Meckel's diverticulum was first described by Fabricius Hildanus in 1598. [1] It represents the patent intestinal end of the vitelline canal and has all three layers of the intestine. In 1907, Salzer described the presence of ectopic gastric mucosa in Meckel's diverticulum. Approximately 50% have heterotopic mucosa, of which 60% are gastric and 15% pancreatic. [2] Various anomalies include a fibrous band from the distal ileum to the anterior abdominal wall, an umbilical-intestinal fistula, a mucosa-lined cyst, or sometimes an umbilical sinus, with Meckel's diverticulum being the most common anomaly. It occurs in approximately 2% of the population, with a male-to-female ratio of 2:1. It is usually located 40–70 cm from the ileocecal valve. [3] [4] Meckel's diverticulum, involving all layers of the intestinal wall, usually remains asymptomatic. However, less than half contain gastric mucosa, which can produce acid, leading to ulceration in the diverticulum or adjacent ileum, causing gastrointestinal bleeding. [4] The presence of heterotopic tissue can lead to complications such as bleeding, chronic peptic ulceration, intestinal obstruction, and perforation.

Although Meckel's diverticulum generally remains asymptomatic, it can present with life-threatening complications such as intestinal obstruction, perforation, and bleeding [5] that mimic common gastrointestinal disorders such as appendicitis, leading to diagnostic problems. Most cases are diagnosed intraoperatively. Meckel's diverticulum is a true diverticulum containing all layers of the bowel and is usually located at the antimesenteric border. It is usually lined by intestinal mucosa but may also contain heterotopic gastric or pancreatic tissue and, less commonly, colonic, endometrial, or hepatobiliary tissue.

 Meckel's diverticulum is the result of failure of regression of the vitelline duct to the 5th-7th week of gestation, which may also lead to a fibrous band attaching the distal ileum to the abdominal wall, fistula, or umbilical sinus. [6] Most patients are asymptomatic; the lifetime risk of developing complications is 4–6%. Bleeding is the most common complication in adults and the second most common in children, often due to ulceration caused by heterotopic gastric or pancreatic mucosa. Obstruction, the most common complication in children and the second most common in adults, can result from volvulus, intussusception, Littre's hernia, adhesion and kinking, or stricture secondary to chronic diverticulitis. [7] [8]

Diagnostic modalities include ultrasonography and contrast computed tomography. If conservative methods fail to control bleeding, diverticulectomy or ileal segment resection with end-to-end anesthesia is performed. Perforation may be caused by diverticulitis, ulceration from heterotopic mucosa, or rarely by foreign bodies such as fish or chicken bones. Treatment of perforation involves segmental resection with end-to-end anastomosis. The pathophysiology of diverticulitis is similar to that of acute appendicitis [9], with inflammation secondary to stasis (due to fecaliths, parasites, or foreign bodies) and bacterial infection or from heterotopic mucosa. Treatment usually involves a diverticulectomy.

AIMS & OBJECTIVES

Highlighting the rare presentation of Meckel’s diverticula and raising awareness among clinicians to ensure early intervention, thereby reducing associated mortality and morbidity.

In the present study, 24 patients in total were assessed, of which 17 were male and seven were female. Detailed patient histories were recorded. X-ray of the erect abdomen and ultrasound were done for any possible abnormalities, and a CECT was advised to confirm the diagnosis. All patients received treatment based on standard guidelines. Patients were planned for surgery after anesthesia clearance. Postoperative complications and recovery were monitored.

Institutional Ethics Committee clearance was obtained, and a written informed consent was taken from the participants for conducting the study.

FUNDING DECLARATION

This research was not funded by any organization or any committee; it was fully completed by the author himself. There is no role of any funder in the design of the study, data collection, analysis, interpretation of data, or in the writing of the manuscript. The views expressed in this paper are those of the authors and do not necessarily represent the views of any funding organization. The author also declares that they have no competing interests in this section.

There were 17 male patients and 7 female patients. 16 patients had symptomatic Meckel's diverticulum, of which 10 patients had guarding with reflex tenderness and pain abdomen, mainly in the right lower quadrant, signs suggestive of peritonitis; four presented with abdominal distension and constipation with intestinal obstruction; and two presented with melena. In the remaining eight patients, the diverticulum was found incidentally during exploratory laparotomy for other conditions: acute appendicitis (n = 4), blunt abdominal trauma (n = 2), ovarian cyst (n = 1), and abdominal pain (n = 1). Four cases had a preoperative confirmatory Meckel's diverticulum. The reason that established or confirmed the diagnosis of Meckel's diverticulum was the clinical features and complications of the diverticulum.

 The most common surgical diverticulectomy is performed with end-to-end anastomosis for cases of peritonitis (41%), intestinal obstruction (16%), lower gastrointestinal bleeding (8%), and intestinal malrotation (4%). For asymptomatic incidental, Meckel's diverticulectomy was most often performed at the time of laparotomy or laparoscopic appendectomy (16%), blunt abdominal trauma (8%), gynecological pathology (4%), and laparotomy for other indications (4%).

The histopathological findings, symptoms, and complications of all cases of Meckel's diverticula are presented in tabular form.

Table: - 2 Histopathological findings in Study

Meckel's diverticulum is presented as the Rule of Two, i.e. in about two percent of the population, and is typically located around two feet proximal to the ileocecal junction. The diverticulum is generally about two inches long and two centimeters in diameter, and although symptoms commonly appear in children under two years of age, they can also occur in adults. Interestingly, symptoms tend to occur twice as often in males. The abnormality may contain two different types of tissue, including stomach or pancreatic tissue, which can lead to complications such as ulceration and bleeding.

Symptomatic cases of Meckel’s diverticulum are managed by surgical resection. This usually involves a wedge resection of the diverticulum and sometimes includes resection of part of the ileum with end-to-end anastomosis. Surgical outcomes are generally excellent, with an incidence of early postoperative complications around 8%, prolonged ileus (4%), including wound infection (3%), and anastomotic leak (1%). The mortality rate is approximately 1%. Incidental diverticulectomies have lower complication rates, with an overall morbidity of 2%. Due to the difficulty in preoperatively diagnosing a pathological Meckel’s diverticulum, surgeons often recommend prophylactic diverticulectomy when it is incidentally found, based on lower morbidity rates compared to resecting pathologic diverticula.

When selecting a resection procedure for Meckel’s diverticulum, it is advisable to prioritize diverticulectomy or segmental resection of the ileum in cases of broad-based Meckel’s diverticulum. This approach is recommended to prevent restriction of the intestinal lumen. Furthermore, in cases of bleeding Meckel’s diverticulum, it is imperative to ensure complete resection of any ectopic gastric tissue and intestinal ulcer. Peptic ulcers originating from ectopic gastric acid production are commonly found in the ileum rather than the Meckel’s itself due to the peristaltic activity within the Meckel’s and the resistance of the ectopic gastric tissue to the acid it produces.11] For long and thin Meckel’s without hemorrhage, a simple resection should be sufficient, as any ectopic tissue within is likely to be confined to the tip.[12]

Solerto et al., based on the assessment of treatment outcomes of 202 patients with MD, stated that the risk of postoperative complications following preventive excision of an unaffected diverticulum is much greater than the risk of any future complications caused by the diverticulum itself when left intact. The authors calculated that, in order to prevent one death due to a fatal complication of MD, it should be resected in 800 patients with accidentally found unaffected diverticulum[13]

Peoples et al. 1995; Lin et al. 2017) do not recommend ‚preventive’ excision of an unaffected accidentally found MD, motivating their approach with the risk of postoperative complications and minimal risk of future complications[14,15]

Matsagas et al. (1995) presented the results of a retrospective analysis of Meckel’s diverticulum cases found accidentally during laparotomy performed due to acute appendicitis or for other indications. In addition, laparotomy cases were studied for symptomatic, abnormal Meckel’s diverticulum. Among 2074 patients undergoing appendectomy, 33 (1.6%) had unaffected Meckel diverticula (1 case for all 62 appendectomies). Among patients operated on for other reasons, 15 had unaffected Meckel’s diverticula. Also, 15 patients were operated on because of abdominal symptoms caused by an abnormal diverticulum; in most cases, the diagnosis was not established before surgery [16].

This study of Meckel’s diverticulum with various presentations underscores its clinical significance. Pre-operative diagnosis is challenging, and it is often made intraoperatively. In cases of suspected appendicitis, the small intestine should be explored to rule out Meckel’s diverticula, particularly if the appendix is normal.

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