CASE 8964 Published on 02.11.2010
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An unusual case of lower GI bleeding due to Meckel\'s diverticulum (ESGAR 2010 Case of the day)

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Kraniotis P, Petsas T, Karatzas A, Kalogeropoulou C.
Univerity Hospital of Patras, Department of Radiology, Patras, Greece.

Connected authors
Patient

15 years, male

Categories
Area of Interest Gastrointestinal tract ; Imaging Technique CT, Nuclear medicine conventional
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Clinical History
A 15 year old adolescent boy presented to the emergency department due to an episode of acute lower GI bleeding. The patient was submitted to abdominal MDCT scan in order to search for the site of haemorrhage. The patient was later submitted to a GI nuclear scan with Tc99m pertechnetate.
Imaging Findings
After contrast administration, there was intramural enhancement in a small bowel loop pouch located in the right upper abdominal quadrant. The enhancement was pronounced during the portal-venous phase with the presence of multiple nodular-wavy areas extending around the loop pouch (Fig 1a-d). No contrast extravasation was noted during the delayed phase (Fig 2).
The GI scan with Tc99m pertechnetate confirmed the presence of a hot spot in the right upper abdominal quadrant, consistent with the presence of aberrant gastric mucosa (Fig 3a-b). Note the good correlation of the hot spots of the nuclear scan with the abnormal bowel loop on the MIP coronal and sagittal CT reformations (Fig 4a-b). The findings were surgically confirmed.
Discussion
Meckel diverticulum (MD) represents a true diverticulum of the ileum containing all 3 layers of the bowel wall. It develops if the omphalomesenteric or vitelline duct connecting the primitive midgut with the yolk sac, fails to obliterate. This normally occurs at 7-8 weeks of gestation. MD is located within the terminal 6 feet of ileum usually within 2 feet of the ileocecal valve. It is usually symptomatic before the age of 2. Heterotopic tissue, including gastric mucosa and pancreatic tissue, is present in 50% of patients.
Symptoms resulting from a MD occur because of complications and are more frequent in children than in adults. These include haemorrhage and intestinal obstruction. Haemorrhage is usually due to erosion of the adjacent ileal mucosa by acid produced by ectopic gastric mucosa (in >95% of the cases). Intestinal obstruction is most often due to volvulus about the MD or intussusception with the diverticulum as the lead point.
Meckel diverticulum is notoriously difficult to diagnose after childhood on both clinical and imaging grounds because the symptoms and imaging features are nonspecific.
In cases of GI bleeding and clinical suspicion of aberrant gastric mucosa in a MD, the role of a Tc99m-pertechnatate scan is well established. The specificity is far greater in children (>95%) than in adults.
Although the role of MDCT scanning is well known when searching for causes of GI bleeding, a high degree of suspicion is needed to establish the diagnosis of an ulcerated MD.
In such circumstances, the presence of a loop pouch with nodular-wavy enhancing wall, without evidence of frank extravasation may be suggestive of the presence of aberrant gastric mucosa in a MD.
Surgery is warranted for treating bleeding Meckel diverticuli.
Radiologists should bear in mind the probability of this diagnosis mainly in children and adolescents, even in unusual locations.
Differential Diagnosis List
Hemorrhage due to the presence of an ulcerated Meckel’s diverticulum, located in an unsual position.
Ulcerated Meckel’s diverticulum
Arteriovenous malformation
Crohn's disease
Final Diagnosis
Hemorrhage due to the presence of an ulcerated Meckel’s diverticulum, located in an unsual position.
Case information
URL: https://www.eurorad.org/case/8964
DOI: 10.1594/EURORAD/CASE.8964
ISSN: 1563-4086
Figure 1

Axial PV-phase CT images

Axial PV-phase CT images
Axial post-contrast CT, portal-venous phase. Contiguous images of 1.25 mm from above to below. There is intense nodular-wavy intramural enhancement around the abnormal loop (red circle).
Axial PV-phase CT images
Axial post-contrast CT, portal-venous phase. Contiguous images of 1.25 mm from above to below. There is intense nodular-wavy intramural enhancement around the abnormal loop (red circle).
Axial PV-phase CT images
Axial post-contrast CT, portal-venous phase. Contiguous images of 1.25 mm from above to below. There is intense nodular-wavy intramural enhancement around the abnormal loop (red circle).
Axial PV-phase CT images
Axial post-contrast CT, portal-venous phase. Contiguous images of 1.25 mm from above to below. There is intense nodular-wavy intramural enhancement around the abnormal loop (red circle).
Figure 2

Delayed phase CT image

Delayed phase CT image
Post-contrast CT of the abdomen, delayed phase (note ureteral contrast excretion-yellow arrows). Image is at the same level with figure 1a. There is no presence of contrast extravasation (red circle).
Figure 3

Nuclear scan images

Nuclear scan images
Anterior view: There is a hot spot in the right upper quadrant of the abdomen (red arrow).
Nuclear scan images
Right lateral view: The hot spot is noted again; marked with a red arrow.
Figure 4

CT MIP reformations

CT MIP reformations
Coronal MIP reformation of the abdomen: The abnormal bowel loop is encircled in red. Compare with figure 3a. There is a good correlation with the nuclear scan.
CT MIP reformations
Sagittal MIP reformation of the abdomen: The abnormal bowel loop is marked again with a red circle. The image is also very well correlated with the lateral view of the nuclear scan (figure 3b)