Who was Hilidanus

A. Adegbesan,
 Case 1

68 year old lady admitted with a 2 day history of

diffuse abdominal pain and vomiting.
Acute onset intermittent sharp epigastric pain,
rated 7/10 with no aggravating or relieving
factors.
Bowel motion and flatus last passed 3 day
previously
Poor appetite.
No recent alcohol ingestion as per patient.
 Case History
Past Medical History:
PUD
Hiatus hernia
Chronic Kidney Disease
COPD

Past Surgical History

Hysterectomy
Cholecystectomy
Appendectomy
 Case History
Family History
Nil significant
Social History
Ex smoker
ROS:
Nil significant
 On Examination
Vital Signs:
BP 111/74
HR 92
Temp 36.2
RR 16
O2 SATS 100% on RA
Abdomen was not distended. Tenderness in
epigastrium with mild guarding. No rebound.
Bowel sounds exaggerated. Hernial orifices
were intact.
 Investigations
WCC 7.4; Hb 13.3; Plts 433; CRP 17
Urea 42; Na 125; K 7.4; Creat 609 (baseline
60-120)
ABG: pH 7.38, pCO2 4.57, pO2 12.4, HCO3 20
Amylase 160
ECG: NSR; tachycardic; tented T waves
CXR: no free air under diaphragm.
PFA: prominent small bowel loops
 Management
Initially admitted medically with
Acute on chronic renal failure
Dehydration

Upon surgical review:

Features of small bowel obstruction for
conservative management.
 Management
Day 1 post admission:
Abdomen now distended, non tender, BS
present. PFA showed progression - ? small
bowel obstruction 2o to adhesions.

Day 2 post admission:

Medical review re: acute renal failure, hyperkalaemia
and hyponatraemia.
Surgical team review
To continue conservative management
NG tube and urinary catheter placed
 Management

Day 5 post admission:

Renal failure indices resolved
Abdominal distension still persistent
Obstipated
PFA showed increasing bowel dilatation
NG tube active
Proceeded to laparotomy
 Operative findings
Small bowel volvolus with fulcrum around
meckels diverticulum adherent to pelvic
sidewall.
Merckels diverticulum and adjacent small
bowel were resected and sent for
histology.
Side to side anastomosis
 Post Operative
The post operative period was uneventful.

Histology
Gastric body type mucosa
No helicobacter pylori
No evidence of malignancy
 Case 2
31 year old gentleman admitted with:
1/7 history of sudden onset non-radiating
colicky lower abdominal pain.
No associated nausea, vomiting or altered
bowel habit.
No previous medical/surgical hx.
ROS nil significant
 On Examination
Vital Signs:
BP 115/68
HR 93
O2 SATS 99% on RA
Apyrexial 36.2oC

On examination:
Tenderness and guarding in lower abdomen
Reduced bowel sounds.
 Investigations
Urinalysis
NAD
Bloods
WCC 13.4 (neuts 10.58), Hb 13.4, CRP 49, Amylase
107
Sickle cell screen negative
CXR
No air under the diaphragm
PFA
Bowel gas pattern normal. No bowel distension or
obstruction. No free air.
 Investigations
CT Abdomen/Pelvis
Minor stranding of fat around a loop of small
bowel in right lower quadrant (differential
included inflammatory change around a
meckels diverticulum)
Small nodes in the adjacent mesentery.
No evidence of large colonic diverticulitis and
normal appearance of the appendix.
CT Abdo/Pelvis
 Management
On admission:
IV fluids, co-amoxiclav and analgesia

Day 2 post admission:

Proceeded to Laparoscopy:
Operative findings:
Perforated merckels diverticulum which was resected at its
base using Endo GIA and sent for histology
Appendix long and injected but not acutely inflamed - most
likely not the cause of his symptoms but removed.
 Histological Findings

Ectopic gastric tissue at the fundus of the

meckels diverticulum.
The excised edge was free of ectopic
gastric tissue
 Introduction
A true congenital diverticulum, a congenital
bulge in the small intestine.
It is a vestigial remnant of the
omphalomesenteric duct
is the most frequent malformation of the
gastrointestinal tract
It was first described by Fabricius Hildanus,
German surgeon, in 1598
Johann Friedrich Meckel, described the
embryological origin of this type of diverticulum
in 1809
 Pathophysiology
It is a vestigial remnant of the
omphalomesenteric (vitellointestinal) duct
Human embryos initially have convex umbilical
loops of primitive gut that communicate freely
with the yolk sac through the
omphalomesenteric (vitellointestinal) duct
As development proceeds, the duct normally
becomes occluded and disappears entirely by
weeks 8-10 of gestation
Results from the failure of the vitelline duct to
obliterate during the fifth week of fetal
development
 Pathophysiology
The following anomalies are caused by the persistence
of the omphalomesenteric (vitellointestinal) duct
 Epidemiology
Autopsy records show an incidence of
about 2% in the general population.
For asymptomatic diverticula there is no
gender predominance,.
For symptomatic diverticula some studies
give a 3:1 male to female ratio, while
others have detected little difference.
The risk of complications ranges from 4-
25% in various studies.
 Anatomic Considerations
Meckel's diverticulum is located in the
distal ileum, on its antimesenteric border.
usually within about 60-100 cm of the
ileocecal valve
It can also be present as an indirect
hernia, typically on the right side, where it
is known as a "Hernia of Littre."
 Anatomic consideration
Topography of abdomen
 Anatomic Considerations
A memory aid is the rule of 2's:
2% (of the population)
2 feet (from the ileocecal valve)
2 inches (in length)
2% are symptomatic
2 types of common ectopic tissue (gastric 80% ,
pancreatic, colonic and other tissues 20%),
The most common age at clinical presentation is
2, and
males are 2 times as likely
 Clinical features
Asymptomatic in majority of cases
Painless rectal bleeding,
Intestinal obstruction,
Volvulus and Intussusception.
Meckel's diverticulitis may present with all the
features of acute appendicitis.
Epigastric pain & Bloating
Neoplasm - lipoma, leiomyoma, neurofibroma
and angioma, leiomyosarcoma and carcinoid,
which represent about 80% & adenocarcinoma
and metastatic lesions
 Diagnosis
A technetium-99m (99mTc) pertechnetate scan
is commonly used to diagnose Meckel's
diverticulum Gastric tissue.
Abd CT
Barium studies to out rule enterocolitis and
intussuception
Laparoscopy
A bleeding scan.
Selective arteriography
Wireless capsule endoscopy
Abd USS
 Treatment

Surgical for symptomatic Merckels diverticulum

Incidental Meckels diverticulum in asymptomatic
patients remains controversial Narrow vs wide
Excision is carried out by performing a wedge
resection of adjacent ileum and anastomosis
a primitive persistent right vitelline artery
originating from the mesentery has been found
during operation - Bleeding
 Histology
Heterotropic gastric mucosa 62%
pancreatic tissue 6%,
Both pancreatic tissue and gastric mucosa
were found in 5%,
Jejunal mucosa was found in 2%,
Brunner tissue was found in 2%, and
Both gastric and duodenal mucosa were
found in 2%
 Take home message
Meckel's diverticulum is the most common
congenital abnormality of the
gastrointestinal tract.
it is often difficult to diagnose
It may remain asymptomatic
it may mimic disorders such as Crohn's
disease, appendicitis, peptic ulcer disease,
obstruction and bleeding.
 Thank you

Who should take credit for this clinical

entity
Fabricius Hildanus,, in 1598
Johann Friedrich Meckel, 1809