Pediatric Meckel's Diverticulum

Introduction to the children's Meckel's diverticulum Meckeldiverticulum, also known as the distal ileum, is a common digestive tract malformation. When complications such as inflammation, necrotic perforation, intestinal obstruction, and hemorrhage occur, the patient is treated with surgical acute abdomen. basic knowledge The proportion of illness: 0.06% Susceptible people: children Mode of infection: non-infectious Complications: umbilical bulge, intestinal malrotation in children, intestinal obstruction

The cause of pediatric Merkel diverticulum

(1) Causes of the disease

During embryonic development, the midgut is connected to the yolk sac by the yolk tube. About the fifth week of the embryo, the blood circulation of the placenta has formed, and the yolk sac is no longer needed. Therefore, the body cavity part of the yolk tube begins to become thinner and gradually closes, shrinking into After a cord is absorbed, when the dysplasia is abnormal, one or all of the yolk tube is atrophied and closed, and various types of yolk tube abnormalities can be produced. There are umbilical hernia, umbilical sinus, umbilical cord, yolk tube cyst, and Meckel's diverticulum. And umbilical cordula.

The yolk tube begins to shrink from the umbilical end to the intestine end. If the umbilical end is degraded, the intestine end is not degraded to form a blind sac, called the distal ileum diverticulum. In 1809, Meckel suffered from this congenital malformation. It is described in detail in embryology and clinical aspects and is therefore called the Meckel's diverticulum.

(two) pathogenesis

The diverticulum is generally located 20 to 100 cm from the ileocecal valve to the lateral edge of the mesorectum, 2 to 5 cm long, with independent blood supply, and an independent mesangium. The diverticulum is often free in the abdominal cavity and there may be residual cord attached to the umbilicus. The intestinal fistula can be twisted around the cord or compressed by the cord to cause intestinal obstruction. The top of the diverticulum can also adhere to other intestinal fistulas to cause intestinal obstruction, and sometimes the intestine turns into the intussusception starting point to cause intussusception.

The diverticulum wall contains 3 layers of serosa, muscle layer and mucosa. The mucosa is usually the ileal mucosa. About 50% contain ectopic tissues such as gastric mucosa and pancreatic tissue. The most common gastric mucosa, these tissues can secrete hydrochloric acid and digestive enzymes. It can corrode the diverticulum and its surrounding tissues, causing ulcer bleeding and perforation.

The diverticulum can also be obstructed by its own twist, aphid or foreign body entry, acute inflammation, necrosis and perforation.

Pediatric Merkel diverticulum prevention

At present, there are no definite preventive measures. Take the same preventive measures as other congenital malformations, and do a good job in pregnancy health care and genetic counseling. Refer to other birth defects diseases, prevention should be carried out from pre-pregnancy to prenatal.

1. The pre-marital medical examination plays a positive role in preventing birth defects. The size depends on the examination items and contents, mainly including serological examination (such as hepatitis B virus, Treponema pallidum, HIV), reproductive system examination (such as screening for cervical inflammation). , general physical examination (such as blood pressure, electrocardiogram) and ask about the family history of the disease, personal medical history, etc., do a good job in genetic disease counseling.

2. Pregnant women should avoid harmful factors including smoke, ethanol, drugs, radiation, pesticides, noise, volatile harmful gases, toxic and harmful heavy metals, etc. In the process of antenatal care during pregnancy, systematic screening of birth defects is required. Including regular ultrasound examination, serological screening, etc., if necessary, also to carry out chromosome examinations to take practical treatment measures.

Pediatric Merkel diverticulum complications Complications, umbilical bulge, intestinal malrotation, intestinal obstruction

Meckel's diverticulum can also be associated with other malformations, such as umbilical bulging, poor intestinal rotation, intestinal atresia, intestinal duplication and congenital heart disease. It has been reported in the literature to have an incidence of 8.4%. The disease accounts for 15% to 30%. Complications can occur at any age. Before the age of 10, half of the patients have complications such as intestinal obstruction, diverticulum ulcer bleeding, diverticulitis or perforation, and diverticulosis.

Pediatric Merkel diverticulum symptoms common symptoms abdominal pain fever irritability abdominal muscle tension pale diarrhea peritonitis peptic ulcer bloody chamber bleeding

In the normal population, the incidence of Meckel's diverticulum is 2%. Most people with diverticulum are usually asymptomatic for life. Occasionally, Meckel's diverticulum is found during surgery or autopsy. More than half of the infants and young children under 3 years of age develop symptoms. It is very serious and requires more surgical treatment. The symptoms occur only in the case of merging in the Meckel's diverticulum. The literature reports that complications occur in 15% to 30%. Complications can occur at any age, half of the time before the age of 10, combined In the case of small bowel obstruction (30%), acute gastrointestinal bleeding (40%) and acute diverticulitis (20%).

1, intestinal obstruction

In the 83 cases of pediatric Meckel's diverticulum reported by China Medical University, there were 29 cases of intestinal obstruction caused by intestinal adhesions, 8 cases of intestinal necrosis, 8 cases of acute intussusception caused by diverticulum, and 1 case of chronic intussusception. A total of 46 cases (55.4%), recently encountered a case of neonates in the hospital because of the Meckel's diverticulum and cords embedded in the intestine, and the formation of intra-abdominal hernia, intestinal obstruction peritonitis, intestinal perforation, emergency surgery, removal of necrotic intestines and The diverticulum is cured. It is generally reported that 25% to 54% of the Meckel's diverticulum develop intestinal obstruction. The intestinal obstruction caused by diverticulum is mainly low, and most of them are strangulated. It is difficult to identify small intestinal obstruction caused by other adhesion cords. Intussusception caused by varus can be determined when the pathological specimen is examined during or after surgery. The main manifestations of low intestinal obstruction caused by Meckel's diverticulum are: paroxysmal crying or abdominal pain, with malignant, vomiting, and even Fever, abdominal pain, defecation, reduced exhaust or stop defecation, venting, accompanied by intussusception, can appear jam-like bloody stools, the abdomen touches the sausage-shaped mass, with umbilical pressure, if accompanied by intestinal torsion or strangulation Intestinal obstruction Deterioration, and electrolyte imbalance obvious edema, shock and severe peritonitis.

2, diverticulum ulcer bleeding

Because there is an ectopic gastric mucosa in the sputum, its gland is the fundus gland, and there is also a pyloric gland. The fundus gland is composed of parietal cells secreting hydrochloric acid, secreting digestive enzymes and mucinous cells, and the pyloric gland is composed of mucous cells and CT" cell composition, "CT" cells can secrete gastrin, hydrochloric acid secreted by the fundus gland in the ectopic gastric mucosa of the sputum and gastrin secreted by the "CT" cells in the pyloric gland stimulate the parietal cells to secrete a large amount of hydrochloric acid, corroding the diverticulum The mucosa and blood vessels can cause mucosal erosion and peptic ulcer, which can lead to hemorrhage and perforation of the diverticulum. In the cases of bloody stools in the Meckel's diverticulum, the detection rate of ectopic mucosa is as high as 81% to 100%, causing ulcers. Bleeding accounts for about 30%, up to 70%, more common in infants and young children, generally no prodromal symptoms, vomiting and other gastrointestinal symptoms, usually sudden painless whole blood, a large amount of blood in the stool, with or without abdominal pain, at first It is dark purple or dark brown bloody stool, mixed with fecal matter; blood is dark red or bright red when there is a lot of bleeding, it can be 3 to 5 times in a day and night, lasting 2 to 3 days, the sick child will soon appear pale, thirsty Irritability , wilting, weak pulse, weak limbs, oliguria and other hemorrhagic shock, but at this time there are few signs of abdominal, occasionally tender tenderness, most of the sick children after blood transfusion and other supportive therapy conservative treatment, blood in the stool can temporarily Stop, but after some time repeated bleeding, such as bleeding, children with anemia, in the data we collected, diverticulum bleeding accounted for 25%.

3, diverticulitis or perforation

China Medical University reported a total of 2 cases of diverticulitis, no necrosis, 6 cases of necrosis, 17 cases of diverticulitis with perforated peritonitis, a total of 25 cases (30.1%), the majority of necrotic perforation (23/25) accounted for 92% It is believed that diverticulitis is caused by foreign bodies in the sputum. The clinical manifestations of acute diverticulitis are difficult to distinguish from acute appendicitis. The disease begins with right lower quadrant pain, usually persistent abdominal pain, no metastasis of right lower quadrant pain, and muscle tension and The tenderness point is closer to the right umbilical side, which is higher than the general appendix. It is often accompanied by diarrhea or blood in the stool. The anal examination of the right side of the rectum is not obvious. It causes peritonitis when the diverticulitis is complicated with perforation. %, it is reported that accounted for 55% (Cobb), at this time the sick children may have severe abdominal pain, vomiting, fever, increased white blood cells, obvious signs of peritoneal irritation in the abdomen, may appear pneumoperitoneum, total abdominal tenderness, abdominal muscle tension, lung and lung dullness The disappearance of the boundary, the bowel sounds weakened or hyperthyroidism, but also the symptoms of small bowel obstruction, due to symptoms such as adhesive intestinal obstruction or inflammatory bowel paralysis caused by diverticulitis, occasionally there is a history of blood in the stool before perforation, clinically Diagnosis of a ruptured appendix and peritonitis surgical treatment.

4, other

The Meckel's diverticulum can enter the groin, the sac or the umbilical hernia. The right side is more than the left side. There are more males than females. The diverticulum is more common in the inguinal hernia. It is called the diverticulum, and the Meckel's diverticulum. Separately embedded in the hernia sac, the diagnosis is extremely difficult, easy to be misdiagnosed, and delayed treatment, clinical symptoms, most of the complaints of the inguinal area sensitive, but no tenderness, individual with intra-abdominal pain, manifested as incomplete intestinal obstruction, when examined, can It was found that there is another cone in the groin parallel to the spermatic cord, which has obvious tenderness and tenderness. At this time, it is suspected that there is a diverticulum, which should be diagnosed and treated promptly. It is difficult to diagnose the Meckel's diverticulum before surgery, so it is inflammation in the right lower quadrant. Low intestinal obstruction and lower gastrointestinal bleeding (especially with a history of 2 to 3 recurrences) should consider the possibility of diverticular complications. In order to diagnose the cause of gastrointestinal bleeding, radionuclide (99mTc) can be used. There are ectopic gastric mucosa in Meckel's sputum, which may show radioactive concentration in the mid-abdomen of the right lower abdomen or near umbilicus. All the above complications are not effective when they are not treated by non-surgical treatment. Such as hair When the disease does not match with the original proposed diagnosis must carefully check the terminal ileum from the cecum at 100cm, is to determine whether the cause diverticulitis.

Pediatric Merkel diverticulum examination

Routine blood and blood biochemical tests, white blood cells and neutrophils are significantly increased in inflammation; hemoglobin and red blood cells are reduced in anemia; thrombocytopenia can be found in severe cases, creatinine can be found in blood biochemical tests, urea nitrogen is increased; Balance disorder, should check the blood sodium, potassium, calcium and blood pH, etc., routine stool examination can be found bloody stool and fecal occult blood positive.

1. X-ray examination: Abdominal plain film can only find changes in intestinal obstruction. If there is perforation of the diverticulum, there may be free gas under the armpit. Except for colonic polyps and hemangiomas except barium enema.

2.99mTc scan test: Because 99mTc has a special affinity for gastric mucosal cells, it can be absorbed by gastric mucosa, so that the local radioactive concentration area can be diagnosed with an accuracy of more than 90%. Most of this nuclides are collected through gastric mucosa. And excretion, bleeding in the sputum often accompanied by ectopic gastric mucosa, intravenous injection of 99 citrate (99mTcO4-) 1 ~ 3 millicurie, scan every 15min, continuous observation for 1 ~ 3h, the abdomen has Abnormal radioactive accumulation area can help diagnosis, Zhou Yiming and other 13 cases of bloody stool patients with 99mTcO4- imaging examination, 11 cases were positive and obtained preoperative diagnosis, the diagnosis rate was 84.6%, the examination was negative, subcutaneous injection of five Repeated photography after peptide gastrin can improve the diagnostic rate. Zhang Changbao et al. showed abnormal radioactive concentration in two cases of intermittent bloody stools with no abnormal radioactive concentration in the abdomen of gamma photography. The diagnosis was confirmed by the area and confirmed by surgery and pathology. This change also had the same result in intestinal duplication and gastrointestinal bleeding. It was too late for the sick child who had symptoms of acute abdomen to do this kind of examination, but not helpless. For diagnosis.

Diagnosis and identification of pediatric Merkel diverticulum

Meckel's diverticulum causes intestinal obstruction, diverticulitis or perforation, the symptoms and signs appear similar to general intestinal obstruction or appendicitis, or basically the same, it is still difficult to make a correct diagnosis before surgery, when gastrointestinal bleeding, Colon polyps, hemorrhagic necrotizing enterocolitis.

1. Colon polyps: generally have a long history of a small amount of blood in the stool, showing a bright red color. If there is polyps falling off, there may be a lot of bleeding, which can cause anemia. The defect of polyps can be seen in the barium enema. The fiberoptic colonoscopy or sigmoidoscopy can be used to diagnose and remove polyps. .

2. Acute hemorrhagic necrotizing enterocolitis: Most of them have diarrhea, which is a watery stool of rice water, accompanied by high fever, abdominal pain and toxic shock, often accompanied by symptoms of intestinal obstruction and signs of peritonitis.

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