Is Meckel's disease dangerous for children? Symptoms of Meckel's diverticulum

A) Indications for surgery for Meckel's diverticulum:
- Planned: when making a diagnosis, considering that complications of this obliteration occur in 40% of cases.
- Contraindications: widespread peritonitis; There are no contraindications for complicated diverticula.
- Alternative operations: laparoscopic removal.

b) Preoperative preparation . Preoperative investigations: usually an incidental intraoperative finding, indicated X-ray examination with double contrast; V in rare cases angiography, scintigraphy (the so-called Meckle's diverticulum scan).

V) Specific risks, informed consent of the patient:
- Clinical acute symptoms from the middle or right half abdominal cavity may be signs of Meckle's diverticulum (1-2% of cases in the general population)
- Seam divergence
- Peritonitis

G) Anesthesia. General anesthesia(intubation).

d) Patient position. Lying on your back.

e) Online access with Meckel's diverticulum. Usually midline laparotomy.

and) Operation stages:
- Skeletonization of the diverticulum
- Determination of the resection margin
- Diverticulum removal
- Sheathing the hardware seam line
- Clearance width confirmation

h) Anatomical features, serious risks, operational techniques:
- The diverticulum is localized in terminal department ileum, approximately 1 meter proximal to the ileocecal valve (incidence up to 4% of cases).
- Meckle's diverticula are always located on the antimesenteric edge
- The proper mesentery of the diverticulum is ligated separately
- Excision with a stapler (3.5 mm) is also possible
- Closure with sutures is always performed perpendicular to the longitudinal axis of the intestine.

And) Measures for specific complications. For very wide diverticula, resection of a short segment with end-to-end anastomosis is indicated.

To) Postoperative care:
- Medical care: depends on general situation. If only the diverticulum is removed, remove the nasogastric tube for 1-2 days.
- Resumption of nutrition: allow sips of liquid from the 2nd day; solid food from the 4th postoperative day if good peristaltic sounds are heard.
- Activation: immediately.
- Period of incapacity: 1-2 weeks.

k) Stages and technique of surgery for Meckel's diverticulum:
1. Skeletonization of the diverticulum
2. Determination of the resection margin
3. Diverticulum removal
4. Sheathing the hardware seam line
5. Clearance width confirmation

1. Skeletonization of the diverticulum. Meckel's diverticulum is a relatively common incidental finding at laparotomy, but is rarely the cause independent disease. Intraoperative detection is a sufficient basis for its removal, given that complications such as perforation or bleeding occur relatively frequently in the long term, and their differential diagnosis may be difficult.

Resection of Meckel's diverticulum begins with skeletonization of its own mesentery. The mesentery crosses the lateral wall of the intestine and supplies blood only to the Meckel's diverticulum. An Overholt clamp is placed under it, and it is crossed between the ligatures.

2. Determining the resection margin. The resection edge should be close to the mesenteric edge, where stay sutures are placed to stretch the intestine in the transverse direction.

3. Diverticulum removal. Meckel's diverticulum is excised between stay sutures. Excision can be performed using a TA-30 stapler or open method. For the open procedure, separate sutures (3-0 PGA) are used, although the staple technique is simpler. After the stapling device is activated, the excess edge of the intestine is cut off with a scalpel along the staple line. To avoid narrowing of the lumen of the jejunum, the transverse direction of resection is chosen.

4. Sewing the hardware seam line. The hardware seam line is sewn with separate seams (3-0 PGA). This suture line is not required, but the authors use it to achieve complete hemostasis.

5. Clearance Width Confirmation. After completing the seam line, the gap width is checked with the thumb and forefinger.

Meckel's diverticulum is congenital disease and occurs in one in fifty people. This disease mainly affects men. Inflammation of the diverticulum in both adults and children can occur with symptoms acute abdomen Therefore, it is important to know the manifestations of the disease and its distinctive features.

Characteristics of the disease in adults and children

Meckel's diverticulum is a pouch-like protrusion of the ileum that occurs at a distance of 20 cm from the point of its transition into the blind section of the large intestine. This pathology is congenital and is an open vitelline duct. At the stage embryonic development it connects the ileum and the yolk sac. A wall may enter the cavity of Meckel's diverticulum duodenum, gastric mucosa or part of the pancreas. Its length is on average 3 cm.

Meckel's diverticulum - pouch-like protrusion small intestine

This formation in children is most often detected before the age of 10 years, but it can be asymptomatic and manifest at a later age. Pathology in children is dangerous because it can suddenly manifest itself with manifestations of an acute abdomen. In adults, Meckel's diverticulum is most often detected before the age of 30.

The mechanism of formation of Meckel's diverticulum - video

Causes

Meckel's diverticulum is a pathology that occurs in the prenatal period. In the first weeks of life, the fetus has a vitelline duct. It is part of the umbilical cord and is necessary to connect the ileum and the yolk sac. During fetal development, the vitelline duct gradually becomes overgrown and atrophies. If this process has not been completed by the time of birth, then either a direct connection of the small intestine with the anterior abdominal wall or a pathological protrusion, called Meckel's diverticulum, occurs.

Meckel's diverticulum is classified as a true diverticulum, since it follows the structure of the small intestine. It may include part of the gastric mucosa or pancreatic tissue. In the first case, there is a selection hydrochloric acid, which leads to ulceration of the protrusion and the development of bleeding. This phenomenon most often develops in children. At this age, it can be combined with such malformations of the digestive system as:

• Crohn's disease;
• esophageal atresia;
• atresia of the anus and rectum.

The diverticulum, as a rule, is freely located in the abdominal cavity and may have its own mesentery.

According to research, gastric mucosa as part of a diverticulum occurs in 10% of cases, and pancreatic tissue in 6% of cases. Very rarely it contains the ileum, jejunum, and duodenum.

Classification of the disease

Depending on the mechanism of occurrence, the following types of diverticula are distinguished:

1. Congenital. It involves the entire wall of the small intestine.
2. Acquired. This diverticulum consists of mucosa and arises from the mesenteric side of the ileum.

Depending on the volume of patency of the vitelline duct, there are different types pathological protrusions of the small intestine:

1. Patency of the entire vitelline duct:
   • open diverticulum;
   • partially open diverticulum;
   • closed diverticulum.
2. Patency of part of the vitelline duct:
   • omphalocele - open from the navel;
   • Meckel's diverticulum - open from the intestinal side:
   • enterocystoma - open in the middle.

Symptoms and signs

Meckel's diverticulum is most often asymptomatic. Whenever inflammatory process in the protrusion cavity (diverticulitis), a clinical picture similar to appendicitis develops. In this case, the following symptoms occur:

• increased body temperature;
• pain in the navel or right side of the abdomen;
• vomit;
• positive Shchetkin-Blumberg sign, which is a sign of an inflammatory process of the peritoneum. It is considered positive if, after pressing on the abdominal wall and sharply withdrawing the hand, the patient experiences severe pain.
• leukocytosis.

Often, with such manifestations, the patient is suspected of appendicitis and the diverticulum is discovered only during surgery.

It is believed that Meckel's diverticulum is asymptomatic in 95% of cases.

With the development of bleeding caused by a peptic ulcer of the protrusion wall, the following symptoms occur:

• pale skin;
• dizziness;
• black color of stool;
• general weakness;
• frequent heartbeat.

Infringement of the diverticulum or the development of intestinal obstruction will also be manifested by intense pain, vomiting, and intoxication.

In rare cases, it is possible for a neoplasm to develop in a pathological protrusion - both benign and malignant. In this case, the clinical picture of the disease will be determined by its nature.

Features of the clinical picture - video

Methods for diagnosing the disease

Due to the fact that the disease has non-specific clinic, most often the diverticulum is detected during surgery. To facilitate diagnosis, use a whole series instrumental and laboratory studies.

Diagnostic methods - table

Study	Characteristic
General analysis blood	Leukocytosis is detected as a sign of inflammation and iron deficiency anemia is the result of bleeding.
Fecal occult blood test	Determination of bleeding in the digestive system.
Irrigoscopy	This method refers to x-ray examinations with the introduction of a contrast agent into the intestinal lumen. Allows you to identify protrusion and assess the condition of the wall of the entire intestine.
MRI	This study allows you to get a complete picture of the condition of the abdominal organs.
Colonoscopy	Using a special probe that is inserted into the intestinal lumen, you can determine the location of the diverticulum and examine its contents.
Laparoscopy	If the effectiveness of the above methods is low, the laparoscope is inserted through a small incision into the abdominal wall. If a Meckel's diverticulum is identified, it can be removed immediately.

It is possible to use research methods such as ultrasound of the abdominal cavity and FGDS, but they are not very informative and only allow one to exclude other causes of bleeding.

Treatment

If the disease is asymptomatic, then, as a rule, treatment is not required. In other cases, it is prescribed complex therapy, which includes:

• surgical removal;
• drug treatment;
• diet.

Surgical intervention

Removal of diverticulum in the absence clinical picture recommended only in the following cases:

• the length of the formation is more than 3 cm;
• very thin walls of the protrusion;
• the patient's age is over 40 years;
• narrow neck of the diverticulum;
• Fibrous cords are identified in the abdominal cavity.

If diverticulitis or intestinal bleeding develops, immediate surgical treatment is necessary. It is carried out in two ways:

1. Abdominal surgery (laparotomy). This method provides wide access to the abdominal cavity, which allows for complete visualization of the diverticulum area and its excision.
2. Laparoscopy. This method is based on the introduction through a small incision of a special tube with a camera, which allows you to detect the formation and carry out its resection without a significant incision in the abdominal wall.

Drug therapy

Drug treatment is carried out in childhood and after surgery. The following groups of drugs are distinguished to eliminate the manifestations of pathology:

1. Non-steroidal anti-inflammatory drugs. They eliminate inflammation and have an analgesic effect. The most commonly used drugs are Ibuprofen, Piroxicam, Indomethacin.
2. Antispasmodics. Used for pain relief and regulation of intestinal motility (Drotaverine, Duspatalin, Trimedat).
3. Antibacterial agents. These include Azithromycin, Clarithromycin, Erythromycin. These drugs are most often prescribed after surgical treatment to reduce the risk of inflammation.
4. Detoxifying agents. Among the drugs in this group are Trental, plasma substitutes, and Complamin. This therapy helps with the development of complications and reduces the severity of inflammation.

In addition, antisecretory drugs are used in treatment practice. They reduce the acidity of the stomach, which is especially important when part of the mucous membrane of this organ gets into the protrusion and increased risk ulcer development.

If intestinal bleeding develops, hemostatic agents are used, for example, Vikasol.

Medicines in the photo

Trental improves nutrition of inflamed tissues
Azithromycin eliminates the bacterial component of inflammation
Ibuprofen effectively relieves inflammation
Drotaverine relieves pain

If the above treatment is carried out in a timely manner and in full, then the prognosis is favorable. In case of late treatment, development of complications and lack of adequate therapy, death may occur.

Nutrition rules

From start to use medications to reduce the risk of complications and speed up recovery, prescribe special diet. The main principle of this diet is to consume foods rich in fiber and exclude foods from the diet that increase bloating and gas formation. Food should be well boiled or steamed. You should not eat foods that are difficult to digest, too hot or cold. It is recommended to eat frequently, in small portions.

Table of permitted and prohibited products

Soup is a nutritious and easily digestible dish.
Compote promotes digestion without irritating the intestinal mucosa

Possible consequences and complications

Most often, Meckel's diverticulum leads to complications such as:

• intestinal obstruction;
• internal bleeding caused by peptic ulcers;
• diverticulitis;
• diverticulum rupture;
• hernia formation;
• neoplasms - both malignant and benign.

The incidence of peptic ulcer is 43%, diverticulitis - 14%, intussusception - 25%, hernia - 11%.

About the occurrence internal bleeding symptoms such as:

• general weakness;
• rapid heartbeat;
• dizziness;
• pale skin;
• anemia.

Manifestations of intestinal obstruction are:

• nausea and vomiting;
• pale skin;
• dizziness;
• spasmodic abdominal pain.

In addition, complications can be postoperative, these include:

• pulmonary embolism;
• failure of sutures;
• intra-abdominal abscess.

Meckel's diverticulum is often asymptomatic and is detected after the development of complications. In this regard, it is necessary to know it possible manifestations and immediately consult a doctor if they occur, since only timely and adequate treatment can protect against the development of dangerous complications.

Meckel's diverticulum in children and its complications: clinical picture, diagnosis, treatment

1. The concept of Meckel's diverticulum. Classification.

2. Clinic, complications.

3. Diagnostics, differential diagnosis.

4. Treatment.

5. Laparoscopic methods in the diagnosis and treatment of Meckel’s diverticulum.

6. Littre's hernia.

7. Conclusion.

8. Literature.

THE CONCEPT OF MECKEL'S DIVERTICULUM. CLASSIFICATION

Meckel's diverticulum (ileal diverticulum) is a congenital anomaly of the small intestine associated with a violation of the reverse development of the proximal vitelline duct (the duct between the navel and the intestine), when its proximal part remains unobliterated (unclosed).

In the first weeks intrauterine development In humans, embryonic ducts function - the vitelline duct (ductus omphaloentericus) and the urinary duct (urachus), which are part of the umbilical cord. The first serves to nourish the fetus, connecting the intestines with the yolk sac, the second carries out the outflow of urine into the amniotic fluid. At 3-5 months of intrauterine life, reverse development of the ducts is observed: the vitelline duct completely atrophies, turning into the middle ligament, located with inner surface anterior abdominal wall. Depending on the extent and at what level the unobliterated vitelline duct is preserved, there are: 1. Umbilical fistulas, complete and incomplete; 2. Meckel's diverticulum; 3. Enterocystoma.

Rice. 1, 2. Meckel's diverticulum during surgery.

This anomaly was discovered by Johann Friedrich Meckel the Younger (1781 - 1833), a German anatomist from Halle. He identified the difference between two types of small intestinal diverticula:

1) acquired on the mesenteric side of the small intestine, consisting only of mucosa;

2) congenital true diverticulum, involving all layers of the wall and extending antimesenterically.

In works published between 1808 and 1820, he indicated that the second of the named diverticula should be considered as a remnant of the ductus omphaloentericus (ductus omphalomesentericus, ductus vitellinus), and argued this as follows:

More than one diverticulum with a structure resembling that of the small intestine is never found in one individual;

The diverticulum is always located in the distal small intestine on the antimesenteric side;

The presence of a diverticulum is often accompanied by other congenital disorders;

It is also found in animals that in their embryonic development have a yolk sac;

A case was recorded where the diverticulum persisted to the umbilicus.

The diverticulum arises from the embryonic communication between the yolk sac and the midgut, so various forms of total or partial persistence with the presence or absence of a lumen are possible. They can be divided as follows.

1. Persistence of the entire duct:

Fully open;

Partially open:

a) on the intestinal side - Meckel’s diverticulum,

b) on the umbilical side - omphalocele,

c) in the middle - enterocystoma;

Completely closed.

2. Persistence of part of the duct:

Open from the umbilical side - omphalocele

Open from the intestinal side - Meckel's diverticulum

Meckel's diverticulum, with or without connection, is the most common (70% of cases). The incidence of Meckel's diverticulum, according to various authors, is 1 - 4%, the ratio of men to women is approximately 2:1, in case of complications even 5:1. 50% of cases are children under 10 years of age, the rest manifest before the age of 30 years. Frequency of combination with others birth defects development - up to 12%. There are no indications of familial occurrence.

The length of a diverticulum averages 2 - 3 cm (from 1 to 26 cm), it can be as thick as a finger or narrow, like an appendix, and has a conical or cylindrical shape. Typically, the diverticulum is located on the side of the ileum opposite the mesentery (along the free edge of the intestine, antimesenteric), on average at a distance of 40 - 50 cm (from 3 to 150 cm) from the bauhinian valve. It can be soldered by a connective tissue cord (remnant of the vitelline duct) to the mesentery, anterior abdominal wall or intestinal loops.

Meckel's diverticulum is considered a true diverticulum, because During histological examination, all layers of the intestine are found in its wall. But it has been known for 100 years that heterotopically located gastric mucosa can also be found there (1882, Timmans) - the epithelium of approximately one third of the diverticula is classified as glandular epithelium, capable of producing hydrochloric acid; as well as pancreatic tissue (1861, Zenker). This is the cause of one of the complications - erosion of its wall and intestinal bleeding.

Uncomplicated diverticulum (95% of cases) is asymptomatic. Ileal diverticulum is most often discovered accidentally during laparotomy (surgery on the abdominal organs) performed for another reason or due to the development of complications.

Complications of Meckel's diverticulum include:

Peptic ulcer with possible bleeding and perforation - 43%;

Intestinal obstruction due to cord, obstruction, volvulus and intussusception - 25.3%;

Diverticulitis - 14%;

Hernia formation (often Littre's hernia - 11%);

Umbilical fistula - 3.4%;

Tumors - 3%.

In children, peptic ulceration of islands of ectopic gastric mucosa (the nearby ileal mucosa) occurs, which often causes massive intestinal bleeding. Bleeding can occur acutely and be profuse, but chronic bleeding in small portions is also observed. These bleedings occur during full health and are repeated at intervals

3-4 months, which leads to anemia, pallor, tachycardia, collapse.

The first stool is usually dark in color, followed by a dark color.

(scarlet) blood without clots and mucus. Unlike gastrointestinal blood

bleeding of another origin with Meckel's diverticulum does not occur

howl of vomit.

Adults may experience:

Acute diverticulitis. The clinical manifestations are so similar to those of acute appendicitis (nausea, abdominal pain, fever, leukocytosis) that a differential diagnosis before surgery is almost impossible. If an intact appendix is ​​found during the operation, revision of the ileum is necessary approximately 100 cm from the ileocecal angle.

Intestinal obstruction due to intussusception, which occurs with typical symptoms (sudden onset, paroxysmal abdominal pain, vomiting, intestinal bleeding), the diverticulum is discovered at surgery after disintussusception; intestinal obstruction can also be caused by torsion of intestinal loops around a diverticulum adhered to the anterior abdominal wall, or by pinching them when the diverticulum is fixed to the mesentery or intestinal loops, caused by chronic diverticulitis of the adhesive process; in some cases, symptoms increase slowly and are accompanied by symptoms of first partial and then complete intestinal obstruction.

Perforation of a diverticulum into the free abdominal cavity with the development of peritonitis usually occurs as a result of its inflammation and ulceration, less often as a result of a bedsore with a fecal stone or a foreign body.

Malignization of the ectopic gastric mucosa with the development of cancer.

A combination of several complications is possible.

Rare complications of Meckel's diverticulum include perforation by foreign bodies (in particular, fish bones).

DIAGNOSTICS. DIFFERENTIAL DIAGNOSIS

Basic method - X-ray examination with contrasting the intestines with a suspension of barium sulfate. Ultrasound is used as an auxiliary method. The diagnosis of Meckel's diverticulum can be established using radioisotope scintigraphy with hechnetium-99t (the so-called "Meckel scan"). In this case, a heterotopic gastric mucosa can be detected (technetium has an affinity for the parietal cells of the stomach). The sensitivity of this test in children reaches 75-100% and is slightly lower in adults. In 15% of cases, false positive results are obtained and in 25% - false negative results.

If bleeding from Meckel's diverticulum continues, the diagnosis can be made using arteriography.

Differential diagnosis.

One of the most important clinical manifestations of Meckel's diverticulum is recurrent abdominal pain (RAP). It is also characteristic of other organic diseases, as well as various functional and psychogenic disorders.

Most Frequent organic reasons RAB and methods for their verification

Cause	Diagnostic measures
Congenital anomalies of kidney development, intestinal malrotation	X-ray examination of the gastrointestinal tract with barium, ultrasound, urography
Infections urinary tract	Bacteriological examination of urine
Inflammatory diseases of the pelvic organs	Pelvic examination
Ovarian cyst, endometriosis	Consultation with a gynecologist, ultrasound
Diaphragmatic hernia	X-ray examination with barium
	Liver function test
Cholecystitis	Cholecystography, ultrasound
Pancreatitis	Serum amylase
Hernias of the anterior abdominal wall, inguinal hernias	Consultation pediatric surgeon
Peptic ulcer	FGDS, Hp test (Role Helicobacter pylori(HP) in the pathogenesis of chronic abdominal pain is not precisely defined. Many researchers recommend treating this infection only if there are structural changes in the gastrointestinal tract.), tests for blood in stool
Meckel's diverticulum	Scanning with technetium
Crohn's disease	ESR, X-ray examination with contrast, endoscopic examination - FGDS, colonoscopy, sigmoidoscopy
Non-specific ulcerative colitis
Adhesive disease after surgery	X-ray examination with contrast
Pancreatic pseudocysts	Abdominal ultrasound
Chronic appendicitis	Ultrasound, X-ray examination
Lead poisoning
Hemorrhagic vasculitis	History, urine test
Sickle cell disease	Blood test, genealogical history
Food allergies	Hypoallergenic elimination diet
Abdominal epilepsy, migraine	EEG, consultation with a neurologist
Porphyria	Porphyrin level in urine
Familial Mediterranean anemia, familial angioedema, abdominal migraine	Characteristic anamnesis
Lactase deficiency	History, elimination diet

4. TREATMENT Asymptomatic diverticula should not be removed. Meckel's diverticulum must be removed in case of diverticulitis, diverticulum ulcers, intestinal obstruction caused by diverticulum, umbilical fistulas, and also, according to a number of experts, if it is accidentally discovered during surgery. Resection of the diverticulum is performed with suturing of the intestinal wall (resectio diverticuli Meckelii). Technique of operation. After opening the abdominal cavity, the ileum along with the diverticulum is removed. If the diameter of the diverticulum is small, then the technique for removing it is no different from a conventional appendectomy. In cases where the diverticulum is wide and has a mesentery, the latter is ligated and crossed, freeing the base of the diverticulum. Then a soft intestinal sponge is applied to the intestine and the diverticulum is cut off at its base (Fig. 3). The intestinal wound is sutured in a transverse direction to its axis with a double-row suture (Fig. 4). The abdominal cavity is sutured tightly. Rice. 3. Resection of Meckel's diverticulum. Cutting off the diverticulum. Rice. 4. Resection of Meckel's diverticulum. Suturing the defect in the intestinal wall with a double-row suture: a - application of a furrier's suture; b - application of interrupted seromuscular sutures. The prognosis is favorable. 5. LAPAROSCOPIC METHODS IN DIAGNOSIS AND TREATMENT OF MECKEL’S DIVERTICULUS

Recently, laparoscopic diagnosis and laparoscopic treatment of Meckel's diverticulum have become most widespread throughout the world.

During laparoscopy, Meckel's diverticulum, which has no pathological changes, is detected in the form of a protrusion of the ileal wall of various lengths and shapes. The diverticulum is usually located at the antimesenteric edge of the intestine. Its base can be quite wide, and in these cases the diverticulum is usually short. With a narrow base, the diverticulum is often more extended.

An important diagnostic sign of a diverticulum is the presence of a well-defined feeding vascular bundle or a small mesentery. The vessel is found on one side of the diverticulum and is located in its central part. It seems to be spread out on the diverticulum and, giving off small branches, gradually decreases towards the apex. In the presence of a small mesentery, the diverticulum can be located along the small intestine, closely adjacent to it.

Near the diverticulum, a thin, dense fibrous cord is sometimes found, extending from the mesentery of the small intestine to the parietal peritoneum in the area of ​​the umbilical ring. Apparently, it represents the remains of embryonic umbilical communications. On instrumental palpation, the diverticulum is soft, easily displaced and does not differ from the wall of the small intestine.

In pathological conditions, the diverticulum often undergoes significant changes. A bleeding diverticulum appears as a fairly dense protrusion, sometimes whitish in color. Often the diverticulum is located at the mesenteric edge. The small intestine can be deformed and, as it were, pulled towards the diverticulum.

The degree of pathological changes is apparently related to the duration of the bleeding diverticulum ulcer and its extent. In any case, with a long history of previous intestinal bleeding, more obvious changes in the diverticulum should be expected. Deep damage to the intestinal wall by the ulcerative process leads to a pronounced perifocal reaction. The omentum and surrounding intestinal loops are soldered to the diverticulum. All this leads to the formation of a conglomerate with rough adhesions, inside of which there is a highly deformed diverticulum with thinned walls.

With diverticulitis, the pathological changes are extremely similar to those with appendicitis. Due to inflammatory infiltration of the wall, the diverticulum appears thickened, hyperemic, and may have fibrin deposits. When a diverticulum becomes inflamed, its fusion with the surrounding loops of the small intestine and omentum occurs quite quickly, which is detected externally in the form of an inflammatory infiltrate.

A diverticulum involved in small bowel intussusception is usually not detected during laparoscopy. In rare cases, when the intussusception is not very old and the diverticulum is not deeply embedded, its base can be detected. However, intussusception can also begin from the diverticulum itself, in which case it is completely turned into the lumen of the small intestine and disappears without a trace in the depths of the intussusception.

Tactics of laparoscopic revision

Laparoscopic search for Meckel's diverticulum is one of the most difficult and delicate diagnostic laparoscopic procedures. Indirect signs inflammation caused by Meckel's diverticulum can be detected already during a panoramic examination of the abdominal cavity: in particular, hyperemia of the omentum, interloop adhesions, local inflammatory changes in intestinal loops, pathological effusion.

A detailed examination reveals an infiltrate, which consists of intestinal loops and is usually located in the middle part of the abdominal cavity or in the right sections. If there are no primary inflammatory changes vermiform appendix, then the most likely cause of the infiltrate may be the pathology of Meckel’s diverticulum. You should not try to separate the adhesions, since the risk of intestinal perforation in the area of ​​the altered diverticulum is very high.

If intestinal obstruction associated with small-bowel intussusception is detected in the mid-small intestine, Meckel's diverticulum should also be considered. It is also possible to develop strangulation obstruction in the presence of fibrous strands between the diverticulum and the umbilical region.

Thus, with severe pathology of Meckel's diverticulum, laparoscopic examination is rarely possible, and endoscopic diagnosis is based on indirect signs and is presumptive.

In case of intestinal bleeding of unknown etiology, a targeted search for the diverticulum is undertaken, and in the early stages of the disease, the diverticulum can be detected and examined directly. The revision is carried out from the ileocecal junction. First of all, when examining the small intestine, its condition and color are determined. With continued bleeding, the intestine becomes dark or bluish in color due to the presence of blood in its lumen. Similar changes are observed in the colon. With a large amount of blood, the small intestine becomes somewhat paretic and edematous. In the case of stopped or minor bleeding, only individual fragments of the small intestine have dark contents. The intestine is in a normal, somewhat spasmodic state. It should be remembered that if there are dark-colored foods in the intestinal lumen, a similar picture may be observed.

When revising the small intestine, a clear sequence and slowness must be observed. If the loop is lost from sight, you should return to the previously examined sections and repeat the inspection. Difficulties arise with dyskinetic phenomena, since the combination of spasmodic and paretic sections often creates the illusion of protrusion of the intestinal wall. However, all suspicious areas of the intestine should be examined bilaterally.

Particular attention should be paid to the unexpectedly distinct course of the vessel on the intestinal wall, since the diverticulum may be low, on a wide base, and its feeding vessel is the only landmark during endoscopic search. We should not forget that a bleeding diverticulum is often located on the mesenteric edge (perhaps this is why it often causes heavy intestinal bleeding), and therefore inspection of the intestine should be done on both sides. To some extent, laparoscopic search for a diverticulum resembles the technique for examining the small intestine for gunshot wounds of the abdominal cavity.

At the time of examination, very easy handling of the manipulator is required with concentration on the sensations that arise when the intestinal loops are displaced. The slightest rigidity or incomprehensible resistance should immediately draw special attention to the intestinal fragment being examined.

The success of the study largely depends on the technique of performing the revision and the observation of the surgeon. Once the required skill is achieved, the likelihood of detecting a diverticulum and other pathological formations of the small intestine becomes very high.

Diagnostic laparoscopy in children should be performed as gently as possible, using small diameter trocars (3-5 mm). If pronounced inflammatory changes are detected in the diverticulum and adjacent areas of the intestine, a transition to open surgery(circular resection of the intestine with a diverticulum within healthy tissue). In the preoperative period, it is advisable to conduct a radioisotope study with 99mTc. If the condition of the diverticulum and adjacent areas of the intestine is relatively satisfactory, laparoscopic resection can be performed. There are several methods for performing endoscopic resection of Meckel's diverticulum:

using the Endo-Gia-30 stapler;

using the ligature method, with the application of a Raeder loop to the base of the diverticulum - with its width up to 1-1.5 cm;

with suturing of the intestine with a double-row intracorporeal endoscopic suture.

In the postoperative period, adhesive intestinal obstruction may occur in a small number of patients.

However, the laparoscopic method has established itself as the most reliable in diagnosing Meckel’s diverticulum (the correct diagnosis was made in almost 100% of cases), relatively safe (it avoids pathological accumulation of radiopharmaceuticals in the area of ​​the diverticulum, which often occurs with radioisotope scintigraphy), and also effective in plan for the treatment of this pathology, which allows many specialists to consider it the method of choice in pediatric surgery.

6. LITTER HERNIA

Enough a common complication Meckel's diverticulum is a so-called Littre hernia.

In 1700, A. Littre described strangulation of Meckel's diverticulum in inguinal hernia. It has now been established that such strangulations account for no more than 0.5% of the total number of strangulated hernias. According to M.I. Rostovtsev, in the vast majority of cases, isolated infringement of Meckel’s diverticulum occurs. Thus, this strangulation can be equated to a regular parietal strangulation, with the only difference being that due to worse blood supply conditions, the strangulated diverticulum undergoes necrosis more quickly than the normal intestinal wall. Most often, strangulation of Mikkel's diverticulum occurs in inguinal and femoral hernias.

In this case, typical signs of strangulated hernia are observed:

1) sharp pain;

2) irreducibility of the hernia;

4) absence of transmission of the cough impulse.

At strangulated hernia Littre's Meckel's diverticulum must be resected in any case, regardless of whether its viability is restored or not. The need to remove a diverticulum is caused by the fact that this rudiment, as a rule, lacks its own mesentery, comes from the free edge of the small intestine and has a poor blood supply. In this regard, even short-term strangulation of Meckel's diverticulum is associated with the risk of necrosis. To remove a diverticulum, either use a ligature-purse string method, similar to an appendectomy, or perform a wedge-shaped resection of the intestine, including the base of the diverticulum.

7. CONCLUSION

The incidence of Meckel's diverticulum and its complications is highly variable, since it is sometimes determined on the basis of the results of large series of autopsies, as well as findings during laparotomies, and Meckel's diverticulum can be discovered incidentally. The question is whether the possible complications of resection of an incidentally found Meckel's diverticulum outweigh the 4-5% risk of complications. It is believed that 800 resections are necessary to prevent fatal complications in one (!) patient.

Previously, a so-called open resection was usually performed, with the wall defect closed with two layers of absorbable sutures. IN recent years resection is usually carried out using a "stapling machine". Sometimes it is necessary to perform block resection of the diverticulum with part of the small intestine.

There are no data on complications of resection of incidentally identified diverticula. Under ideal circumstances, such a resection can be performed without risk, thereby preventing future reoperation due to complications. On the other hand, caution is required in patients with peritonitis, Crohn's disease, or intestinal obstruction in which the diverticulum is located in the dilated part. The use of a “stapling machine” reduces the already low risk due to the fact that the intestinal lumen is not opened. Whether to remove an accidentally discovered diverticulum or not still depends on the personal opinion of the surgeon.

8. LITERATURE

1. Abalmasov P.K. - Planned surgery. - Moscow. – 2000.

2. Blinnikov O.I. - Laparoscopic diagnosis of emergency diseases of the abdominal organs in children. - Journal of Pediatric Laparoscopy. - 2000.

3. Verbitsky D. A. - Meckel's diverticulum. - Pediatric surgery. Articles. - 2003.

4. Voylenko V.N., Medelyan A.I., Omelchenko V.M. - Atlas of operations on the abdominal wall and abdominal organs.

5. Dronov A.F., Poddubny I.V., Kotlobovsky V.I., Al-Mashat N.A., Yarustovsky P.M. - Videolaparoscopic operations for the pathology of Meckel’s diverticulum in children. - Khirurgiia (Mosk) 2002.

6. Meckel's diverticulum. - Medical encyclopedia. - 2003.

7. Isakov Yu. F. – Pediatric surgery. - Moscow. – 1983.

8. Roshchupkina A.K., Dronov A.F. - Use of laparoscopy for the diagnosis and treatment of Meckel's diverticulum in children. - 2004.

Meckel's diverticulum is a disease first described by Johann Friedrich Meckel. Its essence lies in disorders of intrauterine development of a person. Due to the influence of certain factors in the ileum, namely in its lower part, a kind of protrusion is formed. This disease is the most common type of gastrointestinal disease. In this article we will try to determine the essence of Meckel’s diverticulum, what symptoms it has, and what is the danger of this disease. How can you get rid of it?

What is Diverticulitis?

At the first stage bile duct, which is located from the ileum, namely its terminal section to the navel and gall sac, is usually obliterated by the seventh week. If the area connecting it to the ileum does not atrophy, Meckel's diverticulum is formed.

This diverticulum is called congenital and it extends along the edge of the mesentery opposite the attachment and has all the characteristics of the intestine. In five cases out of ten, Meckel's diverticulum has heterotopic gastric tissue or pancreatic tissue or two organs at once.

Complications after the development of Meckel's diverticulum occur in only 2% of patients. As for gender, complications develop 2-3 times more often in men. Complications include bleeding, obstruction, diverticulitis, and tumor formation.

Causes and symptoms of diverticulitis

Diverticulitis occurs due to the retention of food debris in the diverticulum and, as a result, the formation of fecal stones, which is accompanied by infection. The inflammatory process can only be represented by a diverticulum. In addition, neighboring organs and tissues are at risk of inflammation, which consists of the development of an interintestinal abscess or the occurrence of peritonitis.

Most obvious signs of this disease determined by the type of protrusion. According to this criterion, a separate type of Meckel's diverticulum is determined. Most often, protrusion is represented by the formation of intestinal cells.

This feature allows the diverticulum to perform normal bowel functions. As a result, it is possible complete absence symptoms confirming the presence of this disease. In this case, a list of special tests is necessary, since standard diagnostics cannot detect Meckel’s disease behind the masking signs. Cases of diverticulum formation based on cells of the stomach or pancreas are common.

At the stage when the protrusion is already part of the intestine, the symptoms become more pronounced. Among them are:

• blockage of the intestinal tract;
• bleeding, which leads to the presence of blood in the stool;
• inflammation;
• pain and others discomfort varying degrees;
• anemia;
• febrile processes caused by inflammation;
• vomit;
• problems with stool.

When determining symptoms, the age of the patient should be taken into account. Thus, in childhood, intestinal blockage predominates among the symptoms. As for bleeding, it appears in a child at an older age. As a rule, the disease is detected before 10 years of age.

In addition, symptoms of an irregular nature are possible. For example, bleeding may occur for several days, after which the stool returns to normal. This feature creates additional problems in determining Meckel's diverticulum.

It is extremely rare to experience blood in the stool all the time. This could be the reason iron deficiency anemia, which is one of the signs of the disease. However, this symptom indicates a danger to the patient’s life. Surgery is required to remove Meckel's diverticulum.

Diverticulosis and its diagnosis

Intestinal diverticula in the model.

In determining the diagnosis of Meckel's diverticulum, the symptoms shown and the qualifications of the attending physician play a role. Bloody stool in a child, as a rule, is a defining indicator of the disease. In 1967, a method for diagnosing the gastric mucosa called “scintigraphy” was created. This method began to operate in 1970. The procedure is based on examining the gastric mucosa for its ability to absorb and excrete isotopes. As soon as the isotope enters the body, a scanogram is performed in several projections.

At in good condition in the stomach and bladder a high accumulation of radionuclides is formed, which accumulate due to the duodenum and small intestine, namely its proximal part. A diagnosis of the kidneys and urinary system is carried out. Scintigraphy is considered positive if pathology of radionuclide accumulation is observed.

The location of Meckel's diverticulum is usually localized in the lower abdomen. However, his mobility gives him the ability to change positions.

Credibility this method defined in percentage from 50 to 92%. The result directly depends on the properties of the isotope and blood circulation in the area where the diverticulum is supposed to be located. You should also take into account its size and characteristics regarding the excretion of the isotope and the rate of its leaching from a given area.

In case positive result diagnostics should be carried out differential type another area of ​​the gastric mucosa to determine the authenticity of the results. Suitable areas for this procedure include gastrogenic cysts, enteral type duplications, and Barrett's esophagus. The reason for the first diagnosis error may be hyperemia of the mucous membrane or the presence of blood, which defines intestinal disease as ulcers, intussusception, intestinal obstruction and others.

Most often, the pathology of Meckel's diverticulum is confused with intestinal duplications. The accuracy of diagnosis can be increased through the use of pentagastrin, which helps increase the absorption functions of the gastric mucosa, and cimetidine, which slows down the release of nuclides from the area being diagnosed. In addition, the quality of the examination is improved by scanning in the lateral projection after urination. When bright pronounced signs diseases and negative result scintigraphy should be repeated.

If symptoms include intestinal obstruction and abdominal discomfort, Meckel's diverticulum is not diagnosed until after surgery. Given the patient's age and severity of symptoms, intussusception may be suspected. IN in this case, in the absence of peritonitis, diagnosis is carried out by filling the colon with barium, which, in addition, has healing effect. X-ray examination for diverticulosis does not make sense.

Symptoms in full form intestinal obstruction or peritonitis are grounds for exploratory laparotomy. In this case, the disease is diagnosed at the stage of surgery.

Treatment of diverticulosis

The treatment method for Meckel's disease, namely surgery, depends directly on how exactly the small intestinal diverticulum was detected: based on symptoms or during surgery. If symptoms of disease are present, treatment depends on surgical findings. As a rule, when gastrointestinal bleeding it may suddenly stop. It is at these moments that the diverticulum should be removed by transverse suturing of the intestine.

Typically this procedure occurs using a stapler. The first step is to determine where the source of bleeding is located. Yes, when heavy bleeding not from the diverticulum, but from the ileum the right decision will perform segmental resection of this area of ​​the intestine along with the diverticulum. Typically, resection helps eliminate bleeding.

In the case of intestinal obstruction in the form of intussusception, disintussusception should initially be carried out if possible, and only then proceed with removal of the diverticulum. If the resection is the cause of narrowing of the intestine, segmental intestinal resection should be performed. The consequences of intussusception cannot be corrected in the presence of Meckel's diverticulum or intestinal gangrene. Intestinal resection and anastomosis should be used. In extreme cases, with local changes, it is necessary to apply temporary stomas.

After the operation there comes full recovery.

The cause of intestinal obstruction in children is a volvulus or herniation, which is a consequence of the presence of remnants of the bile duct. In this case, the treatment method is the elimination of volvulus or strangulation and resection of the remaining portion of the bile duct. The following procedure is identical to the above instructions. Deterioration of the clinical picture is possible with perforation of Meckel's diverticulum or intestinal gangrene, volvulus or strangulated hernia. Child mortality reaches 10% and is directly related to the presence of complications in the form of infection. Adhesions and intestinal obstruction may occur, which is a common consequence of laparotomy.

Among the pathologies of the navel, the most popular are granulomas. Their treatment is quite simple, namely by cauterization with silver nitrate. In the absence of treatment results, one should assume the presence of an open bile duct, communication with gastrointestinal tract or urachus. Diagnosis occurs by performing a fistulogram. If a connection with the gastrointestinal tract is determined, it is necessary to excision the duct by suturing the ileum.

Problems with choosing a method surgical intervention associated with the presence of symptoms of the disease. The likelihood of sudden diverticulum activity decreases as the person gets older. The best option is to perform resection of the diverticulum in childhood or if a seal is detected. Excision of the diverticulum is the right decision in the absence of other treatment methods.

A diverticulum is a congenital or acquired pathology in the form of a pouch-like protrusion of the intestinal wall. True small bowel diverticulum (Meckel's diverticulum) is a congenital anomaly with a prevalence of 2% in the population. It occurs twice as often in boys as in girls.

There are also false acquired diverticula, in which the mucous membrane protrudes through the gaps in muscle layer near the vessels. In some cases, a false diverticulum forms from the wall of the descending colon.

Reasons

A diverticulum is a protrusion of the intestinal wall.

True Meckel's diverticulum is one of the most common congenital anomalies digestive tract. It is formed at the stage of intrauterine development, if complete blockage and atrophy of the vitelline duct does not occur at 3-5 months of pregnancy.

Meckel's diverticulum is located in the region of the lower 1/3 of the ileum, approximately 60 cm from the junction small intestine in thick. The length of the diverticulum, which looks like a cylinder or cone on the intestinal wall, is 2-4 cm.

The wall of the diverticulum has the same structure as the wall of the intestine. In addition, in 80% of cases, the diverticulum contains ectopic (abnormally located) gastric mucosa, in 5% - ectopic pancreatic tissue. Because of this, hydrochloric acid produced by the gastric mucosa in the diverticulum very often causes diverticulum ulcers that can bleed.

Meckel's diverticulum can be combined with other congenital malformations:

• atresia (fusion) of the rectum or anus;
• esophageal atresia;
• omphalocele (umbilical cord hernia).

False diverticula can also be located in the descending colon or sigmoid colon. They are divided into traction and pulsion. Pulsion are formed due to pressure on the defective intestinal wall from the inside. Traction occurs as a result of fixation of the intestinal wall with adhesions.

The following factors contribute to the formation of false diverticula:

• impaired intestinal motility;
• increased intra-abdominal pressure;
• weakness of the intestinal wall.

Symptoms

In uncomplicated cases, Meckel's diverticulum has no clinical manifestations and can be detected incidentally during examination for other indications or during laparotomy ( surgical intervention in the abdominal cavity) due to another disease.

Clinical manifestations of Meckel's diverticulum occur only in the event of complications.

Intestinal bleeding

It is the most common complication (occurs in 2.2% of cases of diverticulum) in children in the first 4 years of life. It develops with a bleeding peptic ulcer, formed under the influence of hydrochloric acid secreted ectopically into the diverticulum of the gastric mucosa. Bleeding can be intense, acute or hidden, chronic.

Symptoms of bleeding:

• weakness;
• dizziness;
• rapid pulse;

Diverticulitis

Acute inflammation of the diverticulum is manifested by symptoms reminiscent of acute appendicitis:

• abdominal pain localized in the umbilical region or in the lower abdomen on the right;
• nausea;
• increase in temperature;
• local tension of the abdominal wall when the doctor feels the abdomen and other signs of peritoneal irritation;
• an increase in the number of leukocytes in a blood test.

The correct diagnosis is made already during surgery when an unchanged vermiform appendix (appendix) is detected. An inspection of the intestine reveals an inflamed diverticulum.

Volvulus

One of the symptoms of complications of diverticular disease is abdominal pain.

Intestinal obstruction can be caused by intestinal torsion, intussusception (the insertion of part of one intestine into another) or volvulus due to a diverticulum.

It manifests itself:

• cramping paroxysmal pain in the abdomen;
• nausea;
• repeated vomiting;
• intoxication increasing in dynamics;
• bloody discharge from the intestines.

During the examination, the doctor can feel the tumor-like formation.

Hernia

Meckel's diverticulum can also be strangulated in the hernial sac in a femoral or inguinal hernia. In this case there appear sharp pains in the stomach. The hernial protrusion will be tense and cannot be reduced.

Peritonitis

Inflammation of the peritoneum is a serious complication, the development of which is possible with Meckel’s diverticulum in the event of perforation (perforation) of its wall due to ulceration and inflammation. Abdominal pain becomes widespread; examination reveals signs of peritoneal irritation and increasing symptoms of intoxication.

Tumors

Benign (lipoma, fibroids, hamartoma) or malignant (carcinoid, adenocarcinoma) diverticulum tumors develop in rare cases in children. The manifestation is the symptoms of intoxication, which increase over time.

Diagnostics

Clinical diagnosis of uncomplicated cases of diverticulum is difficult. Most often they are discovered by chance.

When complications of diverticulum develop, the following diagnostic research methods are used:

• Ultrasound of the abdominal organs;
• X-ray of the intestine with a contrast agent (a suspension of barium sulfate is injected);
• scintigraphy using a radioactive isotope (technetium-99) is especially necessary for bleeding diverticulum, as it detects ectopia of the gastric mucosa with a confidence of 75 to 100%;
• FGDS and colonoscopy are necessary to exclude another cause of bleeding;
• feces for occult blood in chronic occult bleeding;
• plain radiography for symptoms of intestinal obstruction.

Sometimes a diverticulum is discovered only when diagnostic laparoscopy(examination of abdominal organs special device– laparoscope – through a small puncture in the abdominal wall) or during surgery. Preoperative diagnosis accounts for less than 10% of cases.

In adolescents, the main diagnostic method To detect a diverticulum, colonoscopy is used (a doctor's examination of the inside of the walls of the large intestine using a flexible endoscope equipped with fiber optics, a light guide and a miniature camera). The X-ray method of research is less informative and also carries a radiation load on the child’s body.

Treatment

The diet of a child suffering from diverticular disease should include: sufficient quantity foods that contain fiber.

One of the important components of treatment for diverticulosis is diet. Its peculiarity is the exclusion or limitation in the diet of foods that can aggravate the situation. Firstly, it is necessary to consume a sufficient amount according to age, which will help prevent. For teenagers this is at least 1.5 liters per day.

The diet should include a sufficient amount of vegetables and fruits, food products high content.

These berries and fruits include:

• apples;
• raspberry;
• avocado;
• pears;

It is recommended to eat whole grain bread or porridge, whole grain porridge, and brown rice. Plant fiber and bran are able to retain water in the intestines, thereby facilitating the movement of feces through the intestines. Lentils, legumes, and pumpkin seeds have a beneficial effect on digestion.

If inflammation develops, you should exclude radishes, cabbage, sweets, grapes, flour products, milk, eggs. It is better to cook dishes by steaming or in a slow cooker. It is advisable to boil vegetables before eating.

The child must chew food thoroughly. You need to avoid rough foods that can damage the intestinal wall, dry foods, and long intervals between feedings.

Carbonated drinks, foods with dyes and harmful additives, spicy dishes. It is not advisable to give your child vegetables or fruits that are difficult to chew.

It is necessary to achieve regular bowel movements. Matters physical activity child, physical therapy. For constipation, you can use enemas with herbal decoctions.

To improve the condition of the intestines, it is recommended to prepare a decoction for your child from a mixture of chamomile flowers, berries, nettle herbs, dill, and motherwort taken in equal parts (1 tablespoon of the mixture per glass of boiling water, leave for 1.5 hours). Give 50-100 ml (depending on age) 2 times a day for a month.

If a diverticulum of the large intestine is accidentally detected, dispensary observation for the child and a diet that avoids constipation is recommended.

In case of development of the inflammatory process and diagnosis of diverticulitis, antibiotics, antispasmodics (No-shpa, Platyfillin, Spasmomen, Riabal), and irrigation of the intestinal mucosa with a solution of furatsilin are used. If the disease becomes chronic and recurrent, then the issue of surgical treatment is decided.

Regarding the identified uncomplicated Meckel's diverticulum, experts do not have a common point of view regarding further tactics. Some pediatric surgeons consider it necessary and mandatory to remove an unchanged diverticulum discovered during surgery. Other specialists do not see the need to remove it if there are no complications.

A developed complication of a diverticulum (bleeding, perforation, intestinal obstruction, strangulation) requires only urgent surgical intervention.

Volume surgical treatment can be different: removal of the small intestinal diverticulum itself (diverticulectomy), or a part of the small intestine is cut out and an anastomosis (connection) is performed end to end. The operation can be performed using a more preferable and less traumatic endoscopic method.

When peritonitis develops, in addition to resection of the small intestinal segment, the abdominal cavity is sanitized and drained. The situation requires intensive antibiotic therapy and the injection of solutions into a vein for the purpose of detoxification.

Forecast

Meckel's diverticulum in most children (95%) does not manifest itself clinically throughout their life. Complications of diverticulum develop in 5% of patients. The prognosis depends on the timeliness of surgical treatment.

Probability postoperative complications is low, but the development of adhesive disease, which can lead to intestinal obstruction, cannot be ruled out.

Summary for parents

Detect uncomplicated diverticulum by clinical manifestations almost impossible - they may not exist at all. It is sometimes discovered accidentally during examination or surgery. If your child has any complaints from the gastrointestinal tract, you should consult a doctor. This will help to diagnose the pathology in a timely manner and carry out the necessary treatment.