A case series of Meckel’s diverticulum: usefulness of double-balloon enteroscopy for diagnosis

Meckel’s diverticulum (MD) is a congenital anomaly of the gastrointestinal tract. MD is usually located about 100 cm proximal to the ileocecal valve. Although MD is usually asymptomatic, about 2% of cases are symptomatic. Sixty percent of patients who develop complications are younger than 2 years old. Among patients with symptomatic MD, the male: female ratio is approximately 3:1 [1].

Observation of the small intestine has become easier since the development of double-balloon enteroscopy (DBE) and single-balloon enteroscopy. The number of reports of MD observed by DBE is increasing [2‐4]. The present case series describes 10 patients with MD in whom DBE was useful for diagnosis.

From May 2004 through May 2013, a total of 10 patients (8 men, 2 women) with MD underwent DBE at Kobe City Medical Center General Hospital. Their median age was 31.5 years (range, 14–83 years). Nine patients underwent esophagogastroduodenoscopy (EGD) before DBE. All patients underwent colonoscopy (CS) before DBE. The EN-450 T5/W and EN-450P5/20 gastrointestinal endoscopes (Fujifilm Corporation, Tokyo, Japan) were used in this case series. Ten retrograde and two anterograde DBEs were performed. All patients underwent conscious sedation with midazolam and pentazocine administered by an endoscopist. Patients who were scheduled to undergo retrograde DBE underwent bowel preparation using polyethylene glycol electrolyte solution (2 L). Two patients underwent capsule endoscopy (CE) (Pillcam SB and PillCam SB2; Given Imaging, Yokneam, Israel). Abdominal computed tomography (CT) was performed in all patients. Technetium-99 m (Tc-99 m) pertechnetate scintigraphy and a small bowel series were carried out in six patients.

The clinical characteristics of patients who underwent DBE for MD are shown in Table 1. Overt gastrointestinal bleeding occurred in eight patients. Abdominal pain developed in three patients. DBE showed MD in nine patients (Figure 1A,B), but an inverted MD was diagnosed as a lipoma in Case 4. MD was detected by iodinated contrast medium during anterograde DBE in Case 7. Although CT revealed abnormalities in six patients, MD was suspected in only two (Figure 2A,B). Tc-99 m pertechnetate scintigraphy revealed MD in one patient (Neither cimetidine nor proton pump inhibitors were used in all cases before MD scan). MD was suspected using CE in one patient (Figure 3). A small bowel series revealed MD in three patients (Figure 4). Surgery was performed in eight patients, and endoscopic resection was carried out in one patient. One patient was transferred to another hospital. Ectopic gastric tissue was found in five patients, and ectopic pancreatic tissue was found in two patients. Ulcer formation was found in or near MD in eight patients. Symptoms associated with MD were not seen after the operation or endoscopic resection in all patients with the exception of Case 3.

The area evaluated during small bowel examination has increased with the development of DBE, single-balloon enteroscopy, and CE. In the diagnosis of MD, DBE and single-balloon enteroscopy are useful especially because direct observation of MD and ulceration is possible. DBE and single-balloon enteroscopy also enable the performance of biopsy and endoscopic hemostasis. We directly observed MD using DBE in nine cases. MD is usually situated about 100 cm from the ileocecal valve, so retrograde DBE is particularly useful. A restriction of emergent retrograde DBE is that bowel preparation is required. In Case 7, we could not reach MD by anterograde DBE, but we identified MD using iodinated contrast medium through the scope. This method is useful when retrograde DBE is difficult because of massive hemorrhage and clots; however, this method is not always successful, as shown in Case 8. CE is also effective; however, the movement of the capsule is passive, making biopsy, insufflation, and endoscopic hemostasis impossible. The capsule could become trapped in MD [4]. CE may be more useful to determine the approach of DBE (peroral or anal). Whether DBE or CE is performed first depends on the current clinical situation. DBE should precede CE in an emergency. Abdominal CT, Tc-99 m pertechnetate scintigraphy, and small bowel series are also effective. Abdominal CT is particularly useful to detect bleeding, intussusception, and similar conditions. However, DBE is comparatively better able to identify MD as shown in the present report. Tc-99 m pertechnetate scintigraphy revealed MD in only one of six patients. If Tc-99 m pertechnetate scintigraphy results are negative, the presence of MD cannot be denied. Tc-99 m pertechnetate scintigraphy is a good diagnostic modality for children because of its minimal invasiveness. Our hospital’s diagnostic flowchart for MD is shown in Figure 5.

In Case 8, the histological findings indicated an inverted MD, but it was not inverted when DBE was performed. How inversion of MD occurs is unknown. It has been suggested that abnormal peristaltic movement caused by ulceration or ectopic tissue at the bottom of MD may cause it to invert [6]. In Cases 4, 8, 9, and 10 (and possibly Case 3), MD was inverted at least once. In Cases 4, 8, and 10, there was no ectopic gastric tissue, but ulceration of MD was observed. Endoscopic observation of the ulcers in MD provides important evidence of bleeding [4]. How ulcerations develop without ectopic gastric tissue is unknown. Chronic mechanical trauma or ischemia due to intermittent intussusception can be a cause [3, 7]. A persistent omphalomesenteric artery, which is a feeding artery of MD, is an end branch of the superior mesenteric artery and does not anastomose with other ileal branches. Therefore, this may provide another theory regarding ischemic ulceration of MD, whether inverted or not [8]. As shown in Case 9, an ulcer is not always seen in MD with ectopic gastric tissue. An ulcer may recover automatically; however, it is necessary to consider other factors as the cause of bleeding. In Case 9, mechanical stimulation and ischemia due to intussusception were considered to be the cause of bleeding, as in MD without ectopic gastric tissue.

Endoscopic resection of an inverted MD was carried out in Case 4 [5]. Adverse events did not occur, but perforation due to endoscopic resection has been reported [9]. Diagnosis of inverted MD is difficult; however, careful observation of the surface pattern of MD and abdominal CT lead to the diagnosis.

DBE and single-balloon enteroscopy are excellent for MD diagnosis; however, it is necessary to use other modalities complementarily. Symptomatic MD (gastrointestinal bleeding, abdominal pain, intussusception, and so on) necessitates surgery.

Written informed consent was obtained from all patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Series Editor of this journal.