Bleeding Meckel's diverticulum diagnosed and treated by double-balloon enteroscopy

Heterotopic pancreas in Meckel's diverticulum causing perforation in an infant: a case report

Perforation of Meckel's diverticulum caused by heterotopic pancreas is a rare condition. Despite recent improvements in imaging studies, Meckel"'s diverticulitis and heterotopic pancreas are difficult to diagnose preoperatively and are often diagnosed during autopsy or laparotomy. Symptomatic patients are typically >1 year, and cases of infants displaying symptoms are rarely reported. We report a rare case of heterotopic pancreas in Meckel's diverticulum causing perforation in an infant. In cases of infants presenting with unexplained acute abdominal pain, there should be a high index of suspicion for congenital gastrointestinal malformations. Prompt action in the form of exploratory laparotomy or laparoscopy is crucial to prevent the escalation of complications and to definitively confirm the diagnosis.

Clinical Practice Guideline for Enteroscopy

Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.

Balloon-assisted enteroscopy for suspected Meckel’s diverticulum and indefinite diagnostic imaging workup

Meckel’s diverticulum (MD) is estimated to affect 1%-2% of the general population, and it represents a clinically silent finding of a congenital anomaly in up to 85% of the cases. In adults, MD may cause symptoms, such as overt occult lower gastrointestinal bleeding. The diagnostic imaging workup includes computed tomography scan, magnetic resonance imaging enterography, technetium 99m scintigraphy (99mTc) using either labeled red blood cells or pertechnetate (known as the Meckel’s scan) and angiography. The preoperative detection rate of MD in adults is low, and many patients ultimately undergo exploratory laparoscopy. More recently, however, endoscopic identification of MD has been possible with the use of balloon-assisted enteroscopy via direct luminal access, which also provides visualization of the diverticular ostium. The aim of this study was to review the diagnosis by double-balloon enteroscopy of 4 adults with symptomatic MD but who had negative diagnostic imaging workups. These cases indicate that balloon-assisted enteroscopy is a valuable diagnostic method and should be considered in adult patients who have suspected MD and indefinite findings on diagnostic imaging workup, including negative Meckel’s scan.

Meckel's diverticulum in an adult: an obscure presentation of gastrointestinal bleeding

A 17-year-old boy, with a background of haemophilia A, presented to hospital with an episode of brisk and painless per rectal (PR) bleeding. Initial investigation with gastroscopy and colonoscopy revealed no source of bleeding. Examination of the small bowel including MRI, CT angiogram and capsule endoscopy revealed no abnormalities. Double balloon enteroscopy (DBE) from an antegrade position was attempted, with no abnormalities noted. The symptoms persisted and DBE was attempted again from a retrograde approach and a diverticulum was subsequently noted. Laparoscopic surgery was performed identifying a diverticulum as the source of bleeding, 110 cm from the ileocaecal valve, which is more proximal than is normally seen. Histological examination revealed a Meckel's diverticulum. The case described here, although more unusual in adults, demonstrates that complete visualisation of the small bowel remains challenging and that newer modalities of enteroscopy including DBE can help aid in the diagnosis of obscure gastrointestinal bleeding.

Diagnosis and minimally invasive surgical treatment of bleeding Meckel's diverticulum in children using double-balloon enteroscopy

BACKGROUND/PURPOSE

To demonstrate the diagnosis of bleeding Meckel's diverticulum (MD) using double-balloon enteroscopy (DBE) and to highlight the utility of this technique for guidance in minimally invasive surgery.

MATERIALS AND METHODS

From August 2011 to September 2014, 21 pediatric patients with bloody diarrhea underwent transanal DBE examinations. When a lesion such as MD or a tumor was detected, the enteroscopic light source was brought as close to the umbilicus as possible. A small incision was made at the umbilicus, and the lesion indicated by the enteroscopic light source was pulled out of the umbilicus for lesion removal and intestinal anastomosis. If no lesion was detected, the DBE exam was ended after the scope had been advanced at least 200 cm into the ileum. All patients were followed closely after discharge.

RESULTS

Fourteen children were diagnosed with MD and underwent successful removal via an umbilical incision using enteroscopic light guidance; a standard resection was then performed. Two patients were diagnosed with lymphoma and successfully treated using the same method. Five patients had negative enteroscopic findings. Of these, a 4-year-old boy had recurrent bloody diarrhea and a negative laparoscopic evaluation after 7 months. In 4 patients, bloody diarrhea did not recur during follow-up.

CONCLUSIONS

DBE is an ideal tool for the diagnosis and minimally invasive treatment of bleeding MD in children.