Diagnosis of bleeding Meckel's by lap surgery - Forum

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Marcel

Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#1 »

Diagnosis and Rx of bleeding Meckel's by lap surgery.

With 600 + members, it is likely that every few weeks some member of our meets a case of bleeding Meckels.

This case was published. A 15 year old boy collapsed at home after 4 days of bright PR bleeding. Abdo was soft and non-tender, and there was dark blood PR. The family doctor made the correct ultimate diagnosis.

He was resuscitated in hospital, and then bled more, dropping his Hb from 10.4 to 8.2 g over a day. He was transfused. A Meckel's nuclear scan was negative, and so were endoscopy, colonoscopy, and barium enema.

Laparoscopy showed the diverticulum, which was removed after stapling the base, transecting, and oversewing a bleeding point with 3/0 silk.

Discussion in the paper referred to earlier similar reports, and the false positives and false negatives when looking for a bleeding Meckel's.

My own comment: I would have been tempted to use laparoscopy for the definitive diagnosis and then use surgeons's previously described technique to exteriorise the Meckel's through the extended telescope port after gripping it with a duckbill from an extra 5 mm port. [I have an old English paper by Prudhov, the father of a surgeon I met in Dubois's OR in Paris, describing a similar technique using a cystoscope]. This could have substituted a simple suture for stapling and an extra port. I am stingy and penny-pinching, and begrudge the use of staplers where feasible.

Bleeding Meckel's this month, anyone? How diagnosed, treated?


Gemcitabine

Re: Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#2 »

I have a case of GI bleed that is still in the work.

56 y old male, previously healthy, admitted through our ER for BRBPR ( Bright Red Blood Per Rectum). Hgb on admission of 102. The only med is NSAID. Not alcoholic. Gastroscopy was completely normal, colonoscopy to the ascending colon,did not show anything but blood, there was blood in the cecum, but it was not fresh. Meckel Scan ( negative); mesenteric angiogram shows a branch of the ileo-colic with an abnormal end ( it has an acute curve without beiing aneurysmal), there was no extravasation. Laparoscopy was not done but at laparotomy there was a short segment (5 cm) of the ileum, 45 cm from the ileo-cecal junction that was inflammed ( very similar to Crohn's). Because of the angio results I decided to do a right hemicolectomy and I resected the segment of ileum. Pathology is pending, but I remember a case while in training where a short segment of ileum was iflammed and the final conclusion was that it was related to NSAID rather than IBD.

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A Doctor

Re: Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#3 »

I've had two cases where the technology failed and the clincal impression prevailed. Basically in this case, what the hell else is it going to be? Spending bundles of cash through new technology won't refute the clinical impression too many times, and if it does so what? What's the worst case scenario here? The occasional patient with some unusual non macroscopic vascular malformation gets a BIGGER incision than he might have otherwise (a 3 cm gridiron). These patients are almost always KIDS or TEENAGERS! Do they have to get back to their bread winning status a few days earlier. ?Time to sober up from our intoxication with technology?

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Surgeon

Re: Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#4 »

I recently had a patient with all most the same clinical presentation. A 35 year old male came with bleeding PR for 5 days. He was severly anaemic (30%). We don't have facilities for angio or isotope scan or colonoscopy. I did an upper GIT endoscopy which was normal. It was late at night and I could see the pt deteriorating fast. I didnot think I should spend the extra time in diagnosing the cause of bleeding through laparoscope. At laparatomy I could see the colon full of blood and the caecum was contracted and hard. Terminal ileum was healthy. I did a rt hemicolectomy with ileo-transverse anatomosis. Histopathology revealed a large TB ulcer in the caecum with a large eroded vessel in the floor. Post operative recovery was uneventful.

Wired

Re: Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#5 »

As a technical point, I was taught to resect the ileum adjacent to the the Meckel's because that is "always" where the ulcer occurred necessitating an anastamosis rather then simply amputating the appendix. In my experience of two cases that I can recall, the ulcers were in the Meckel's. Is amputation adequate for a bleeding Meckel's diverticulum?

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Doctor Green

Re: Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#6 »

The standard of treatment for a symptomatic Meckels diverticulum is not to staple the base of the diverticulum as indicated. It should at least be a V resection or intestinal resection in the area of the diverticulum as the ectopic tissues are frequently found in the ileum around the area of diverticulum. I have reviewed literature on this subject and just stapling the base of the diverticulum is not the surgical treatment.

Priya

Re: Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#7 »

Since it is impossible to figure out if the bleed is from the ileum or from the diverticulum just amputation is not safe. I would rather go in an resect the diverticulum witha segement of ileum (laparoscop or no laparoscope).

Marcel

Re: Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#8 »

When there is a bleeding duodenal ulcer do we resect the duodenum? No. We remove the acid source (vagotomy +- gastric resection). Acid source in Meckels is gastric mucosa within the Meckels. Remove the acid source. Does it matter where the bleeding is located (unless, of course, it is uncontrolled)?

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Schom

Re: Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#9 »

Sure, nobody would resect the duodenum for a bleeding duodenal ulcer but also adding a gastric resection -to the vagotomy-should belong to annals of history. Unfortunately, it appears that for many surgeons the present and history co-exist.

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StSt

Re: Diagnosis of bleeding Meckel's by lap surgery - Ärzteforum

Post#10 »

I have a couple of questions about your case:
(1) what was the indication to explore your patient ?(one episode of BRBPR in a hemodynamically stable patient with a negative evaluation for identification of a definitive bleeding source....I probably would have repeated colonoscopy after a good prep and not have explored)
(2) was anoscopy done to r/o hemorrhoids? (granted blood in the cecum makes this diagnosis very unlikely)
(3) was the duodenum normal on endoscopy?
(4) why did you do right hemicolectomy instead of a segmental ileal resection? (I did not understand the significance of the abdnormality on angio)
(5) were there any signs of Crohn's disease (creeping fat, etc.)?
(6) please let us know the final path

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