| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Original Report |
1 Departmento de Radiologia, Hospital da Criança
Conceição—Ministério da Saúde, Rua Francisco
Trein 596, Porto Alegre, RS, Brazil 91350-200.
2 Department of Patologia Hospital da Criança
Conceição—Ministério da Saúde, Porto Alegre,
RS, Brazil 91350-200.
3 Departamento de Pediatria, Hospital da Criança
Conceição—Ministério da Saúde, Porto Alegre,
RS Brazil 91350-200.
Received February 11, 2002;
accepted after revision July 22, 2002.
Address correspondence to M. Baldisserotto.
Abstract
 Top Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CONCLUSION. Sonographic findings of an inflamed Meckel's diverticulum may mimic findings for acute appendicitis or intestinal duplication. In patients with rectal bleeding due to diverticulitis, the visualization of a tubular hyperechoic structure on sonography is suggestive of Meckel's diverticulum. The inflamed Meckel's diverticulum may present as a cyst, but its mucosal layer is more irregular than that found in an intestinal duplication. We found that routine color Doppler sonography revealed anomalous vessels and signs of inflammation on the wall of the Meckel's diverticulum.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
A study by Daneman et al. [3] assessed the value of different imaging methods in the diagnosis of complications from Meckel's diverticulum such as inflammation or intestinal invagination. Those authors showed that in many patients, the inflamed Meckel's diverticulum can be identified on sonography. In nine of their patients, sonographic findings were specific for complications of Meckel's diverticulum. The spectrum of features they identified were as follows: in four patients, the Meckel's diverticulum appeared as a cystlike mass that had a thick, irregular internal wall with an external hypoechoic rim corresponding to the muscle layer and an internal hyperechoic line corresponding to the submucosal and mucosal layers, an appearance that has also been called the gut signature [4]; in two patients, the Meckel's diverticulum had a tear-drop shape; in one patient, a tubular shape; in another, a cul-de-sac shape; and in the ninth patient, a round masslike shape. Sonography was reported to be an alternative option when scintigraphic findings are negative for this disease or when the patient presents with atypical clinical signs and symptoms. Apart from the study by Daneman et al., few cases of Meckel's diverticulum detected on sonography have been reported [5,6,7,8,9,10].
We have retrospectively studied 10 cases of inflamed Meckel's diverticula for which sonographic findings were obtained. Only two patients presented with rectal bleeding, whereas six presented with clinical signs suggestive of acute appendicitis. In addition, two patients in this series also underwent color Doppler sonography for assessment of the lesion. We present these clinical, sonographic, surgical, and pathologic findings.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Nine patients presented with abdominal pain, the most frequently reported symptom. Six of these patients also presented with clinical signs suggestive of acute appendicitis: pain in the right iliac fossa that resulted in guarding behavior and hemographic results that were indicative of infection. Only two patients presented with rectal bleeding. In one patient, the bleeding was severe and in the other, moderately intense. Both presented with nonspecific clinical signs and symptoms, such as abdominal distention and vomiting. The patient with the less intense rectal bleeding had pain in the right iliac fossa with guarding; the other patient had no pain.
Sonographic examinations were performed with either a SSD-630 scanner (Aloka, Tokyo, Japan) with a curved 5.0-MHz transducer and a linear 7.5-MHz transducer or with a 128XP-10 scanner (Acuson, Mountain View, CA) with a curved 3.75-MHz transducer and a linear 7.0-MHz transducer. The two patients with rectal bleeding underwent 99mTc pertechnetate scintigraphy in addition to color Doppler sonography. The sonography equipment was adjusted to detect low-velocity blood flow.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
|
|
|
In two patients, the Meckel's diverticulum was visualized as an oval cystlike structure in the right iliac fossa next to the anterior abdominal wall; the wall of the structure exhibited the gut signature (Figs. 3A,3B,3C,3D,3E and 4A,4B). This structure was compressible when pressure was applied with the transducer and mobile when there was peristaltic activity of the adjacent bowel loops. In one patient, the Meckel's diverticulum filled with air during the sonographic examination (Fig. 3B). Doppler sonography in both patients revealed hypervascularization of the Meckel's diverticulum wall and the presence of a large-caliber anomalous artery that supplied blood to the lesion (Figs. 3C, 3D, and 4A,4B).
|
|
|
|
|
|
|
In all 10 patients, surgical and pathologic findings indicated that the Meckel's diverticulum showed signs of inflammation, and the cecal appendix was removed. At pathology, the appendix from all the patients proved to be normal.
Surgical and pathologic findings revealed that the diverticular inflammation in six patients was a result of the presence of ectopic gastric mucosa; wall ulceration was observed in three of these patients (Fig. 3E). In the four other patients, inflammation was caused by obstruction of the lumen with vascular involvement. In two of these patients, the obstruction was caused by the mesodiverticular band with an internal hernia; in another patient, the presence of an intestinal volvulus around the omphalomesenteric band caused obstruction of the base of the diverticulum. A volvulus of the diverticulum was identified in the fourth patient.
In three of the six Meckel's diverticula that were visualized as cul-de-sac tubular structures on sonography, inflammation was associated with ectopic gastric mucosa. Inflammation in the other three patients was related to a mesodiverticular band with hernia, an intestinal volvulus around the omphalomesenteric band, and a volvulus of the diverticulum. However, the two patients with an internal band also had intestinal obstruction, and distended loops of small bowel with increased peristaltic activity were observed on sonography. The Meckel's diverticulum was inflamed and presented as a perforated ulceration and an abscess in a seventh patient, in whom sonography revealed a complex mass in the umbilical region.
For the two patients in whom a cystlike structure with a gut signature was visualized on sonography, surgical and pathologic findings revealed that the diverticular inflammation resulted from ectopic gastric mucosa with wall ulceration. Scintigraphic findings were negative for one of these patients. Sonographic findings for the 10th patient suggested an intestinal sub-occlusion (i.e., loops of small bowel distended with increased peristaltic activity), and the Meckel's diverticulum was not visualized.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
The frequency rates of the different clinical presentations of the Meckel's diverticulum are as follows: inflammation with hematochezia, 40%; an intestinal obstruction, 30%; inflammation without hemorrhaging, 20%; and umbilical disease, 6% [1]. In our study, however, only two patients had hematochezia, and most patients presented with clinical signs and symptoms that mimicked acute appendicitis.
We do not know why our findings differ from those reported in the literature. We will, therefore, continue this investigation to assess clinical presentations in a larger number of cases.
We believe that the more important findings of our study are that in our patients, diverticulitis mimicked appendicitis clinically and on sonography and that the inflamed Meckel's diverticulum was wrongly interpreted as an abnormal cecal appendix in several patients. Although the sonographic diagnosis was incorrect, the identification of an abnormal intraabdominal structure—a tubular hypoechoic structure (six patients) or a complex mass (one patient)—led to the correct therapeutic measures because both Meckel's diverticulum and an abnormal intraabdominal structure require surgery. Little has been reported concerning the fact that the presence of an inflamed Meckel's diverticulum can result in false-positive results in the sonographic diagnosis of appendicitis [3].
The cystlike structure with characteristics of the intestinal wall, such as an inner hyperechoic surface corresponding to the mucosa and an external hypoechoic rim corresponding to the muscle layer (the gut signature), has been described as highly suggestive of an intestinal duplication cyst on sonography [3]. Daneman et al. [3] observed this sonographic feature in four patients and drew attention to the fact that the Meckel's diverticulum has a more irregular wall than a duplication cyst, a finding that we also observed in two of our patients. We also found this sign in six patients in whom the inflamed Meckel's diverticulum presented as a tubular structure. It is important to remember that the gut signature can also be found on sonography in patients with normal or abnormal appendixes.
Other case reports have illustrated the same cystlike appearance of this disease on sonography [7,8,9,10]. In one of our patients with enterorrhagia, the identification of the Meckel's diverticulum on sonography was useful in establishing the diagnosis because scintigraphic findings had been negative. A similar case was reported by Panuel et al. [7]; the findings of scintigraphy had been negative, and the Meckel's diverticulum was identified only on sonography.
Another characteristic feature we noted was the change in the appearance of the Meckel's diverticulum during the sonographic examination (Fig. 3A,3B,3C,3D,3E). The presence of air inside the Meckel's diverticulum and its mobility during the peristaltic activity of the adjacent bowel loops can give the Meckel's diverticulum an appearance that is similar to the rest of the intestine. In this case, a detailed examination of the intestine in the right lower quadrant with high-frequency transducers is necessary to identify the Meckel's diverticulum, especially when an inflamed Meckel's diverticulum is clinically suspected.
We found color Doppler sonography to be important in revealing hypervascularization and signs of inflammation of the Meckel's diverticulum in the two patients in whom cysts were visualized. Color Doppler sonography was also useful in showing the presence of anomalous vessels, an appearance not found in the rest of the intestine.
Only one case of Meckel's diverticulum was not identified on sonography. This patient presented with nonspecific clinical signs and symptoms, such as abdominal distention and pain. On sonography, only distended small-bowel loops with increased peristaltic activity were visualized. Surgery revealed an inflamed Meckel's diverticulum with a band running to the umbilicus, causing intestinal obstruction. Daneman et al. [3] described two patients with a teardrop-shaped Meckel's diverticulum, but we found no such Meckel's diverticulum in our study population.
We do not believe that sonography will supersede 99mTc pertechnetate scintigraphy because scintigraphy is a highly accurate tool to use in establishing the diagnosis of an inflamed Meckel's diverticulum. Sonography may, however, be useful in patients who have rectal bleeding and whose scintigraphic findings are negative. For patients with diverticulitis and clinical signs and symptoms suggestive of appendicitis, a sonographic diagnosis may be made if the Meckel's diverticulum presents as a cystlike structure with a wall exhibiting the gut signature. Routine color Doppler sonography reveals anomalous vessels and signs of inflammation on the wall of the Meckel's diverticulum. In patients in whom appendicitis is clinically suspected, the finding of a hypoechoic tubular structure in the iliac fossa on sonography is not a specific sign of appendicitis, and the possibility of an inflamed Meckel's diverticulum must be considered in the differential diagnosis.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  T. Hamada, M. Tanaka, Y. Hashimoto, M. Yamauchi, N. Shigeoka, K. Nakai, and K. Suenaga Contrast-enhanced sonographic findings of gangrenous meckel diverticulitis. J. Ultrasound Med., September 1, 2006; 25(9): 1227 - 1231. [Full Text] [PDF]
|
|
|
|
 |
|
 T. Sung, M. J. Callahan, and G. A. Taylor Clinical and Imaging Mimickers of Acute Appendicitis in the Pediatric Population Am. J. Roentgenol., January 1, 2006; 186(1): 67 - 74. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Baldisserotto Color Doppler Sonographic Findings of Inflamed and Perforated Meckel Diverticulum J. Ultrasound Med., June 1, 2004; 23(6): 843 - 848. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. L. Bennett, B. A. Birnbaum, and E. J. Balthazar CT of Meckel's Diverticulitis in 11 Patients Am. J. Roentgenol., March 1, 2004; 182(3): 625 - 629. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. D. Levy and C. M. Hobbs From the Archives of the AFIP: Meckel Diverticulum: Radiologic Features with Pathologic Correlation RadioGraphics, March 1, 2004; 24(2): 565 - 587. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
