Meckel's diverticulum with emphasis on the roentgen diagnosis.

Abstract

The preoperative diagnosis of Meckel's diverticulum is seldom made. The first mention of the roentgen demonstration of this structure was by Case in 1926 (7), though Pfahler (30) is generally given credit for introducing the roentgenologic diagnosis in 1934. We have reviewed, from the literature, 33 cases in which a preoperative roentgen diagnosis was obtained. Thirty of these diagnoses were confirmed by operation or autopsy. The methods by which the diverticula were demonstrated are shown in Table I, which includes also the original references. The barium sulfate meal followed by serial films of the small intestine was the procedure most successfully used. This method was employed in 20 cases. Lipiodol injection into an umbilical fistula, with a subsequent roentgenogram, led to the diagnosis in 1 instance. Seven cases were demonstrated by a barium sulfate enema. Lerner et al. (23) described an air-filled Meckel's diverticulum, confirmed by a barium enema. Basile and Elfersy (3) demonstrated an opaque calculus within the diverticulum on a plain film. Pathology The definition of Meckel's diverticulum requires that it project from the free border of the intestine, have a complete intestinal wall, be conical in shape, and have a wide mouth (23). This anomaly was first described and correctly interpreted by Meckel in 1812. Embryologically, it represents a partial persistence of the yolk stalk and the omphalomesenteric attachment (4, 12, 28). The diverticulum may retain a patent opening through the umbilicus, it may be joined to the umbilicus by a fibrous cord, or it may remain as a freely movable blind pouch of various dimensions (28). It arises from the distal ileum, 1 to 3 feet proximal to the ileocecal valve. In a large proportion of cases, aberrant tissue is present. Ectopic gastric tissue has been found in 16 per cent of all Meckel's diverticula, often accounting for hemorrhage (17, 18). Aberrant pancreatic tissue occurs in 3 to 4 per cent. Less commonly, duodenal or bile duct tissue is encountered (19). Two per cent of autopsy subjects are said to have Meckel's diverticula, in a ratio of 3 males to 1 female (28). Clinical Features The morbidity and clinical symptoms associated with Meckel's diverticulum are the result of complications, as hemorrhage, perforation, volvulus, intussusception, or intestinal obstruction. Symptoms and signs are more common in childhood and frequently mimic acute appendicitis. This is due to inflammation at the mouth of the diverticulum, with subsequent narrowing (8, 19, 29, 30). Less commonly there may be an umbilical discharge or formation of a cystic tumor. The diverticulum may be incarcerated in a hernia. Foreign bodies such as fish bones sometimes become lodged within a diverticulum and lead to perforation.