Symptomatic Meckelʼs Diverticulum in a Geriatric Patient Evaluated for Ongoing Gastrointestinal Bleeding and Hemodynamic Instability

Abstract

Background: Meckel's diverticulum is the most common congenital anomaly of the small intestine, presenting in 1-3% of the general population. When symptomatic, common complications include painless bleeding, intestinal obstruction, umbilical discharge, perforation, and peritonitis. It is classically a pediatric disorder, and 30-40% of cases are asymptomatic. Meckel's diverticulum is infrequently considered in the differential diagnosis for geriatric patients presenting with common gastrointestinal symptoms. We report a rare case in which ongoing gastrointestinal bleeding and hemodynamic instability were signs of symptomatic Meckel's diverticulum in a geriatric patient. Case Presentation: A 90-year-old male presented for evaluation of a painful, localized swelling on the right upper thigh. Hemoglobin was 115 g/L. He was found to have a ruptured right femoral artery aneurysm, requiring urgent surgical repair. Twelve days post-operatively, the patient had ongoing melena suggestive of upper GI bleeding and became hemodynamically unstable. Hemoglobin dropped as low as 67 g/L, and rose only to 70 g/L following transfusion. The patient underwent urgent upper endoscopy, revealing an oozing duodenal ulcer, which was hemoclipped. However, the bleeding and hemodynamic instability continued. Repeat endoscopy revealed ongoing bleeding in the duodenum; however, an actively bleeding vessel was not found by superior mesenteric arteriography. The gastroduodenal artery was empirically embolized. Bleeding continued despite embolization. The patient underwent an exploratory laparotomy. This revealed a Meckel's diverticulum in the small intestine, filled with blood and with distended vascular malformations at the apex. A wedge resection of the diverticulum was performed and hemoglobin stabilized at 81 g/L post-operatively. Discussion: Symptomatic Meckel's diverticulum has been reported as an uncommon complication in the elderly. In patients older than 65 years, it has masqueraded as more common gastrointestinal disorders such as small bowel obstruction, ischemic colitis, diverticulitis, and appendicitis. Presenting complaints reported in geriatric patients include nausea, vomiting, diffuse, severe abdominal pain with intestinal obstruction, periumbilical pain, constipation and rectal bleeding. Similar to our case, hematochezia was reported in an elderly patient with a bleeding Meckel's diverticulum. Rare complications in the elderly include gastrointestinal stromal tumor, and Littre hernia as a cause of unexpected death. Although rare in the geriatric population, the potential for complications should alert clinicians to the possibility of a Meckel's diverticulum in older adults with obscure GI bleeding.