathology need to be eliminated.

Complications of Meckel's diverticulum

According to medical observations, diverticulum causes life-threatening complications in 7% of all cases. Each requires surgical treatment.

The main complications of Meckel's diverticulum:

intussusception: a similar pathology occurs in 15-17% of all cases and is diagnosed only during surgery; pain in the lower abdomen, vomiting accompanied by nausea, as well as constipation are the first signals of the development of intestinal obstruction;
bleeding: about 30% of patients have bleeding from the anus during bowel movements; men and children aged 1-2 years are at particular risk;
umbilical pathology: diagnosed in 10% of all cases, the danger is that without treatment a hernia or volvulus may develop;
neoplasms: can occur in only 5-6% of patients, a biopsy will help determine the nature of the tumor, and other tests will help the doctor decide on treatment.

Severe complications occur in a small percentage of all patients. In order to prevent the disease from worsening, you need to pay attention to all the signals from your body and follow the recommendations of your doctor.

Both during conservative treatment, when the disease is in the first stage of development and has no complications, and after surgical treatment, a person must adhere to clinical recommendations for Meckel’s diverticulum. They come down to proper nutrition.

The nutritional peculiarity consists of the following rules:

It is recommended to drink fermented milk products daily (consuming kefir and fermented baked milk will help eliminate constipation);
it is recommended to include grain porridge and bran in the menu: these products contain dietary fiber that will help improve digestion;
it is important to exclude those foods that cause fermentation in the intestines: legumes, fresh fruits, sunflower seeds, some types of vegetables, fresh milk, white cabbage;
in order to improve the water-salt balance and normalize the absorption of coarse fibers by the intestines, you need to drink more than two liters of still water daily.

Meals should be balanced and mostly consist of liquid dishes. It is recommended to eat small meals up to 7-8 times a day. It is better to boil or bake vegetables. During treatment, you should forget about fatty and spicy foods.

Meckel's diverticulum, in most cases, occurs without visible symptoms for several years. This is the whole danger of the disease. You need to listen to your health and consult a doctor in a timely manner.

Meckel's diverticulum is a congenital defect of the ileum that occurs during fetal development. The cause of the pathology is the incorrect formation of the proximal bile duct with the formation of a pouch (diverticulum) in the lower part of the ileum near the small intestine.

This defect may not have noticeable symptoms for a long time. Clinical signs manifest themselves in the process of complications of the pathology with intestinal obstruction, hemorrhages, and severe pain.

Meckel's diverticulum is quite common in children: the anomaly occurs in 1 child out of 50 infants. The disease is included in the worldwide classification and has its own ICD code - Q43.0.

To diagnose pathology, X-rays of the small intestine, scintigraphy, ultrasound of the peritoneal organs, and laparoscopy should be performed. In cases with pathological complications, resection of the diverticulum is prescribed.

Therapeutic measures depend on the patient’s condition and the degree of complication of the disease.

Etiology

Experts note that Meckel's diverticulum is the result of incomplete healing of the gall sac during the intrauterine formation of the fetus. The embryo at the early stage of formation (from 7 weeks to 5 months) is nourished by the yolk sac (special embryonic tissue). Until the placenta has formed, the sac is located in the navel area and is connected to the small intestine of the embryo through a specific narrow channel - the vitelline duct.

When the placental umbilical cord with the placental blood circulation has completely completed its formation, the reverse process of development begins with temporary structures. The yolk sac with its duct disappears and resolves. If a malfunction occurs during this period, part of the duct connects to the small intestine, protruding on its surface - this will be a diverticulum.

The abnormal sac is 1–20 cm long and shaped like a cone or cylinder. The pathology appears within 10–30 years.

Pathology is often combined with the following diseases:

. Congenital underdevelopment of the esophagus with the absence of physiological lumen and esophageal obstruction. Symptomatically manifested by impaired breathing, problems with eating, bloating or retraction of the abdomen.
Atresia of the anus and rectum. A congenital malformation of the anorectal region, when the rectal canal and posterior opening are absent.
. Pathology of the anterior abdominal wall, which is characterized by the exit of organs beyond the peritoneum into the composition of the hernial sac.
. Pathological inflammation of various parts of the digestive system. May be accompanied by bleeding and diarrhea.

When diagnosing, a comprehensive examination is required to identify associated anomalies in the body of a child or in adults.

Classification

According to the degree of the pathological process, the course of Meckel's diverticulum is:

asymptomatic form - in 80% of cases there are no clinical manifestations;
complicated form - characterized by the presence of intestinal obstruction, bleeding, diverticulitis, requires emergency care, is found in 20% of patients;
aggravated form - aggravated by a number of chronic complications (cancer tumors, diverticulosis).

According to the development mechanism there are:

false form, where the resulting sac does not have a muscle layer and is localized in a place where there are no blood vessels;
the true form is represented by all layers of the intestinal wall.

In most cases, the disease is detected during the first ten years of a child’s life; very rarely it manifests itself in adulthood.

Symptoms

Meckel's diverticulum of an uncomplicated form without symptomatic manifestations can be detected accidentally during diagnostic measures for another disease.

Complications of the disease provoke the appearance of clinical signs:

intestinal bleeding;
tumor formation.

Hemorrhage from a peptic ulcer can be profuse (in acute form) and hidden (in chronic form). Externally, the child manifests itself as black stools, severe weakness, pale skin, and dizziness.

The acute form of the disease is similar to the acute one: pain in the abdominal area, nausea, high body temperature. Perforation may result from inflammation of the diverticulum and the development of peritonitis.

Obstruction in the intestines is accompanied by nausea, vomiting and severe.

A diverticulum can be strangulated in the hernial sac in the groin or femoral area. When compressed, the hernia causes sharp pain.

Rarely, the disease is complicated by neoplasms of a benign or malignant nature.

Diagnostics

Diagnosis of Meckel's diverticulum includes several stages:

Initial examination of the patient, palpation of the abdominal cavity.
Blood chemistry.
Stool test for the presence of occult blood.
Ultrasound examination makes it possible to see only the inflammatory process.
X-ray of the small intestine with contrast allows you to see the full picture of the disease.
Scintigraphy with a radioactive isotope makes it possible to detect hidden hemorrhage.
Computed tomography of the abdominal cavity is performed to clarify the cause of bleeding.

After a comprehensive examination, the doctor excludes related pathologies, makes a final diagnosis, and selects individual therapy. If the patient has allergic reactions to any medications, parents should be informed.

Treatment

Meckel's diverticulum in children in an asymptomatic form requires adherence to a diet and subsequent removal if the patient's age meets the acceptable norm.

The complicated form requires immediate surgical intervention to remove the formation and normalize the functioning of the intestine.

If blood loss is severe, a blood transfusion is given to stabilize the patient.

Resection of Meckel's diverticulum proceeds according to the following scheme:

Preparatory stage. The patient is prepared for the procedure to remove the anomaly.
Use of anesthesia with pain relief.
The peritoneum is opened and the diverticulum is removed along with the intestine. A small tumor is removed as with a regular appendectomy. When the diverticulum is wide with the mesentery, it is ligated and then divided to release the diverticulum. After this, a special soft pulp is applied to the intestine and the bag with the base is cut off.
The wound is sutured with a double-row transverse suture.
The edges of the abdominal cavity are pulled together and sutured.

When the anomaly is accompanied by peritonitis, drainage and sanitation of the peritoneum are added to resection. The patient receives a course of antibiotics and detoxification drugs.

Drug treatment of the disease consists of taking the following drugs:

agents that reduce the formation of gastric juice;
solutions for restoring water-salt balance;
medications to help stop bleeding;
antibiotics to relieve inflammation;
painkillers, which are prescribed for spastic pain;
means for normalizing intestinal function.

After the operation and before, the patient is prescribed a special diet. Portions become small, meals are split - 5-6 times a day. Only boiled or baked foods are acceptable. Avoid alcohol, carbonated drinks, fatty meats and raw vegetables.

Possible complications

Complications of Meckel's diverticulum appear as the pathology progresses with the occurrence of an inflammatory process, which can cause bleeding, intestinal obstruction, and there is a risk of benign or malignant tumors.

This is a congenital pathology; the only preventive measure is to follow a special diet if a latent form of the disease is detected.

The mechanism of bleeding from Meckel's diverticulum is associated with its peptic ulceration due to the secretion of hydrochloric acid by the cells of the ectopic gastric mucosa. The ileum, unlike the stomach, is not able to weaken the effect of hydrochloric acid, which leads to ulceration. The typical localization of such ulcers is at the base of the diverticulum at the border of the ectopic gastric mucosa and the normal ileal mucosa.

It is the second most common complication of Meckel's diverticulum:

intestines, caused by Meckel's diverticulum, manifests itself in children in the first years of life with repeated vomiting, paroxysmal abdominal pain, bloody discharge from the rectum, and a palpable tumor-like formation in the abdominal cavity;
intestinal obstruction caused by volvulus is clinically the most severe and is characterized by sudden paroxysmal abdominal pain. The intensity of the abdominal pain is such that the child may have a shock-like state;
The strangulation type of intestinal obstruction, caused by persistent vascular or vitelline debris, is also clinically characterized by paroxysmal abdominal pain, repeated vomiting, which may be fecal as the disease progresses.

Meckel's diverticulitis in children is clinically similar to acute diverticulitis. Inflammation of Meckel's diverticulum develops as a result of prolonged retention of its contents or obstruction of its lumen. The peptic nature of the inflammation due to ulceration of the stomach lining cannot be ruled out. Perhaps the cause of inflammation of the diverticulum is its partial or complete torsion with impaired blood supply and secondary inflammation.

Perforation of Meckel's diverticulum can be caused by the progression of inflammation in it, ulceration of the ectopic gastric mucosa.

The clinical picture of perforation of Meckel's diverticulum is similar to that of any hollow organ and is characterized by symptoms of generalized peritonitis.

Tumors of Meckel's diverticulum are very rare, with an incidence of 0.5 to 1.9%. They can be benign (neuromuscular and vascular hamartoma) and malignant (adenocarcinoma). Meckel's diverticulum carcinoid is clinically similar to appendiceal carcinoid. However, immunophenotypically and biologically it is closer to small intestinal carcinoid, which has a higher degree of metastatic activity than. The clinical manifestation of Meckel's diverticulum tumors is very diverse. They can manifest themselves as symptoms of perforation of a hollow organ, bleeding, and intestinal obstruction.

Diagnosis of Meckel's diverticulum in children

The gold standard in the diagnosis of Meckel's diverticulum complicated by bleeding can be considered scintigraphy using isotopes (technetium pertechnetate). The high diagnostic sensitivity of this method is based on the fact that in 95% of patients the bleeding diverticulum contains ectopic gastric mucosa, capable of accumulating the isotope. Normally, a high concentration of the isotope is determined in the stomach and bladder. A positive conclusion about the diagnosis is made if the isotope accumulates in addition to the indicated organs. Most often, the accumulation of radionuclide with diverticulum is observed in the right lower quadrant of the abdomen. The diagnostic accuracy of scintigraphy can be increased by using pentagastrin, which can enhance the absorption capacity of the gastric mucosa, or glucagon to inhibit intestinal motility and retain the isotope in the diverticulum.

The next step in the diagnosis of bleeding Meckel's diverticulum in children is laparoscopy, especially with negative scintigraphy findings and ongoing bleeding.

For Meckel's diverticulum it is useful in 50% of children with diverticulitis.

Treatment of Meckel's diverticulum in children

Surgical removal of Meckel's diverticulum is the method of choice in the treatment of complicated forms. However, there are contradictions in treatment tactics when a diverticulum is accidentally discovered during other operations.

There is an opinion that Meckel's diverticulum should be removed in all cases when it becomes complicated. In complicated forms of acute appendicitis, an accidentally discovered Meckel's diverticulum should be left, while in uncomplicated forms, an intact diverticulum should be removed.

Resection of complicated Meckel's diverticulum in adult patients is accompanied by complications in 0.2% of cases and mortality in 0.04% of cases. Whereas during resection of an incidentally discovered uncomplicated diverticulum, the complication rate is 4.6%, and the mortality rate is 0.2%.

Surgical treatment for Meckel's diverticulum in children consists of its resection (diverticulectomy) or resection of part of the ileum along with the diverticulum and subsequent enteroanastomosis. The operation can be performed laparotomically or laparoscopically.

When choosing a method of surgical treatment, one should remember that there is a danger of leaving areas of ectopic gastric mucosa or, in cases of bleeding, of maintaining ulcerated tissue on the mesenteric edge of the intestine. For example, a short diverticulum less than 2 cm long always has a more extensive distribution of ectopic gastric mucosa, affecting the entire diverticulum and its base (up to 60% of all cases). This circumstance may limit the use of laparoscopy in the resection of Meckel's diverticulum.

Undoubtedly, laparoscopy serves as a minimally invasive method in the diagnosis and treatment of Meckel's diverticulum in children. A long diverticulum with a narrow base can be removed using the . However, it is advisable to resect short diverticula with a wide base within intact areas of the ileum, followed by end-to-end enteroanastomosis.

The article was prepared and edited by: surgeon