Uniformed Services University of the Health Sciences Bethesda, MD, United States
Julia M. Krum, 1, John W. Lee, MD2, John G. McCarthy, MD2 1Uniformed Services University of the Health Sciences, Bethesda, MD; 2Walter Reed National Military Medical Center, Bethesda, MD
Introduction: Meckel’s diverticulum (MD) is a congenital malformation of the GI tract present in 1-4% of the population, and only 4-16% of patients with MD develop complications such as bleeding, ulceration, intussusception, obstruction, or perforation. Given rarity and location, diagnosis of MD remains challenging and therefore necessitates a high index of suspicion. We present a case of symptomatic MD diagnosed with classic findings on video capsule endoscopy (VCE) and Technetium-99m pertechnetate scintigraphy (Meckel’s scan).
Case Description/Methods: A 22 year old man presented with several years of intermittent nausea, vomiting, and colicky epigastric pain followed by bouts of self-limited hematochezia. Prior colonoscopy showed distal proctopathy and despite lack of chronic inflammation on pathology, he was prescribed rectal mesalamine for presumed ulcerative proctitis; he never initiated treatment given infrequency of symptoms. EGD was normal, but repeat colonoscopy revealed maroon-colored blood in the right colon and terminal ileum with normal underlying mucosa. MR enterography (MRE), pursued to further evaluate for IBD, neoplasm, and risk of VCE capsule retention, returned normal. On VCE, the double lumen sign was seen in the distal small bowel consistent with a diverticulum (see Image 1). Subsequent Meckel’s scan showed abnormal uptake in a focus of mid to distal ileum. Resection of small bowel with associated diverticulum revealed heterotopic gastric mucosa on pathology. Patient has had no further recurrence of hematochezia.
Discussion: Elucidating the etiology of transient small bowel bleeds remains challenging. In young patients, the differential includes IBD, Dieulafoy lesions, neoplasms and Meckel’s. Available diagnostics include MRE, VCE, Meckel’s scan, angiography, and double balloon enteroscopy. The double lumen sign on VCE has been found in up to 68.8% of patients with MD. Other signs of MD on VCE include visible blood and the diaphragm sign. Meckel’s scan (the gold standard with sensitivity of 85%) can still yield false positives from bowel inflammation, obstruction, intussusception, or vascular lesions. In this case, the additional finding on VCE reduced the likelihood of false positive Meckel’s scan. This case highlights the utility of VCE used in conjunction with Meckel’s scan.
Figure: A) VCE: Distal small bowel imaging showing double lumen sign (asterisks) consistent with diverticulum B) Meckel’s scan: Abnormal uptake (white arrow) in a focus of mid to distal ileum.
Julia Krum indicated no relevant financial relationships.
John Lee indicated no relevant financial relationships.
John McCarthy indicated no relevant financial relationships.
Julia M. Krum, 1, John W. Lee, MD2, John G. McCarthy, MD2. P2594 - Hunting for Small Bowel Bleeding: Using Video Capsule Endoscopy in Conjunction With Meckel’s Scan in a Classic Case of Meckel’s Diverticulum, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.