Review Question - QID 103313

This patient's clinical presentation is consistent with an evolving intestinal obstruction secondary to Meckel's diverticulum. Treatment should involve management of the obstruction with eventual surgical removal of the diverticulum.

Meckel's diverticulum is a commonly congenital anomaly due to incomplete regression of the omphalomesenteric duct. The most common type of ectopic tissue found in the diverticulum is gastric mucosa. Meckel's diverticulum follows the rule of 2's: located within 2 feet of the ileocecal valve, usually 2 inches in length, 2% of the population is affected, and presents before the age of two. Painless rectal bleeding and obstruction, secondary to volvulus or intussusception are the two most common presentations. Technetium-99 pertechnetate nuclear scan is the imaging modality of choice.

Leung et al. discuss the differential diagnosis of acute abdominal pain in children. Causes of acute abdominal pain in children can range from benign to life-threatening. The most common cause is gastroenteritis (from E. coli, campylobacter, or yersinia) which typically presents with diarrhea. Appendicitis is also common and presents with right lower quadrant pain. Other more common causes of acute abdominal pain include: renal colic, mesenteric adenitis and constipation. Vomiting, guarding and abdominal distention are signs that the patient may have an acute abdomen and require surgical consult.

Tseng et al. performed a retrospective analysis of the clinical presentation and diagnosis of Meckel's diverticulum. They found the presentation of Meckel's diverticulum to be quite variable. Of the patients in the study vomiting, abdominal pain and blood in stool was present about 50% of the time. Around 25% of patients had fever. As patients with bleeding may have false-negative results on technetium-99 pertechnetate scan, the authors advised considering adding RBC-tagged scanning in this population.

Figure A demonstrates increased uptake in the stomach, urinary bladder and the intestines on nuclear imaging.

Incorrect Answers:
Answer 1: Appendicitis can present with acute right lower quadrant pain, elevated white count and obstruction. The imaging in this vignette suggests Meckel's diverticulum
Answer 2: Gatroenteritis can present in a very similar fashion as seen in this patient, imaging suggests otherwise
Answer 3: DKA can present with abdominal pain, the rest of this clinical presentation in inconsistent with this ailment
Answer 5: Although encopresis is common in children and can present with obstruction, based on the clinical presentation and imaging this is unlikely.