Examqo › Examqo library › Pediatric surgery › Hepatobiliary and gastrointestinal surgery in children
Meckel diverticulum, umbilical remnants and gastrointestinal duplications
A Meckel diverticulum is a remnant of the vitelline (omphalomesenteric) duct on the antimesenteric wall of the ileum; in a child it presents mainly with painless rectal bleeding, caused by an ulcer in the adjacent ileum due to acid from ectopic gastric mucosa.
Why it matters in the exam
The "rule of twos" helps: about 2% of the population, about 2 feet (about 60 cm) from the ileocaecal valve, about 2 inches long, 2 common ectopic tissues (gastric and pancreatic), and most symptomatic cases appear before age 2. The exam asks about the common presentation in children (massive painless bleeding, "brick-red" or dark red), the mechanism (an ulcer in the adjacent ileal wall, not in the diverticulum itself), the diagnostic test (a Meckel scan with technetium-99m pertechnetate, taken up by gastric mucosa) and treatment.
Other presentations: bowel obstruction — intussusception with the diverticulum as a "lead point", or volvulus around a fibrous band joining the diverticulum to the umbilicus; diverticulitis mimicking appendicitis; and a Littre hernia (a diverticulum inside a hernia sac). For the scan, giving an H2 blocker beforehand improves sensitivity. For bleeding, segmental resection of the ileum together with the diverticulum is done, because the ulcer lies in the adjacent wall. Management of a diverticulum found incidentally at surgery is debated; in children the tendency is to resect.
Other umbilical remnants: an omphalomesenteric fistula (stool discharging from the umbilicus), an umbilical sinus or polyp (red tissue that does not respond to silver nitrate), and urachal remnants (urine discharging from the umbilicus or an infected cyst below it). Gastrointestinal duplications are cystic or tubular structures on the mesenteric side, sharing a muscular wall and blood supply with the adjacent bowel, and lined by gastrointestinal mucosa — sometimes gastric mucosa that causes bleeding. The common site is the ileum. Ultrasound shows the "double wall sign". They present with a mass, obstruction, intussusception or bleeding and are treated by excision. A thoracic duplication with vertebral anomalies raises suspicion of a neurenteric cyst.
Key points
- Meckel — painless rectal bleeding in a child.
- Mechanism: ectopic gastric mucosa and an ulcer in the adjacent ileum.
- Diagnosis by Meckel scan; an H2 blocker improves sensitivity.
- For bleeding — segmental resection.
- Duplication: mesenteric side, shared wall, double wall sign.
Summary table
| Condition | Typical presentation | Test | Treatment |
|---|---|---|---|
| Bleeding Meckel | Massive painless rectal bleeding in a child | Meckel scan | Segmental ileal resection |
| Obstructing Meckel | Intussusception or volvulus around a band to the umbilicus | X-ray, ultrasound | Surgery |
| Omphalomesenteric fistula | Stool discharging from the umbilicus | Fistulogram, ultrasound | Excision of the remnant |
| Urachal remnant | Urine from the umbilicus or an infected cyst | Ultrasound | Drainage if infected, then excision |
| Duplication | Mass, obstruction, bleeding | Ultrasound — double wall | Excision |
A free exam question
בן 4 מגיע למיון עם תלונות על דימום רקטלי אפיזודי שאינו קשור בהכרח ליציאות. בבדיקה גופנית אין ממצאים חריגים למעט טכיקרדיה קלה וחיוורון בלחמיות כמו כן יש סימני דם על התחתונים וסביב האנוס ללא רגישות מקומית. מה מהבאים נכון לגבי? בדיקת מיפוי במקרה זה (the question as examined, in Hebrew)
- א. מיפוי טכנציום חיובי הוא בעל ערך ניבוי חיובי של כ - 60%
- ב. מיפוי טכנציום צריך להעשות מוקדם ככל האפשר
- ג. מיפוי טכנציום שלילי מוטעה– FALSE NEGATIVE יכול להיגרם בשל אנטומיה תוך בטנית
- ד. מיפוי טכנציום כמו גם מיפוי כדוריות אדומות מצריכים דימום פעיל על מנת להגיע לאבחנה חיובית
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Pediatric surgery, Pediatrics.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- Holcomb and Ashcraft's Pediatric Surgery, 7th edition (2019) — Meckel Diverticulum and Other Omphalomesenteric Remnants; Alimentary Tract Duplications
- SNMMI Procedure Standard for Meckel diverticulum scintigraphy, 2014 — Patient preparation and interpretation
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.