S2118 Angiographic Diagnosis and Treatment of Adult GI Bleeding from Meckel’s Diverticulum

Abstract

INTRODUCTION: Meckel's diverticulum is the most common gastrointestinal anomaly resulting from a persistent omphalomesenteric duct. It is usually discovered in children when gastrointestinal (GI) bleeding occurs. This case demonstrates the use of provocative angiography for both the diagnosis and treatment of a bleeding Meckel's diverticulum in an adult. CASE DESCRIPTION/METHODS: A 22-year-old woman with no known past medical history presented to the emergency department with a chief complaint of black stool, lightheadedness and weakness. On exam, her abdomen was soft and non-tender. Rectal exam showed black stool with bloody mucus. Labs were significant for a Hgb of 6.1 (MCV 90.1) from 12.1 one week prior. During her hospitalization she underwent several studies to determine the location of her bleed. Esophagogastroduodenoscopy, colonoscopy, tagged red blood cell scan, and Meckel’s Scan were all normal. Video capsule endoscopy visualized blood in the terminal ileum and cecum mixed with stool, however no lesions were identified in these areas on colonoscopy. Magnetic resonance enterography was without evidence of small bowel inflammation. A visceral arteriogram was performed by interventional radiology, which was negative for bleeding until provocation was done using direct intra-arterial thrombolytic infusion (tissue plasminogen activator) that demonstrated active bleeding in an superior mesenteric artery branch which appeared to be serving a Meckel's diverticulum. Successful embolization was performed with a 3 mm coil and no further bleeding episodes occurred during her hospital stay. One month later she returned for surgical resection. Pathology confirmed Meckel's diverticulum with focal ulceration, underlying granulation tissue, and gastric heterotopia. DISCUSSION: Tc-99m pertechnetate scintigraphy (Meckel's Scan) is helpful in diagnosis of a Meckel’s diverticulum as pertechnetate is taken up by mucin-secreting cells of ectopic gastric tissue. This scan has high sensitivity and specificity in children but is drastically lower in adults as hemorrhage due to ectopic gastric mucosa is primarily a pediatric disease. For adults with suspected bleeding from a Meckel's diverticulum with multiple negative imaging modalities including a Meckel's scan, it is important to continue pursuit of the diagnosis using all means available. This case demonstrates the vital importance of provocation angiography in diagnosis of a Meckel's diverticulum that would have otherwise been missed and therefore left untreated.Figure 1.: Negative Meckel’s Scan. No heterotopic gastric mucosa visualized.Figure 2.: Angiogram before tPA administration. Red arrow indicates suspected Meckel diverticulum served by superior mesenteric artery branch.Figure 3.: Angiogram after tPA administration. Red arrow indicates area of extravasation and active bleeding.