Mesenteric Meckel’s diverticulum: a real variant

Introduction A Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastro-intestinal tract, and can present diagnostic and surgical challenges. Arising from failure of the omphalomesenteric duct to close properly, MD can occur in up to 2% of the population and can manifest as obscure gastrointestinal bleeding, Meckel’s diverticulitis, obstruction, and intussusception [1]. While most MDs present in childhood, adult patients are also at risk for complications, though these tend to decrease with increasing age [2, 3]. Several characteristics that facilitate identification of a Meckel’s diverticulum include location two feet proximal to the ileocecal valve, the presence of an independent vessel supplying the structure, five layers of small intestine, and ectopic mucosa of either gastric, pancreatic or another origin other than small intestine in a majority of specimens [4]. There are very few cases of mesenteric-sided MD reported in surgical literature (Table 1), and several authors have suggested that what some call a mesenteric-sided MD may in fact be an intestinal duplication cyst [4–9]. This study reports a case of what the authors believe to be a mesenteric MD and reviews the literature concerning identification and appropriate treatment of a MD in the minimally invasive era. Case Report A 35-year-old otherwise healthy gentleman noticed a small quantity of maroon colored stools for one week, worsening over time. He eventually reported to a local emergency department with symptoms of orthostasis and required transfusion of 2 units of packed red blood cells. Extensive gastroenterologic workup included a video-capsule endoscopy which identified blood in the ileum. A subsequent double-balloon enteroscopy indicated friable ileal mucosa with contact bleeding reportedly 120 cm from the ileocecal valve. A tattoo was placed at the point of interest. A Meckel’s scan was then performed at the outside facility and was negative. No additional intervention was undertaken by the patient until two weeks prior to his presentation to our clinic, which was one year after his first episode. Upon further questioning the patient had used NSAIDs prior to first episode of bleeding and aspirin prior to second episode. Workup at our institution included computed tomography (CT) scanning with enterography, as well as a review of the patient’s outside capsule endoscopy. CT enterography revealed a “tubular outpouching” adjacent to the distal ileum and ascending colon that was considered consistent with the expected appearance of a Meckel’s diverticulum (Figure 1). In light of Susanne G. CARPENTER [1] Ann E. McCULLOUGH [2] Shabana PASHA [3] Kristi L. HAROLD [1]