MECKEL’S DIVERTICULUM WITH ULCERATION DIAGNOSED BY DOUBLE BALLOON ENTEROSCOPY

A 31‐year‐old man was referred to our hospital for an evaluation of recurrent episodes of melena. Esophagogastroduodenoscopy, total colonoscopy, computed tomography and Tc‐99 m scintigraphy were performed at a previous hospital, but the bleeding source remained unidentified. Double balloon enteroscopy (DBE) was performed with the use of an anal approach at our hospital. DBE was inserted into the ileum approximately 100 cm from the ileocecal valve, and then Meckel’s diverticulum was discovered. There was a circular ulceration in the middle part of the diverticulum without adherent blood clots, visible vessels nor heterotopic gastric mucosa. Meckel’s diverticulum was identified as the bleeding source, but an immediate risk of rebleeding was considered relatively low. The patient chose conservative therapy without surgery. Two years later, he is well, without further bleeding episodes. DBE made it possible not only to diagnose the existence of the Meckel’s diverticulum but also to assess the risk of rebleeding.     

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.     

Inverted Meckel’s diverticulum preoperatively diagnosed using double-balloon enteroscopy

An inverted Meckel’s diverticulum is a rare gastrointestinal congenital anomaly that is difficult to diagnose prior to surgery and presents with anemia, abdominal pain, or intussusception. Here, we report the case of 57-year-old men with an inverted Meckel’s diverticulum, who was preoperatively diagnosed using double-balloon enteroscopy. He had repeatedly experienced epigastric pain for 2 mo. Ultrasonography and computed tomography showed intestinal wall thickening in the pelvis. Double-balloon enteroscopy via the anal route was performed for further examination, which demonstrated an approximately 8-cm, sausage-shaped, submucosal tumor located approximately 80 cm proximal to the ileocecal valve. A small depressed erosion was observed at the tip of this lesion. Forceps biopsy revealed heterotopic gastric mucosa. Thus, the patient was diagnosed with an inverted Meckel’s diverticulum, and single-incision laparoscopic surgery was performed. This case suggests that an inverted Meckel’s diverticulum should be considered as a differential diagnosis for a submucosal tumor in the ileum. Balloon-assisted enteroscopy with forceps biopsy facilitate a precise diagnosis of this condition.     

Meckel＇s diverticulum manifested by a subcutaneous abscess

This case report describes an extremely rare complication of a Meckel's diverticulum: enterocutaneous fistula of the diverticulum. The presence of Meckel's diverticulum is a well known entity, but subcutaneous perforation of the diverticulum is very rare. Here we report the case of a patient with the complaint of a right lower quadrant abscess, preoperatively diagnosed as enterocutaneous fistula, which was determined intraoperatively to be a fistula resulting from Meckel's diverticulum.     

Inverted Meckel's diverticulum preoperatively diagnosed using double-balloon enteroscopy

An inverted Meckel's diverticulum is a rare gastrointestinal congenital anomaly that is difficult to diagnose prior to surgery and presents with anemia, abdominal pain, or intussusception. Here, we report the case of 57-year-old men with an inverted Meckel's diverticulum, who was preoperatively diagnosed using doubleballoon enteroscopy. He had repeatedly experienced epigastric pain for 2 mo. Ultrasonography and computed tomography showed intestinal wall thickening in the pelvis. Double-balloon enteroscopy via the anal route was performed for further examination, which demonstrated an approximately 8-cm, sausage-shaped, submucosal tumor located approximately 80 cm proximal to the ileocecal valve. A small depressed erosion was observed at the tip of this lesion. Forceps biopsy revealed heterotopic gastric mucosa. Thus, the patient was diagnosed with an inverted Meckel's diverticulum, and single-incision laparoscopic surgery was performed. This case suggests that an inverted Meckel's diverticulum should be considered as a differential diagnosis for a submucosal tumor in the ileum. Balloon-assisted enteroscopy with forceps biopsy facilitate a precise diagnosis of this condition.     

Role of Helicobacter pylori infection in complications from Meckel's diverticulum

Our purpose was to evaluate the role of Helicobacter pylori in complications arising from Meckel's diverticulum in the Jewish and Arab populations of Jerusalem. Diverticular tissues were studied by hematoxylin–eosin, Giemsa, and two immunohistochemical stainings. Three groups of patients were identified: (1) 20 patients in whom Meckel's diverticulum was an incidental finding during laparotomy for other causes; (2) 7 patients with heterotopic gastric mucosa who underwent laparotomy because of bleeding from Meckel's diverticulum–-3 were infected with Helicobacter pylori; and (3) 15 patients who underwent operations because of complicated Meckel's diverticulum except for bleeding—7 patients had heterotopic gastric mucosa; only 1 patient had Helicobacter pylori. Demographic, clinical, and pathological findings within the gastric mucosa were not different in patients with and without colonization with Helicobacter pylori. In conclusions, Helicobacter pylori colonizes heterotopic gastric mucosa with Meckel's diverticulum, but probably has a minor role in the complications of Meckel's diverticulum.     

Divertículo de Meckel y enterolitos como complicación de la enfermedad de Crohn

We describe the case of a 43-year-old man recently diagnosed with ileal Crohn's disease complicated by a free peritoneal perforation of a Meckel's diverticulum and the presence of enteroliths in the intestinal lumen. The coexistence of Crohńs disease, Meckel's diverticulum and enteroliths has rarely been reported. Meckel's diverticulum can hamper the management of Crohn's disease.     

Helicobacter pylori in Meckel's diverticulum with heterotopic gastric mucosa in a population with relatively high H. pylori prevalence rate

BACKGROUND: Helicobacter pylori (H. pylori) colonize only foveolar gastric-type mucosa and are associated with active chronic gastritis and peptic ulcer. The aim of this study was to investigate whether H. pylori can also be found in Meckel's diverticulum which contains heterotopic gastric mucosa. METHODS: Biopsy specimens of Meckel's diverticulum resected in Queen Mary Hospital, University of Hong Kong, during the 10 year period 1986-1995 were retrieved and reviewed. Those containing gastric heterotopia were examined for the presence of H. pylori, using Warthin-Starry silver stain. RESULTS: In the 59 cases of Meckel's diverticula studied, 16 were found to contain heterotopic gastric mucosa. Helicobacter pylori were not identified in any of these cases. In one of the 16 patients a concomitant gastric biopsy was performed. Although the gastric mucosa of this patient was heavily colonized by H. pylori, again no H. pylori was found in the heterotopic gastric mucosa in the Meckel's diverticulum. CONCLUSIONS: The absence of H. pylori in all the Meckel's diverticula examined, even when the stomach was heavily colonized by the organisms, suggests that colonization of Meckel's diverticulum by H. pylori is a rare event. This, together with the overall rarity of H. pylori in all reported series of Meckel's diverticulum, argues against its causative role in complications of Meckel's diverticulum.     

Successful treatment with balloon dilatation using a double‐balloon enteroscope for a stricture in the small bowel of a patient with Crohn's disease

The requirement for endoscopic access to a stricture is a major limitation of the endoscopic dilatation for the treatment of strictures in the gastrointestinal tract. We have developed the double‐balloon enteroscopy method that enables visualization of the entire small bowel. In addition, double‐balloon enteroscopy has a potential for the interventional therapy including dilatation of strictures. We present here a case of jejunal strictures in a 47‐year‐old woman with Crohn's disease successfully treated with a balloon catheter in combination with double‐balloon enteroscopy. Balloon dilation with double‐balloon enteroscopy is a promising method for the treatment of small bowel strictures in Crohn's disease.     

Heterotopic gastric mucosa causing significant esophageal stricture in a 14‐year‐old child

Esophageal heterotopic gastric mucosa (HGM) is not uncommon and can be seen in up to 10% of the general population among numerous reports and epidemiologic studies which have been essentially performed in adult population. Pediatric data are still limited. Diagnosis requires clinician awareness of symptomatic cases who present with dysphagia or swallowing difficulties, and thorough endoscopic examination is crucial. Early detection of cases provides favorable clinical outcome and may prevent potential significant or serious long‐term consequences such as esophageal stricture or web, Barrett's esophagus or malignant transformation in pediatric population. We reported a 14‐year‐old male who presented with 1‐year history of gradually worsening dysphagia and was found to have two salmon‐colored patches, which resemble gastric mucosa, in the proximal esophagus causing significant esophageal stricture. Gastric cardiac‐type mucosa with acute and chronic inflammation was documented on biopsy. After several sessions of balloon dilation and endoscopic treatment, the HGM and esophageal stricture resolved and he became asymptomatic.     

Adenocarcinoma of Meckel’s diverticulum diagnosed by capsule endoscopy and single-balloon enteroscopy

A case of adenocarcinoma arising in Meckel’s diverticulum in a 58-year-old man is reported. Abdominal computed tomography and ultrasonography showed a solid tumor in the middle of abdomen. Capsule endoscopy (CE) showed tumorous lesion in the distal ileum. Single-balloon enteroscopy (SBE) subsequently showed the tumor in Meckel’s diverticulum. Furthermore, biopsy specimen obtained from the lesion revealed it as adenocarcinoma. At laparotomy, we found the tumor at the blind end of the diverticulum and enlarged lymph node about 7 cm in diameter in the small intestinal mesentery. Segmental resection of the ileum, including the tumor-bearing diverticulum, was performed along with regional lymph node dissection. Histologically, origin of the tumor was assumed to be ectopic gastric mucosa. Although neoplasm in Meckel’s diverticulum is difficult to diagnose preoperatively, the combination of CE and SBE was useful. Based on our search, this is thought to be the first case of neoplasm in Meckel’s diverticulum diagnosed endoscopically.     

Intususcepción ileocólica en un adulto causado por divertículo de Meckel invertido

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. It is found in 2.00% of the population and is more frequent in children. Invagination is an unusual complication that can cause secondary intestinal intussusception. This event is extremely rare and only a few cases have been reported. We present the case of a 19-year-old male who presented with chronic abdominal pain and weight loss of 23 Kg 6 months prior to hospital admittance. The last episode manifested as intense abdominal pain, nausea, vomiting, and diarrhea with a 6-hour progression. Imaging studies established the diagnosis of bowel obstruction and ileocolic intussusception. Laparotomy with ileocolic resection was performed without reducing the intussusception. The histopathologic study reported inverted Meckel's diverticulum at the base of the ileocolic intussusception. Intestinal intussusception in adults, secondary to inverted Meckel's diverticulum is rare and should be considered in the differential diagnosis of patients presenting with abdominal pain and bowel obstruction.     

Heterotopic gastric mucosa of the gastrointestinal tract

Islets of heterotopic gastric mucosa can occur in the whole alimentary tract as well as in the gallbladder, the extrahepatic bile ducts and the pancreatic tissue. In most cases they have incidentally been discovered in autopsies and surgical specimens. Ectopic gastric mucosa is known to cause gastrointestinal bleeding in Meckel's diverticulum and duplications of the intestine, and, in exceptional cases may show a malignant transformation. In endoscopy of the gastrointestinal tract ectopic gastric epithelium can often be conjectured from certain morphological phenomena. In this paper we review pathogenesis, localization, clinical significance as well as diagnostic and therapeutic aspects of heterotopic gastric mucosa.     

Patient burden and patient preference: Comparing magnetic resonance enteroclysis,capsule endoscopy and balloon‐assisted enteroscopy

Background and Aim: We aimed to prospectively determine patient burden and patient preference for magnetic resonance enteroclysis, capsule endoscopy and balloon‐assisted enteroscopy in patients with suspected or known Crohn's disease (CD) or occult gastrointestinal bleeding (OGIB). Methods: Consecutive consenting patients with CD or OGIB underwent magnetic resonance enteroclysis, capsule endoscopy and balloon‐assisted enteroscopy. Capsule endoscopy was only performed if magnetic resonance enteroclysis showed no high‐grade small bowel stenosis. Patient preference and burden was evaluated by means of standardized questionnaires at five moments in time. Results: From January 2007 until March 2009, 76 patients were included (M/F 31/45; mean age 46.9 years; range 20.0–78.4 years): 38 patients with OGIB and 38 with suspected or known CD. Seventeen patients did not undergo capsule endoscopy because of high‐grade stenosis. Ninety‐five percent (344/363) of the questionnaires were suitable for evaluation. Capsule endoscopy was significantly favored over magnetic resonance enteroclysis and balloon‐assisted enteroscopy with respect to bowel preparation, swallowing of the capsule (compared to insertion of the tube/scope), burden of the entire examination, duration and accordance with the pre‐study information. Capsule endoscopy and magnetic resonance enteroclysis were significantly preferred over balloon‐assisted enteroscopy for clarity of explanation of the examination, and magnetic resonance enteroclysis was significantly preferred over balloon‐assisted enteroscopy for bowel preparation, painfulness and burden of the entire examination. Balloon‐assisted enteroscopy was significantly favored over magnetic resonance enteroclysis for insertion of the scope and procedure duration. Pre‐ and post‐study the order of preference was capsule endoscopy, magnetic resonance enteroclysis and balloon‐assisted enteroscopy. Conclusion: Capsule endoscopy was preferred to magnetic resonance enteroclysis and balloon‐assisted enteroscopy; it also had the lowest burden. Magnetic resonance enteroclysis was preferred over balloon‐assisted enteroscopy for clarity of explanation of the examination, bowel preparation, painfulness and burden of the entire examination, and balloon‐assisted enteroscopy over magnetic resonance enteroclysis for scope insertion and study duration.     

Helicobacter pylori and hetertopic gastric mucosa in the upper esophagus (the inlet patch)

OBJECTIVES: Helicobacter pylori (H. pylori) may colonize gastric mucosa wherever it is found in the GI tract. Heterotopic gastric mucosa in the upper esophagus (inlet patch) is a potential site for H. pylori infection and may provide a reservoir for oral-oral transmission or a niche where antibiotics might have difficulty reaching. The aim of this study was to analyze the intensity and distribution of H. pylori in the inlet patch. METHODS: Whenever a cervical inlet patch was observed, mucosal biopsy samples were taken to confirm the endoscopic diagnosis and to search for H. pylori and active inflammation. In addition, mucosal biopsy samples were also taken from the gastric mucosa. Formalin-fixed biopsy specimens were cut and stained with a new dual stain developed in our laboratory. The stain is a combination of periodic acid-Schiff and a silver stain that allows simultaneous visualization of H. pylori and gastric type epithelium. The density of H. pylori was scored using a visual analog scale of 0 to 5. The type of mucosa in the inlet patch was also recorded. RESULTS: The study included 48 patients; 37 had H. pylori gastritis and 27 of these (73%) had H. pylori identified on their heterotopic gastric mucosa. A higher density of H. pylori in the stomach was associated with a higher prevalence in the inlets. Active inflammation correlated with active infection in the inlet patch and the presence of antral type mucosa. CONCLUSION: H. pylori colonization of heterotopic gastric mucosa in the upper esophagus is common and is closely related to the H. pylori density in the stomach. The fact that H. pylori was not found in all cases suggests that another event such as reflux may be required for H. pylori to colonize heterotopic mucosa.     

A double Meckel's diverticulum as obscure gastrointestinal bleeding cause. Report of a case

Meckel's diverticulum is the most common developmental anomaly of the gastrointestinal tract, affecting 1-4% of the general population. It is usually an incidental finding during laparotomy for other causes; occasional complications are bleeding, obstruction, diverticulitis and perforation. Up to 60% of Meckel's diverticula harbor heterotopic mucosa (mostly gastric or pancreatic), neoplastic degeneration occurs in 1-5% of cases. We report herein a case of obscure gastrointestinal bleeding in a 25-years-old man, due to a double Meckel's diverticulum, both located into jejunum and ileum, harboring ectopic gastric mucosa, diagnosed by a small bowel double contrast enema and managed laparoscopically with a tangential resection. To the best of our knowledge this is an unfrequent case of such a variant of Meckel's diverticulum with ectopic gastric mucosa diagnosed by double contrast enema.     

Evaluation for <Emphasis Type="Italic">Helicobacter pylori</Emphasis> in Meckel’s Diverticulum by Using Real-Time PCR

Background  

Although Helicobacter pylori (H. pylori) has been identified in heterotopic gastric mucosa of Meckel’s diverticulum, controversial results are reported in the pertinent literature.     

Biliary Obstruction by Heterotopic Gastric Mucosa at the Ampulla of Vater

Tumorous growths of heterotopic gastric mucosa have been infrequently found in the small intestine. Some have presented as intussusception and obstruction; others have been associated with mucosal ulceration, bleeding, and even more rarely with perforation. This ease report describes an elderly man who developed biliary obstruction secondary to a tumor mass of heterotopic gastric mucosa at the ampulla of Vater.     

SMALL BOWEL PSEUDOMELANOSIS AND ORAL IRON THERAPY

Small bowel pseudomelanosis is a rarely reported clinical entity characterized by brown pigmentation of small bowel mucosa. The authors describe two cases, both with iron deficiency anemia, one of an 81‐year‐old female patient submitted for capsule endoscopy that revealed a brown pigmentation of all small bowel mucosa and another of an 81‐year‐old male whose retrograde double‐balloon enteroscopy revealed a diffuse brown pattern of small bowel mucosa. Ileal biopsies confirmed intense iron deposition in the macrophages of the lamina propria. Both patients were on oral iron therapy and the second one had a previous double‐balloon enteroscopy, 2 years earlier, which revealed only ileal angiodysplasias. These two cases demonstrate the importance of two new endoscopic methods for diagnosis of small bowel pseudomelanosis, the rarity of such an entity and its close relation with oral iron therapy.     

Endoscopic diagnosis and treatment of inlet patch: Justification,techniques, and results

Esophageal gastric inlet patches (EGIPs) comprise an island of heterotopic gastric columnar epithelium in the cervical esophagus with a reported prevalence of up to 10%. Usually the diagnosis is made by chance in the course of an upper gastrointestinal endoscopy. After histopathologic examination EGIPs can be classified as oxyntic (mucosal glands contain parietal cells), mucoid type (mucosa is composed solely of glands with mucous cells), or mixed type (presence of both: glands with parietal cells and glands of mucous cells). Despite their overall low incidence of clinically relevant conditions, EGIPs seem to be a significant entity. Few individuals with EGIPs report symptoms of globus sensations, dysphagia, hoarseness, or chronic cough that are often misinterpreted as an atypical manifestation of gastroesophageal reflux disease. It is known that these symptoms significantly compromise the patients' quality of life. Therefore, therapy should be initiated. However, proton pump inhibitors' response seems to be poor in these patients. We were able to show that an interventional ablative endoscopic therapy by argon plasma coagulation can be a safe and effective procedure. However, further researches are required to better understand the clinical significance of EGIPs and their association to symptoms.