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

- a congenital anomaly of the ileum, resulting from a violation of the obliteration of the proximal part of the vitelline duct. Meckel's diverticulum in children is dangerous for its complications: bleeding, intestinal obstruction, inflammation, perforation, infringement, tumor processes. In order to diagnose Meckel's diverticulum in children, an x-ray 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 part of the intestine.

General information

Meckel's diverticulum in children is a malformation of the small intestine, which is a pathological sac-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, may have an asymptomatic course throughout life, or manifest itself as a clinic of an acute abdomen already in early childhood. Improving diagnostic and therapeutic algorithms for Meckel's diverticulum in children is an urgent task of 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 in the process of intrauterine development.

In the first months of fetal development, the embryonic yolk duct functions, which is part of the umbilical cord and connects the terminal part of the ileum with the yolk sac. 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 by the time of the birth of the child in one form or another, the following types of anomalies are distinguished: incomplete and complete fistulas of the navel, 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 (ileocecal) angle. Typically, the diverticulum is about 3–4 cm long, cone or cylinder shaped, and is located on the wall of the ileum opposite the mesentery. Meckel's diverticulum in children refers to true diverticula, since its wall completely repeats the morphological structure of the ileum wall. However, the wall of the diverticulum 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 atresia of the esophagus, atresia of the anus and rectum, omphalocele, 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 (invagination, strangulation), tumors.

Bleeding from a peptic ulcer, as the most common complication of Meckel's diverticulum in children, can be acute, profuse or chronic, latent. A sign of intestinal bleeding in Meckel's diverticulum in children is tarry, black stools. Bleeding is accompanied by general weakness, dizziness, tachycardia, pallor, 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 grounds" 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 the ileal loops around the diverticulum, or strangulation of the intestinal loops.

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

Less often than other complications, Meckel's diverticulum tumors occur in children, both benign (hamartomas, fibroids, lipomas) and malignant (adenocarcinomas, carcinoids). 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

The preoperative diagnosis of Meckel's diverticulum in children is established in less than 10% of cases. Physical examination usually shows signs of muscle tension, local tenderness, and peritoneal irritation. Of the laboratory studies, the most important are clinical and biochemical blood tests, feces for occult blood.

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

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

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, the appointment of massive antibiotic therapy, infusion and detoxification therapy.

The prognosis of Meckel's diverticulum in children

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

In the complicated course of Meckel's diverticulum in children, the outcome of the disease is affected by the timeliness of hospitalization and surgical treatment. The risk of surgical complications is low, but sometimes it is possible to develop postoperative

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

Signs of pathology and its localization

The saccular protrusion of the ileum is formed even 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 embryo development.

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

The first manifestations of the disease:

difficulty with defecation;
bleeding from the anus (often blood is present in the stool);
anemia (pallor of the 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 first encountered a similar problem are wondering where Meckel's diverticulum is localized. During a diagnostic study, it was revealed that the saccular protrusion is located between the navel and the intestines, and to be more precise, on the ileum, about 60 cm from the Bauhinian damper (a fold at the site of fusion 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 larger than 2 cm;
acute inflammatory process;
twisting of the base of the saccular protrusion;
inflammation of the umbilical vessels;
fibrous bands in the abdominal cavity;
intestinal obstruction;
the ileum has thin walls;
perforation of the wall of the diverticulum.

Features of the operation

The purpose of the operation will be to remove the protrusion and normalize bowel function. In most cases, the procedure consists only in excising the diverticulum, after which the intestine is sutured in the transverse direction. In cases where the pathology has affected parts 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 in the sac-like protrusion.

In cases where bleeding occurs from the intestine itself, specialists resort to segmental resection along with the diverticulum. Such an operation gives good results, and repeated bleeding is practically excluded. Formed during the development of the pathology, internal hernias or inversions of the base need to be eliminated.

Complications of Meckel's diverticulum

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

The main complications of Meckel's diverticulum:

intestinal invagination: 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, and constipation are the first signals of the development of intestinal obstruction;
bleeding: about 30% of patients have bleeding from the anus during defecation, in a special risk group are men and children aged 1-2 years;
umbilical pathology: diagnosed in 10% of all cases, the danger is that, without treatment, a hernia or intestinal volvulus may develop;
neoplasms: may 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 worsening of the course of the disease, you need to pay attention to all the signals of your body and follow the recommendations of your doctor.

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

The nutritional requirements are as follows:

it is recommended to drink fermented milk products daily (the use of kefir and fermented baked milk will help eliminate constipation);
it is shown to include cereals 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, certain 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 non-carbonated water daily.

Nutrition should be balanced and consist mostly of liquid foods. It is recommended to eat small meals up to 7-8 times a day. Vegetables are best boiled or baked. At the time of treatment, you should forget about fatty and spicy foods.

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

Meckel's diverticulum is a congenital malformation 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 sac (diverticulum) in the lower part of the ileum near the small intestine.

This defect may not have bright symptoms for a long time. Clinical signs are manifested in the process of complication of pathology with intestinal obstruction, hemorrhages, severe pain.

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

To diagnose the pathology, an X-ray of the small intestine, scintigraphy, ultrasound of the peritoneal organs, and laparoscopy should be performed. In cases with a complication of the pathology, resection of the diverticulum is prescribed.

Therapeutic measures depend on the patient's condition, the degree of complication of the disease.

Etiology

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

When the placental umbilical cord with placental circulation completes its formation, the reverse process of development begins with temporary structures. The yolk sac with its duct falls off and dissolves. If a failure occurs during this period, part of the duct connects to the small intestine, protruding on its surface - this will be the diverticulum.

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

Pathology is often combined with such diseases:

. Congenital underdevelopment of the esophagus with the absence of a 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. Congenital malformation of the anorectal region, when there is no canal of the rectum and posterior opening.
. 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, diarrhea.

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

Classification

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

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

According to the mechanism of development, there are:

a false form, where the formed bag does not have a muscle layer and is localized in the place where there are no 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 may be detected by chance, during diagnostic measures for another disease.

Complication of the disease provokes the appearance of clinical signs:

intestinal bleeding;
tumor formation.

Bleeding from a peptic ulcer can be profuse (acute) or latent (chronic). Outwardly, it manifests itself in a child with black stools, severe weakness, pallor of the skin, dizziness.

The acute form of the disease resembles an acute one: pain in the abdomen, nausea, high body temperature. Perforation may result from inflammation of the diverticulum and the development of peritonitis.

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

The diverticulum may be strangulated in the hernial sac in the groin or femur. When squeezed, 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.
Analysis of feces 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.
Radioactive scintigraphy - makes it possible to detect latent 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 an allergic reaction to any medication, parents should be informed.

Treatment

Meckel's diverticulum in asymptomatic children requires a diet and subsequent removal if the patient's age is within the acceptable range.

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

With severe blood loss, a blood transfusion is prescribed to stabilize the patient.

Resection of Meckel's diverticulum is carried out according to the following scheme:

Preparatory stage. The patient is prepared for the procedure for removing the anomaly.
The use of anesthesia with anesthesia.
The peritoneum is opened and the diverticulum is removed along with the intestine. The formation of a small size is eliminated as with a conventional appendectomy. When the diverticulum is wide with a mesentery, it is ligated and then transected to release the diverticulum. After that, 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 the resection. The patient receives a course of antibiotics and detoxification drugs.

Drug treatment of the disease consists of taking such drugs:

drugs that reduce the formation of gastric juice;
solutions for restoring the water-salt balance;
medicines that help stop bleeding;
antibiotics to relieve the inflammatory process;
painkillers, which are prescribed for spastic pain;
means to normalize the work of the intestines.

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

Possible Complications

Complications of Meckel's diverticulum appear in the process of progression of the pathology with the onset of an inflammatory process, due to which bleeding may open, intestinal obstruction may occur, there is a risk of benign or malignant tumors.

This is a congenital pathology, the only preventive measure is the observance of a special diet in case of detection of a latent form of the disease.

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

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

intestines, caused by Meckel's diverticulum, manifests itself in children of 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 pain in the abdomen. The intensity of pain in the abdomen is such that the child may have a shock-like state;
the strangulation type of intestinal obstruction caused by persistent vascular or yolk residues 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 a prolonged retention of its contents or obstruction of its lumen. The peptic nature of inflammation due to ulceration of the stomach lining is not excluded. 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 perforation of any hollow organ and is characterized by symptoms of generalized peritonitis.

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

Diagnosis of Meckel's diverticulum in children

Isotope scintigraphy (technetium pertechnetate) can be considered the gold standard in the diagnosis of Meckel's diverticulum complicated by bleeding. The high diagnostic sensitivity of this method is based on the fact that in 95% of patients the bleeding diverticulum contains an 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 in case of accumulation of the isotope in addition to the indicated organs. Most often, the accumulation of a radionuclide in diverticulum is noted in the right lower quadrant of the abdomen. The diagnostic accuracy of scintigraphy can be improved 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 findings of scintigraphy and ongoing bleeding.

In 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 controversies in the tactics of treatment in case of accidental detection of a diverticulum during other operations.

There is an opinion that Meckel's diverticulum should be removed in all cases with its complication. In complicated forms of acute appendicitis, an incidentally 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%. Whereas during resection of an accidentally 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 in its resection (diverticulectomy) or in the resection of a 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, it should be remembered that there is a risk of leaving areas of ectopic gastric mucosa or, in cases of bleeding, preserving ulcerated tissues on the mesenteric edge of the intestine. For example, a short diverticulum less than 2 cm long always has a more extensive distribution of the ectopic gastric mucosa, with damage to the entire diverticulum and its base (up to 60% of all cases). This circumstance may limit the use of laparoscopy in 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 on a narrow base can be removed using the . However, it is advisable to resect short diverticula with a wide base within the unchanged areas of the ileum, followed by end-to-end enteroanastomosis.

The article was prepared and edited by: surgeon