Meckel’s diverticulum is the most common congenital malformation of the small intestine. Clinical symptoms can mostly be related to a heterotopic tissue in the diverticulum and abnormal fixation of the tip of the diverticulum. Meckel’s diverticulum is diagnosed using multiple modalities such as conventional radiography, barium studies, ultrasonography, computed tomography, scintigraphy, digital subtraction angiography, laparotomy, capsule endoscopy, and double-balloon enteroscopy (DBE) [4, 5]. However, it is known to both radiologists and clinicians that the preoperative diagnosis of symptomatic Meckel’s diverticulum is difficult . Our case was diagnosed by DBE and technetium-99m pertechnetate scintigraphy. DBE is an excellent diagnostic modality because direct observation of both Meckel’s diverticulum and ulceration and histopathological diagnosis by endoscopic biopsy are possible . However, DBE should be used complementarily with other less invasive examinations such as technetium-99m pertechnetate scintigraphy to confirm or establish the diagnosis . We also performed technetium-99m pertechnetate scintigraphy as a supplemental examination, which showed a hot spot in her lower right abdomen. It is a noninvasive examination specifically of ectopic gastric mucosa and not Meckel’s diverticulum, and is helpful in determining the approximate location of a lesion. Furthermore, it is a useful diagnostic method for pediatric patients because it has a higher sensitivity in the range of 85–90 % in children than in adults (approximately 60 %) .
Sagar et al. reported that bleeding from Meckel’s diverticulum due to ectopic gastric mucosa is the most common clinical presentation particularly in young patients . Ectopic gastric and pancreatic tissues frequently found in the diverticulum are the primary causes of gastrointestinal bleeding, because highly acidic secretions from gastric tissues and alkaline secretions from pancreatic tissues cause ulcerations of the adjacent normal ileal mucosa . With regard to the incidence of small bowel tumors, according to a report of analysis of a prospectively collected database of double-balloon enteroscopy, of the 1106 patients who underwent double-balloon enteroscopy procedures, 134 (12.1 %) were reported to have a small bowel tumor, of whom 36 (26.9 %) had obscure gastrointestinal bleeding and 20 (14.9 %) had overt gastrointestinal bleeding . Sometimes, Meckel’s diverticulum may present as an intraluminal polypoid mass causing small bowel obstruction when the diverticulum is inverted into the ileum. In our case, we found a polypoid lesion inside of Meckel’s diverticulum with ectopic gastric mucosa which caused gastrointestinal bleeding. By searching PubMed (www.ncbi.nlm.nih.gov/PubMed, from 1977 to Dec 2015) using a combination of MeSH terms including “Meckel’s diverticulum” and “polyp”, we found only two reported cases of Meckel’s diverticulum with polypoid lesions causing gastrointestinal bleeding diagnosed by capsule endoscopy [9, 10]. In our case, transanal DBE revealed a polypoid lesion inside of the diverticulum and an intestinal ulceration in direct contact with the polypoid lesion. Furthermore, the surgically resected specimen showed a pedunculated polyp in the diverticulum with the ulceration adjacent to the polypoid lesion. Histopathologically, ectopic gastric mucosa existed at the head of the polypoid lesion, indicating that the ulceration was caused by exposure of the ectopic gastric mucosa not by mechanical stimulation or ischemia due to intussusception. How a polypoid lesion in Meckel’s diverticulum develops is unknown. It has been suggested that chronic abnormal peristaltic movements caused by the ectopic tissue at the bottom of Meckel’s diverticulum may secondarily lead to the formation of a polypoid lesion. Moreover, the elevated ectopic gastric mucosa may be easily exposed to the adjacent small intestinal mucosa, formation of ulcer.
Surgical management, including diverticulectomy or segmental bowel resection and anastomosis, is required for Meckel’s diverticulum, and laparoscopic excision has been increasingly used owing to the advances in the development of minimally invasive surgery in children . Furthermore, single-incision laparoscopic techniques have recently been adopted as a laparoscopy-assisted surgical option, which would be otherwise required for specimen extraction, and are potentially associated with the decrease in port-site- and incision-related morbidity, reduced postoperative pain, and improved cosmetic features . In our present case, single-incision laparoscopy-assisted umbilical minilaparatomy was performed, which enabled the examination of the abdominal cavity, easy detection of the lesion, bowel extraction outside of the body, and segmental bowel resection via the smallest possible wound required for anastomosis.