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Letters to the Editor

Indian Pediatrics 2004; 41:747-748

Laparoscopy in Suspected Meckel’s Diverticulum: negative Nuclear Scan Notwithstanding


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]

 

References

1. Martin JP, Connor PD, Charles K. Meckel’s diverticulum. Am Fam Physician 2000; 61: 1037-1042

2. Swaniker F, Soldes O, Hirschi RB. The utility of technetium pertechnetate scintigraphy in the evaluation of patients with Meckel’s diverticulum. J Pediatr Surg 1999; 34: 760-764.

3. Heyman S. Meckel’s diverticulum: possible detection by combining pentagastrin with histamine H2 receptor blocker. J Nucl Med 1994; 35: 1656-1658.

4. Lee KH, Yeung CK, Tam YH, Ng WT, Yip KF. Laparoscopy for definitive diagnosis and treatment of gastrointestinal bleeding of obscure origin in children. J Pediatr Surg 2000;35:1291-1293.

5. Valla JS, Steyaert H, Leculee R, Pebeyre B, Jordana F. Meckel’s diverticulum and laparoscopy of children. What’s new? Eur J Pediatr Surg 1998; 8: 26-28.

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