A one-year-old boy was admitted with painless lower gastrointestinal
bleeding since one week. Investigations done at another hospital
showed a hemoglobin of 6.2 g/dL for which blood transfusion had been
given. The child had also undergone upper and lower gastrointestinal
endoscopy and a technetium99m pertechnetate scan, which were all
reported as normal. At admission to this hospital, physical
examination revealed no abnormality. The clinical possibility of
Meckel’s diverticulum was discussed with the parents and a diagnostic
laparoscopy was offered. Laparoscopy using a 5 mm umbilical port
revealed a Meckel’s diverticulum. Using two 3 mm secondary ports the
diverticulum was delivered out of the abdomen through the umbilical
incision. A wedge resection of the diverticulum with intestinal
anastomosis was done.
Meckel’s diverticulum is the most common congenital
anomaly of the gastro-intestinal tract involving the small bowel(1).
In infants and younger children, painless lower gastrointestinal bleed
is the commonest manifestation. The bleeding may be brisk and blood
transfusion is often required. A pre-operative diagnosis of a Meckel’s
diverti-culum is often difficult to make.
Routine evaluation of these children would include
a hemogram, endoscopic evaluation of the gastrointestinal tract and a
radioisotope scan. Abdominal ultrasono-graphy is commonly performed
but rarely helps in diagnosis. Barium studies have little utility. The
most useful method to detect a Meckel’s diverticulum is the
technetium99m pertechnetate scan. A positive scan depends on tracer
uptake by heterotopic gastric mucosa, which is present in only 50% of
cases(1). Presence of ectopic tissue other than gastric, recent barium
study, a small diverticulum or hemorrhage washing out the isotope, are
all known to lead to false negative results. The negative predictive
value of the scan is a low 0.74(2). The sensitivity and specificity of
Meckel’s scan is approximately 85% and 95% respectively(1). A
combination of pentagastrin and H2 receptor blockers(3) and, more
recently, glucagon has been used to improve results of nuclear
imaging. The low negative predictive value, therefore, necessitates
surgical evaluation despite the scan result.
Laparoscopy in children as a diagnostic tool in
gastrointestinal bleeding of obscure origin holds good promise(4).
Laparoscopy is, both, diagnostic and therapeutic. The whole of the
small bowel can be systematically inspected and the diverticulum can
be easily identified. With the aid of the laparoscope, extracorporeal
or intracorporeal resection(5) may be performed and the need for a
formal exploratory laparotomy avoided. Laparo-scopy also scores over
laparotomy in terms of smaller incision, less pain and earlier
recovery.
A high index of clinical suspicion is important,
particularly, in patients with a negative Meckel’s scan and we
recommend that laparoscopy must be advised in all such cases.
Vishal Raj Saggar,
Anurag Krishna,
Department of Pediatric Surgery,
Sir Ganga Ram Hospital,
New Delhi 110 060, India.
Address for correspondence:
Dr. Anurag Krishna,
6/15, Shanti Niketan, New Delhi 110 021.
E-mail: [email protected]
