Many patients who have a Meckel diverticulum will never find out they have it. It is often found incidentally on imaging studies. If patients do develop symptoms, they usually present in the first 10 years of life with an average age of 2.5 years with painless rectal bleeding.[2]   The rectal bleeding is typically described as currant jelly or the color of brick. Children typically present with the classic “currant jelly” colored stool while adults typically present with melena.[6]  The bleeding usually resolves without intervention. As the patient becomes hypovolemic, the splanchnic vessels vasoconstrict to prevent further bleeding. Patients can present with a variety of GI symptoms other than painless rectal bleeding. It should be suspected in children with recurrent or atypical intussusception, a patient with symptoms of appendicitis after their appendix has been removed, and adults with an unclear source of GI bleeding.[1]  Although it is classically described as painless rectal bleeding, some patients may present with abdominal pain.

Clinically, Meckel diverticulum should be suspected in any child younger than 2 years of age with painless rectal bleeding. It accounts for approximately 50% of all lower GI bleeding in children younger than 2 years of age.[6]   Plain abdominal x-ray is of very low yield. Even barium studies rarely fill the diverticulum. The most sensitive test is a Meckel radionuclide scan (commonly known as Meckel scan).[7]  It is a nuclear study done by injecting technetium-99m which is absorbed by the ectopic gastric mucosa allowing for visualization of the Meckel diverticulum. The uptake of the dye can be enhanced using cimetidine, ranitidine, or glucagon. In patients with active bleeding, a tagged red blood cell (RBC) scan can also be used to detect a Meckel diverticulum. A CT scan of the abdomen and pelvis may show evidence of inflammation or obstruction at the diverticulum. More invasive methods include mesenteric angiography as well as exploratory laparoscopy.[8]

If the patient has had significant blood loss, the patient should undergo volume resuscitation. Patients may require a blood transfusion if a significant amount of blood is lost. The treatment of symptomatic Meckel diverticulum is surgical excision. The diverticulum can be removed via laparoscopic or open technique.[9]  The diverticulum should be excised along with the adjacent ileum. There is a growing trend to perform the excision laparoscopically rather than using the open technique.[9]  The treatment of asymptomatic Meckel diverticulum is controversial (surgery versus observation). When a Meckel diverticulum is incidentally discovered during abdominal surgery for another condition, most surgeons recommend removal.[9]

The differential diagnosis is broad in can including any cause of GI bleeding. Massive GI bleeding is uncommon in childhood. Stool may be mistaken for hematochezia if children ingest bismuth, iron, or spinach.  A hemoccult test will show that the stool will be negative. In infants, swallowed maternal blood from bleeding nipples, milk protein allergy, intussusception, and anal fissures can commonly cause rectal bleeding. Necrotizing enterocolitis should be on the differential in neonates and premature infants. In older children, other common causes of rectal bleeding include colitis, gastroenteritis, HSP, HUS, intussusception, inflammatory bowel disease, and vascular malformation.

The most common complication of Meckel diverticulum in children is rectal bleeding resulting in anemia.[5]  The most common complication in adults is a small bowel obstruction.[10]  The etiology of the obstruction may be secondary to the omphalomesenteric band, internal hernia, volvulus around the vitelline duct remnants, and intussusception in which the diverticulum acts as the lead point.[5]  The diverticulum can become inflamed resulting in Meckel diverticulitis with perforation and peritonitis.

To provide the best care of a patient with Meckel diverticulum, a team approach should be used. There are a number of potential complications and the nurses should be educated by the physicians to watch for them and encouraged to report any abnormal findings. In particular, these patients are at risk of developing a perforation and acute peritonitis. [Level V]