Content uploaded by Mariusz Chabowski
Author content
All content in this area was uploaded by Mariusz Chabowski on May 21, 2016
Content may be subject to copyright.
219
Srp Arh Celok Lek. 2016 Mar-Apr;144(3-4):219-221 DOI: 10.2298/SARH1604219C
ПРИКАЗ БОЛЕСНИКА / CASE REPORT UDC: 616.33-006-005.1
Correspondence to:
Mariusz CHABOWSKI
Dept. of Surgery
4th Military Teaching Hospital
5 Weigla Street
50-981 Wroclaw
Poland
mariusz.chabowski@gmail.com
SUMMARY
Introduction Meckel’s diverticulum is the most common congenital anomaly of the gastro intestinal
tract, present in about 2% of population.
Case Outline The article presents the case of a 44-year-old otherwise healthy man with anemia, who was
diagnosed lower gastrointestinal bleeding. An abdominal CT scan revealed a clearly demarcated solid
tumor in hypogastric region, measuring 65 × 45 mm. A laparotomy through lower midline incision was
performed. A surgical resection of a lesion of a Meckel’s diverticulum was carried out and a final diagnosis
of gastrointestinal stromal tumor was made. The patient made an uneventful recovery.
Conclusion The preoperative diagnosis of a complicated Meckel’s diverticulum may be challenging. CT
is usually an adequate method to diagnose tumors arising from Meckel’s diverticulum.
Keywords: bleeding Meckel’s diverticulum; diverticulectomy; gastrointestinal stromal tumor (GIST)
A massive bleeding from a gastrointestinal stromal
tumor of a Meckel’s diverticulum
Mariusz Chabowski1,2, Anna Szymanska-Chabowska3, Tadeusz Dorobisz1, Dawid Janczak1,
Michał Jelen4, Dariusz Janczak1,2
1Fourth Military Teaching Hospital, Department of Surgery, Wroclaw, Poland;
2Wroclaw Medical University, Faculty of Health Science, Department of Clinical Nursing, Wroclaw, Poland;
3Wroclaw Medical University, Faculty of Medicine, Department of Internal Medicine and Hypertension,
Wroclaw, Poland;
4Wroclaw Medical University, Faculty of Medicine, Department of Pathology, Wroclaw, Poland
INTRODUCTION
Meckel’s diverticulum is the most common
congenital anomaly of the gastrointestinal
tract, present in about 2% of population [1]. It
is the remnant of the omphalomesenteric duct,
which usually obliterates in the fifth to seventh
week of life [1, 2]. The name derives from Jo-
hann Friedrich Meckel (1781–1833), who de-
scribed its pathological features in 1809 [3, 4].
Gastrointestinal bleeding in adults originates
mainly from the upper gastrointestinal tract
(80%). Less than 5% of the bleeding originates
in small intestine [3]. Painless gastrointestinal
bleeding is a common symptom of Meckel’s di-
verticulum. Meckel’s diverticulum is the most
common site of heterotopic gastric mucosa [2].
CASE REPORT
A 44-year-old otherwise healthy man, was ad-
mitted to the internal medicine department of
the regional hospital because of painless rectal
bleeding (hematochezia) resulting in fainting
(syncope) at defecation. Neither fever nor vom-
iting were reported. His past medical history
revealed nothing remarkable. The patient was
hemodynamically stable, his blood pressure
was 110/80 mmHg and heart rate 95 beats per
minute. He had a hemoglobin level of 5.8gm/
dl. His abdomen was soft, non-tender and non-
distended. The patient received five units of
packed red blood cells. Both esophagogastro-
duodenoscopy and colonoscopy discovered no
pathology. An abdominal ultrasound examina-
tion revealed a well marginated vascularized
hypoechoic tumor measuring 59×40mm. Due
to the suspicion of a vascular malformation, the
patient was admitted to the Department of Sur-
gery in September of 2014 (No. 50245/2014).
An abdominal CT scan revealed a clearly de-
marcated solid tumor in hypogastric region,
measuring 65×45 mm (Figure 1).
Figure 1. Contrast-enhanced CT scan of the abdomen
and pelvis showing a clearly demarcated solid tumor
in hypogastric region, measuring 65 × 45 mm in cross
section
220
doi: 10.2298/SARH1604219C
The patient was administered a general anesthesia and
a lower midline incision was used. The tumor of 4cm in
diameter was identified in Meckel’s diverticulum. The seg-
mental ileal resection with tumor and end-to-end anas-
tomosis in two layers were performed (Figure 2). There
was no evidence of distant spread. The tube was inserted.
The postoperative course was uneventful. The patient
was discharged on the seventh postoperative day. The
pathological examination revealed a gastrointestinal stro-
mal tumor (GIST) with spindle cells histologic subtype.
Immunohistochemistry showed positive reaction for
CD117 (as marker for the presence of the KIT protein)
and smooth muscle actin. But the reactions for desmin,
S100, CD34 and Ki67 were negative. The patient had no
further episodes of hematochezia.
DISCUSSION
The clinically applicable is the rule of twos: occurs in 2%
of the population, located two feet of the ileocecal valve,
two inches in length, 2 cm in diameter, 2:1 male:female
ratio, two ectopic tissues (gastric and pancreatic), and
symptomatic before two years old [2]. Ectopic tissue,
mainly gastr ic mucosa, is often found in Meckel’s
diverticula and can lead to ulceration and bleeding [5].
There has been an ongoing debate about the excision
of asymptomatic Meckel’s diverticulum [6]. However,
bleeding, obstruction, diverticulitis, and perforation are
complications which require emergency surgery. The
treatment of choice is then surgical resection by the
diverticulectomy or by the segmental bowel resection and
anastomosis [2].
Both benign and malignant tumors in Meckel’s diver-
ticulum are very rare, with their incidence of 0.5–1.9% [4].
Lipoma, angioma, leiomyoma and hamartoma are benign
lesions. Carcinoids, mesenchymal tumors (i.e. gastrointes-
tinal stromal tumors, leyomyosarcomas) and adenocar-
cinomas are malignant lesions. Of these, 12% of tumors
are GIST [7, 8]. The term GIST was first used in 1983 by
Mazur and Clark. GISTs arise from the interstitial cells of
Cajal, pacemaker cells of gastrointestinal tract [8]. GISTs
arising from Meckel’s diverticulum are extremely rare [8].
Definitive surgery remains the mainstay of treatment for
patients with localized, primary GIST. The diverticulum
is excised with 2–3 cm of adjacent ileum [6]. End-to-end
anastomosis is performed. Either conventional laparotomy
or laparoscopic approach are used.
The preoperative diagnosis of a complicated Meckel’s
diverticulum may be challenging. CT is usually an ad-
equate method to diagnose tumors arising from Meckel’s
diverticulum.
1. Satya R, O’Malley JP. Meckel diverticulum with massive bleeding.
Radiology. 2005; 236:836–840
[DOI: 10.1148/radiol.2363031026] [PMID: 16118164]
2. Poley JR, Thielen TE, Pence JC. Bleeding Meckel’s diverticulum in a
4-month-old infant: treatment with laparoscopic diverticulectomy.
A case report and review of the literature. Clinical and Experimental
Gastroenterology. 2009; 2:37–40
[DOI: 10.2147/CEG.S3792] [PMID: 21694825]
3. Sagar J, Kumar V, Shah DK. Meckel’s diverticulum: a systematic
review. J R Soc Med. 2006; 99:501–505
[DOI: 10.1258/jrsm.99.10.501] [PMID: 17021300]
4. Sharma RK, Jain VK. Emergency surgery for Meckel’s diverticulum.
World Journal of Emergency Surgery. 2008; 3:27
[DOI: 10.1186/1749-7922-3-27] [PMID: 18700974]
5. Zellner C, Roorda AK. A bleeding Meckel’s diverticulum. N Eng J
Med. 2003; 349:e9
[DOI: 10.1056/ENEJMicm020554] [PMID: 12944585]
6. Radovic SV, Albijanic D, Albijanic M, Krstic ZV. Axial torsion and
gangrene of Meckel’s diverticulum: case report. Srp Arh Celok Lek.
2015; 143(1-2):79–82
[DOI: 10.2298/SARH1502079R] [PMID: 25845257]
7. Van Loo S, Van Thielen J, Cools P. Gastrointestinal bleeding caused
by a GIST of a Meckel’s diverticulum – a case report. Acta Chir Belg.
2010; 110:365–366
[DOI: 10.1080/00015458.2010.11680636] [PMID: 20690526]
8. Chandramohan K, Agraval M, Gurjar G, Gatti RC, Patel MH, Trivedi
P, et al. Gastrointestinal stromal tumour in Meckel’s diverticulum.
World J of Surg Oncol. 2007; 5:50
[DOI: 10.1186/1477-7819-5-50] [PMID: 17498311]
Figure 2. Intraoperative photograph showing the tumor arising from
Meckel’s diverticulum located on antimesenteric margin of the ileum
REFERENCES
Chabowski M. et al. A massive bleeding from a gastrointestinal stromal tumor of a Meckel’s diverticulum
221Srp Arh Celok Lek. 2016 Mar-Apr;144(3-4):219-221
www.srpskiarhiv.rs
КРАТАК САДРЖАЈ
Увод Мекелов дивертикулум је најчешћа урођена анома-
лија система органа за варење, присутна у око 2% попу-
лације.
Приказ болесника Чланак приказује случај 44-годишњег
анемичног али иначе здравог мушкарца, са дијагнозом
крварења из доњег дела дигестивног система органа. CT-
скеном абдомена откривен је јасно дефинисан чврст тумор
у хипогастричкој регији, димензија 65 ×45mm. Извршена
је доња медијална лапаратомијa. Спроведена је хируршка
ресекција лезије Мекеловог дивертикулума и постављена
коначна дијагноза гастроинтестиналног стромалног тумора.
Болесник се опоравио без компликација.
Закључак Преоперативно успостављање дијагнозе сложе-
ног Мекеловог дивертикулума може бити тешко. CT-скен је
обично адекватна метода за откривање тумора који настају
из Мекеловог дивертикулума.
Кључне речи: крварење из Мекеловог дивертикулума; ди-
вертикулектомија; гастроинтестинални стромални тумор
(ГИСТ)
Масивно крварење из гастроинтестиналног стромалног тумора Мекеловог
дивертикулума
Маријуш Чабовски1,2, Ана Шиманска-Чабовска3, Тадеуш Доробиш1, Давид Јанчак1, Михал Јелен4, Даријуш Јанчак1,2
1Четврта војнонаставна болница, Одељење хирургије, Вроцлав, Пољска;
2Медицински универзитет у Вроцлаву, Факултет здравствених наука, Катедра за клиничко збрињавање, Вроцлав, Пољска;
3Медицински универзитет у Вроцлаву, Медицински факултет, Катедра за интерну медицину и хипертензију, Вроцлав, Пољска;
4Медицински универзитет у Вроцлаву, Медицински факултет, Катедра за патологију, Вроцлав, Пољска
Примљен • Received: 07/09/2015 Прихваћен • Accepted: 07/12/2015