Meckel's Diverticulum��Revisited

Meckel''s diverticulum is a true intestinal diverticulum that results from the failure of the vitelline duct to obliterate during the fifth week of fetal development. In about 50% cases, it contains ectopic or heterotopic tissue which can be the cause of complications. A systematic review of literature was undertaken to study the history, incidence, embryoanatomy, clinical presentation, complication and management of Meckel''s diverticulum. Although Meckel''s diverticulum is the most common congenital abnormality of the gastrointestinal tract, it is often difficult to diagnose. It may remain asymptomatic or it may mimic disorders such as Crohn''s disease, appendicitis and peptic ulcer disease.     

Enterolith Ileus: A Rare Complication of Duodenal Diverticula

Small bowel obstruction secondary to an enterolith formed within a duodenal diverticulum is a rare complication. Twenty-nine cases of enterolith ileus have been reported in the literature. This is a case report of the 30th, with review of the literature. Enterolith ileus closely resembles gallstone ileus in its clinical presentation. Diagnosis is established by documenting normalcy of gallbladder and the presence of small bowel diverticula.     

Relationship between intraduodenal peri-ampullary diverticulum and biliary disease in 178 patients undergoing ERCP

BACKGROUND:The presence of intraduodenal peri-ampullary diverticulum is often observed during upper digestive tract barium meal studies and endoscopic retrograde cholangiopancreatography(ERCP).A few papers in China and overseas reported that the diverticulum had something to do with the incidence of cholelithiasis. This study was undertaken to further test this notion and ascertain the relationship between intraduodenal peri- ampullary diverticulum and biliary disease,especially the formation of bile duct pigment stones. METHODS:A total of 178 patients who had undergone ERCP or endoscopic sphincterotomy(EST)were studied retrospectively.They were divided into 6 groups according to the category of biliary disease,and the incidence rates of intraduodenal peri-ampullary diverticulum were calculated. RESULTS:There were 44 patients with intraduodenal peri- ampullary diverticulum in 81 patients with primary bile duct pigment stones(54.32%),4 in 8 patients with bile duct stones and gallbladder stones(50%),7 in 33 patients with bile duct stones secondary to gallbladder stones(21.21%), 3 in 21 patients with inflammation and stricture of the end of the bile duct and papilla(14.29%),1 in 22 patients with carcinoma of the end of the bile duct and papilla(4.54%), and 5 in 13 patients with post-cholecystectomy syndrome or sphincter of Oddi dysfunction(38.46%). CONCLUSIONS:The incidence rate of intraduodenal peri- ampullary diverticulum in patients with primary bileduct pigment stones is higher than that in patients with bile duct stones secondary to gallbladder stones,patients with inflammation and stricture of the end of the bile duct and papilla,and patients with carcinoma of the end of the bile duct and papilla.These findings indicate that the anatomical abnormalities and malfunction of the sphincter of Oddi play an important role in the formation of bile duct pigment stones.     

Type II congenital biliary dilation (biliary diverticulum) with pancreaticobiliary maljunction successfully treated by laparoscopic surgery: report of a case

Biliary diverticulum or type II congenital biliary dilation accounts for only 1?C2% of all patients with congenital biliary dilation. The association between pancreaticobiliary maljunction (PBM) and this type of anomaly remains unclear. A 40-year-old Japanese woman presented with a history of repeated upper abdominal pain for more than 30?years. Computed tomography showed a cystic lesion (diameter 30?mm) arising from the common bile duct. Magnetic resonance cholangiopancreatography revealed a biliary diverticulum (diameter 33?mm) and the cystic duct entering the diverticulum. There was no dilation of the intrahepatic or extrahepatic ducts. Endoscopic retrograde cholangiopancreatography demonstrated PBM. A diagnosis of type II biliary diverticulum with PBM was made, and the patient underwent laparoscopic resection of the diverticulum combined with cholecystectomy. Pathological examination of the resected specimen showed slight inflammation, but no malignancy in the diverticulum or gallbladder. The patient??s postoperative course was uneventful. To our knowledge, this is the first report of successful laparoscopic resection of biliary diverticulum associated with pancreaticobiliary maljunction.     

Carcinoid of Meckel's diverticulum. Report of a case and review of the literature

The presence of carcinoid tumor in a Meckel's diverticulum is a rare entity. This report describes a 56-year-old man who was admitted to hospital with symptomatic gallbladder stones. At laparotomy the gallstones were confirmed and routine exploration of the peritoneal cavity identified a small bowel diverticulum about 60 cm of the ileocecal valve. Cholecystectomy and resection of a small bowel segment containing the diverticulum were performed. Histology revealed carcinoid tumour in Meckel's diverticulum.     

Small Bowel Obstruction Due to Enterolith (Bezoar) Formed in a Duodenal Diverticulum: A Case Report and Review of the Literature

An elderly patient with an acute small bowel obstruction due to an enterolith that evolved within a duodenal diverticulum is reported. Twenty-four prior instances of small bowel obstruction due to an enterolith formed within a small bowel diverticulum have been culled from the world literature and tabulated, In toto , 18 subjects are female and seven are male. The median age is 68 yr. Optimal surgical management is either to break up the enterolith and milk the components into the cecum without an enterotomy or., as is more often necessary, to milk the enterolith orad removing the concretion through an enterotomy made in less edematous small intestine. As in managing gallstone ileus, the bowel should be "run" seeking additional enteroliths. The diagnosis can be established only by documenting the normalcy of the gallbladder and the presence of duodenal and/or jejunal diverticula.     

Relationship between perivaterian diverticulum and biliary tract disease

The findings in 107 cases of perivaterian diverticulum diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) were discussed in relation to complicated biliary tract disease. The incidence of abnormality in both gallbladder and bile duct, especially in extrahepatic bile ducts, was more frequent in cases of perivaterian diverticuli more than 11 mm in diameter. Perivaterian diverticuli was most frequently located on the oral side of papilla. Cases with papilla in a diverticulum showed more frequent biliary tract abnormality. Abnormal findings of the distal portion of common bile duct, such as flexion, compression and tapering, were noted in 31% of 107 cases. These findings were seen more frequently in cases with papilla in a diverticulum or with a diverticulum more than 11 mm in diameter. It is considered that these data suggest a mechanism of occurrence of biliary tract disease in cases with perivaterian diverticulum.     

Intraluminal esophageal diverticulum

An intraluminal esophageal diverticulum (IED) is an uncommon entity defined as a double-layered mucosal pouch lying within the lumen of the esophagus. Its characteristic radiological finding is an intraluminal barium collection surrounded by a radiolucent halo. True IED, which is different from a transient radiological artifact, has not been previously reported in the international literature. This article describes the first case of true IED. Differential diagnosis between a true lesion and a transient flow artifact on barium meal is discussed.     

Clinical relevance of gallbladder polyps; is cholecystectomy always necessary?

BackgroundGallbladder polyps are common incidental findings during abdominal ultrasonography. Cholecystectomy is recommended for polyps equal or greater than 10 mm on ultrasound due to their malignant potential. However, the majority of lesions appear to be pseudopolyps with no malignant potential. Our aim was to determine the correlation between ultrasonographic findings and histopathological findings after cholecystectomy for gallbladder polyps in two institutions.MethodA retrospective analysis was performed at two Dutch institutions of patients who underwent cholecystectomy. All cholecystectomies for suspected gallbladder polyps between January 2010 and August 2017 were included. Ultrasonographic and histopathological reports were analyzed.ResultsA total of 108 patients underwent cholecystectomy for gallbladder polyps. At abdominal ultrasound sixty-five patients (60.2%) were diagnosed with multiple gallbladder polyps. The mean diameter of the polyps was 11 mm. On pathological examination after cholecystectomy, only three specimens harbored true polyps. No anomalies were found in 48 (44%) patients and 51 (47%) had cholesterolosis.ConclusionThe prevalence of true gallbladder polyps was much lower in this study than reported in literature. After cholecystectomy for gallbladder polyps diagnosed by ultrasound, 97% of patients had non-neoplastic or not identifiable lesions in the gallbladder. These findings question the usefulness of current guidelines for management of suspected gallbladder polyps.     

Giant colonic diverticulum

PURPOSE: Giant colonic diverticulum are rare, with 103 reported cases in 95 patients. The experience of any one surgeon is limited. We aimed to retrospectively review our experience and to review the literature on origin, pathology, and management of this rare and unusual problem. METHOD: Cases were identified by review of pathologic database and by computerized audit from three hospitals. RESULTS: Five giant colonic diverticulum were identified in four patients, and the pathology and management were reviewed. CONCLUSION: A definition and classification system of giant colonic diverticulum is suggested. Giant colonic diverticulum should be the universal term to cover all colonic diverticulum larger than 4 cm, and we suggest that there are two types based on histology. Literature review reveals 103 reported cases in 95 patients. Type I (87 percent) is a pseudodiverticulum, perhaps related to conventional diverticular disease, whereas Type II (13 percent) is a true diverticulum, which is probably a type of communicating cystic congenital duplication. These lesions tend to occur in the sigmoid colon (93 percent) and present with complications similar to conventional diverticular disease. In the presence of conventional diverticular disease, consideration should be given to anterior resection, and in the absence, diverticulectomy should be considered.     

Acute solitary diverticulitis of the transverse colon in a child

Solitary colonic diverticula are rare. Most have been described in the cecum or ascending colon. Solitary diverticula of the transverse colon are extremely rare, and there are only a few reports in the English medical literature, all occurring in adulthood. This paper reports the case of a 13-year-old girl with a solitary, true diverticulum of the transverse colon, presenting as acute diverticulitis.     

New clues for the developing human biliary system at the porta hepatis

The human biliary system is formed from the hepatic diverticulum, a structure which develops from the embryonic foregut in the fourth week of gestation. The cephalic portion of the hepatic diverticulum lies within the septum transversum, and gives rise to entodermal cells which become the primitive hepatocytes. The caudal part of the hepatic diverticulum is molded by mesenchyme to form the gallbladder, cystic duct, and extrahepatic bile duct. The gallbladder is initially tubular in shape, and undergoes morphological changes to become saccular during the 11th week of gestation. The extrahepatic bile duct elongates and widens as gestation progresses, and intramural mucus glands develop. There is no solid stage during the development of the extrahepatic bile duct. The extrahepatic bile duct is a well‐defined tubular structure by the 6th week of gestation, whereas the intrahepatic biliary system during this period of gestation is represented by the primitive ductal plate. The ductal plate undergoes structural changes from the 11th week of gestation, beginning at the porta hepatis and progressing through gestation to the periphery of the liver. This remodeling process shapes the ductal plate from a flat sheath of biliary epithelium surrounding the portal vein branches into a network of interconnecting tubular structures. Mesenchyme plays an important role in ductal plate remodeling. The intrahepatic biliary system is in luminal continuity with the extrahepatic bile duct throughout gestation at the porta hepatis. The major bile ducts at the porta hepatis are fully formed by the 16th week of gestation.     

Retrospective diagnosis of stromal tumor with liver and nodal metastasis in a hemorrhagic Meckel's diverticulum appearing 8 years after the first resection

Meckel's diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract (0.3-4%). The gastrointestinal stromal tumours (GIST) are rare tumours. Only few cases of GIST developed in Meckel's diverticulum have been published in the literature. We reported a case of a woman with a diagnosis of GIST of Meckel's diverticulum retrospectively made 8 years after the resection of an haemorrhagic Meckel's diverticulum, whom she developed a large size intra-abdominal tumour with liver and nodes metastasis.     

No significant correlation between histologic changes of the papilla of Vater and juxtapapillary diverticulum. Special reference to the pathogenesis of gallstones.

The aim of this study was to investigate the significance of histologic changes of the papilla of Vater in cases with a juxtapapillary diverticulum, with special reference to the pathogenesis of gallstones. Three hundred and sixty-two autopsy cases, mainly of aged people, were analyzed. The incidence of both diverticulum and gallstone increased with age. The presence of diverticulum was associated with a significant increase of gallstones (49% versus 20%; P < 0.01). Analysis by the type of gallstones showed a significantly higher incidence of bilirubinate in cases with juxtapapillary diverticula. Stones both in the gallbladder and in the extrahepatic bile ducts were more prevalent in cases with diverticula as compared with the cases without diverticula. No significant relationship was found between juxtapapillary diverticula and the degree of histologic changes in the papilla of Vater, such as inflammatory cellular infiltration, fibrous proliferation, glandular proliferation, or muscular hypertrophy and proliferation of the sphincter of Oddi. These facts imply that juxtapapillary diverticula are not involved in the formation of gallstones via histologic changes of the papilla of Vater, whereas diverticula may play an important role in the pathogenesis of gallstones, especially of bilirubin stones.     

Juxtapapillary duodenal diverticula: association with biliary stone disease

In order to explore the relationship between duodenal diverticula and biliary stone disease, we reviewed 2231 endoscopic retrograde cholangio-pancreatography procedures. We found at least one juxtapapillary diverticulum per 239 patients (10.8%). The occurrence of duodenal diverticula increases with age. Patients with duodenal diverticula were older, had more gallbladder stones, more common bile duct stones, had undergone cholecystectomy more frequently, and experienced more frequently common bile duct stone recurrence after cholecystectomy. We thus confirm an association between the presence of diverticula of the second part of the duodenum, and biliary stone pathology, including gallbladder stones, common bile duct stones, and recurrent stones after cholecystectomy. We discuss the aetiopathogeny of this affection.     

Giant colonic diverticulum,clinical presentation,diagnosis and treatment: Systematic review of 166 cases

AIM: To investigate the clinical presentation,diagnosis,and treatment of giant colonic diverticulum(GCD,by means of a complete and updated literature review).GCD is a rare manifestation of diverticular disease of the colon.Less than 200 studies on GCD were published in the literature,predominantly case reports or small patient series.METHODS: A systematic review of the literature was performed using the Embase and PubM ed databases toidentify all the GCD studies.The following MESH search headings were used: "giant colonic diverticulum"; "giant sigmoid diverticulum".The "related articles" function was used to broaden the search,and all of the abstracts,studies,and citations were reviewed by two authors.The following outcomes were of interest: the disease and patient characteristics,study design,indications for surgery,type of operation,and postoperative outcomes.Additionally,a subgroup analysis of cases treated in the last 5 years was performed to show the current trends in the treatment of GCD.A GCD case in an elderly patient treated in our department by a sigmoidectomy with primary anastomosis and a diverting ileostomy is presented as a typical example of the disease.RESULTS: In total,166 GCD cases in 138 studies were identified in the literature.The most common clinical presentation was abdominal pain,which occurred in 69% of the cases.Among the physical signs,an abdominal mass was detected in 48% of the cases,whereas 20% of the patients presented with fever and 14% with abdominal tenderness.Diagnosis is based predominantly on abdominal computed tomography.The most frequent treatment was colic resection with en-bloc resection of the diverticulum,performed in 57.2% of cases,whereas Hartmann's procedure was followed in 11.4% of the cases and a diverticulectomy in 10.2%.An analysis of sixteen cases reported in the last 5 years showed that the majority of patients were treated with sigmoidectomy and en-bloc resection of the diverticulum; the postoperative mortality was null,morbidity was very low(1 patient was hospitalized in the intensive care unit for postoperative hypotension),and the patients were discharged 4-14 d after surgery.CONCLUSION: Giant colonic diverticulum is a rare manifestation of diverticular diseases.Surgical treatment,consisting predominantly of colonic resection with en bloc resection of the diverticulum,is thepreferred option for GCD and guarantees excellent results.     

Patterns of intestinal activity with Meckel's scintigraphy

Three patterns of intestinal activity were noted in a review of 64 patients studied with Tc-99m sodium pertechnetate for suspected Meckel's diverticulum: no bowel activity seen (37.5%), bowel activity visualized after stomach activity (39.1%), and diffuse bowel activity seen simultaneously with stomach activity (23.4%). The latter pattern, which is relatively common, could mask a true Meckel's diverticulum and lead to either a false-negative or indeterminate diagnosis. A series of 10 dogs was also studied to evaluate the effects of fasting and feeding on the intestinal pattern. No definite relationship was observed.     

Meckel's Diverticulum: Axial Volvulus Mimicking Emphysematous Cholecystitis

A 48-year-old man presented with symptoms of acute cholecystitis. Abdominal roentgenograms suggested emphysematous cholecystitis. Axial volvulus of a Meckel's diverticulum was discovered at surgery. We discuss this unusual complication of Meckel's diverticula as well as the roentgenographic differential diagnosis of air in the gallbladder.     

Gallstone duodenum: unusual complication of an obstructing intraluminal duodenal diverticulum.

An unusual case of gallstones within the duodenum, secondary to obstruction by an intraluminal diverticulum, is reported. The gallbladder appeared normal an oral cholecystogram, excluding internal biliary fistula as the source of duodenal gallstones.     

Neoplasms of the Meckel diverticulum. Apropos of 2 new cases

We present two new cases of cancer in a Meckel's diverticulum, representing 3.3% of the complicated Meckel's diverticula encountered in our department. The first case was a carcinoid tumor encountered in a pathology study of an inflamed Meckel's diverticulum, and the second case was a leiomyosarcoma on a Meckel's diverticulum that presented as diverticular perforation. We emphasize the advanced age of the two patients and review the cases reported in Spain and in the Western literature.