为了正常的体验网站,请在浏览器设置里面开启Javascript功能!
首页 > Meckel\'s憩室

Meckel\'s憩室

2013-05-01 44页 pdf 1MB 24阅读

用户头像

is_275210

暂无简介

举报
Meckel\'s憩室 Alex Herrera, HMS III Gillian Lieberman, MD Meckel’s Diverticulum Alex Herrera, Harvard Medical School Year III Gillian Lieberman, MD January 2007 2 Alex Herrera, HMS III Gillian Lieberman, MD Meckel’s Embryology • Remnant of omphalomesenteric (vitelline...
Meckel\'s憩室
Alex Herrera, HMS III Gillian Lieberman, MD Meckel’s Diverticulum Alex Herrera, Harvard Medical School Year III Gillian Lieberman, MD January 2007 2 Alex Herrera, HMS III Gillian Lieberman, MD Meckel’s Embryology • Remnant of omphalomesenteric (vitelline) duct – Complete obliteration normally occurs between week 5 and 7 of gestation • Maintains blood supply from remnant of vitelline artery – branch of ileal or (less commonly) ileocecal artery Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with pathologic Correlation. Radiographics. 2004 Mar- Apr;24(2):565-87 Patent Duct Fibrous connection Meckel’s 3 Alex Herrera, HMS III Gillian Lieberman, MD Anatomy of Meckel’s • Blind sac • ANTI-mesenteric • Usually within 40-100 cm of ileocecal valve • True diverticulum • Normal: 5 cm length, 2 cm diameter Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with pathologic Correlation. Radiographics. 2004 Mar-Apr;24(2):565-87. 4 Alex Herrera, HMS III Gillian Lieberman, MD Epidemiology • 2% of population = most common congenital abnormality of GI tract • Most patients present before age 2 (~60%) • Complications occur in 4-16% – 3-4x more frequent in males 5 Alex Herrera, HMS III Gillian Lieberman, MD Heterotopic tissue • Gastric mucosa – 60% of symptomatic pts • Pancreatic tissue – 6% of symptomatic pts • Combined gastric and pancreatic • Other (jejunal, duodenal, etc.) Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with pathologic correlation. Radiographics. 2004 Mar-Apr;24(2):565-87. Ileal mucosa Gastric mucosa 6 Alex Herrera, HMS III Gillian Lieberman, MD Clinical Presentation Meckel’s only presents when there are complications! 7 Alex Herrera, HMS III Gillian Lieberman, MD Clinical Presentation Children • Painless GI bleeding is most common presentation – Peptic ulcer from heterotopic gastric mucosa Adults • Intestinal obstruction is most common presentation – Strangulation of bowel – Intussusception – Littre’s hernia – Neoplasms • Diverticulitis – Gastric acid – Enterolith 8 Alex Herrera, HMS III Gillian Lieberman, MD Companion Patient 1: Enterolith in Diverticulum on Plain Film Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with pathologic Correlation. Radiographics. 2004 Mar-Apr;24(2):565-87 Enterolith Dilated Meckel’s 9 Alex Herrera, HMS III Gillian Lieberman, MD Companion Patient 2: Inverted Meckel’s on SBFT Turkington JR, Devlin PB, Dace S, Madden M. An unusual cause of intermittent abdominal pain (2006: 5b). Inverted Meckel's diverticulum. Eur Radiol. 2006 Aug;16(8):1862-4. Epub 2006 Jun 3 Tubular Filling Defect 10 Alex Herrera, HMS III Gillian Lieberman, MD Companion patient 3: Intussusception of Meckel’s on CT Scan Turkington JR, Devlin PB, Dace S, Madden M. An unusual cause of intermittent abdominal pain (2006: 5b). Inverted Meckel's diverticulum. Eur Radiol. 2006 Aug;16(8):1862-4. Epub 2006 Jun 3 Meckel’s telescoped into normal bowel Ring of mesenteric fat 11 Alex Herrera, HMS III Gillian Lieberman, MD Possible Imaging Modalities • Abdominal plain film • Ultrasound • CT • Barium studies • Nuclear medicine scans – Meckel’s scan – GI Bleeding scan • Angiography Unreliable for diagnosis of Meckel’s 12 Alex Herrera, HMS III Gillian Lieberman, MD Abdominal Plain Film and Companion Patient 4 • Poor sensitivity Radiographic signs are nonspecific: • Intestinal obstruction • Enterolith • Air/fluid levels Outpouching suggestive of Meckel’s Ojha S, Menon P and Rao K. Meckels diverticulum with segmental dilatation of the ileum: radiographic diagnosis in a neonate. Pediatr Radiol. 2004 Aug;34(8):649-51. Epub 2004 Mar 12. 13 Alex Herrera, HMS III Gillian Lieberman, MD Ultrasound and Companion Patient 5 • Hypoechoic, fluid-filled, tubular structure in RLQ • Can be cystic • Hypervascularization on Doppler Can visualize: Diverticulitis Intussusception Ddx: • Appendicitis • Intestinal duplication M Baldisserotto, et al. AJR 2003; 180:425-428 Hyper- vasculariztion 14 Alex Herrera, HMS III Gillian Lieberman, MD CT and Companion Patient 6 and 7 • Non-specific findings unless attached to umbilicus or there is complication Common findings: • Pouch containing fluid and air or particulate material • Inflammatory changes in surrounding mesenteric fat • Mural enhancement Ectopic pancreatic tissue Bennett GL, Birnbaum BA, Balthazar EJ. CT of Meckel's diverticulitis in 11 patients. AJR Am J Roentgenol. 2004 Mar;182(3):625-9. Connection to umbilicus Mural enhancement 15 Alex Herrera, HMS III Gillian Lieberman, MD Possible Imaging Modalities • Abdominal plain film • Ultrasound • CT • Barium studies • Nuclear medicine scans – Meckel’s scan – GI Bleeding scan • Angiography Preferred diagnostic tests for diagnosing Meckel’s diverticulum 16 Alex Herrera, HMS III Gillian Lieberman, MD Barium Studies: SBFT and Enteroclysis • Unreliable for detection of Meckel’s Findings: • Blind ending pouch • Filling defect (inverted) • Mucosal pattern: – Triradiate – Triangular plateau Limitations: – Stenosis of neck – Intestinal contents – Peristalsis – Small size Triradiate (surrounding bowel is collapsed) Triangular Plateau (surrounding bowel is patent) Eisenberg RL. GI Radiology: A Pattern Approach, 2nd edition. Philadelphia: Lippincott, 1990. 536-538. 17 Alex Herrera, HMS III Gillian Lieberman, MD Companion patients 8 and 9: Mucosal Pattern of Meckel’s on SBFT Triradiate patternTriangular plateau Meckel diverticulum: Radiologic features with pathologic Correlation. Radiographics. 2004 Mar-Apr;24(2):565-87. Eisenberg RL. GI Radiology: A Pattern Approach, 2nd edition. Philadelphia: Lippincott, 1990. 536- 538. 18 Alex Herrera, HMS III Gillian Lieberman, MD Enteroclysis • Preferred by some radiologists – Continuous distension of abnormal loops – Frequent flouroscopy • Limitations: – Discomfort – Side effects – Increased radiation exposure 19 Alex Herrera, HMS III Gillian Lieberman, MD Meckel’s Scan • 99mTc-Pertechnetate concentrates in mucus- secreting cells of gastric mucosa – Uptake in stomach and Meckel’s simultaneous within 10 minutes of administration – Pharmacologic enhancement (pentagastrin, cimetidine, glucagon) Advantages: • Highly sensitive and specific (>90%) in children Disadvantages: • Less sensitive and specific in adults • 99mTc-Pertechnetate concentrates in areas of increased blood flow 20 Alex Herrera, HMS III Gillian Lieberman, MD Limitations of Meckel’s Scan False Positive “Fake-outs” • Intestinal duplication • Hemangiomas/AVMs • Neoplasm (e.g. carcinoid) • IBD and small bowel inflammation (hyperemia) False Negatives • Absence of gastric mucosa • Impaired vascular supply • Brisk hemorrhage 21 Alex Herrera, HMS III Gillian Lieberman, MD Companion Patient 10: Meckel’s Scan http://gamma.wustl.edu/ms001te272.html Focus of Tc uptake in RLQ Anterior View Stomach Meckel’s typically appears in RLQ, but can present on either side of midline 22 Alex Herrera, HMS III Gillian Lieberman, MD GI Bleeding Scan • 99mTc-labeled autologous RBC accumulate in bowel at sites of active hemorrhage • Sensitive for bleeding Meckel’s, but not specific – Specificity ~100% if subsequent Meckel’s scan is positive Advantages: • Can detect intermittent bleeding • High sensitivity for low bleeding rate – Bleeding rate of only 0.1 cc/sec required for detection 23 Alex Herrera, HMS III Gillian Lieberman, MD Companion Patient 11: GI Bleeding Scan PACS, BIDMC Posterior View Area of increased activity • Meckel’s usually present as increased activity in RLQ • Can appear more superiorly or on either side of midline 24 Alex Herrera, HMS III Gillian Lieberman, MD Angiography Indications: • Active GI bleeding • High suspicion for Meckel’s with negative Meckel’s scan and barium studies Technique: • Superselective SMA or ileal arteriography Positive findings: • Extravasation = at least 0.5cc bleeding/sec • Persistent vitelline artery supplying tubular structure in RLQ 25 Alex Herrera, HMS III Gillian Lieberman, MD Companion Patient 12: Selective SMA and Ileal Arteriography Mitchell AW, Spencer J, Allison DJ, Jackson JE. Meckel's diverticulum: angiographic findings in 16 patients. AJR Am J Roentgenol. 1998 May;170(5):1329-33. SMA Ileal artery Vascular blush Vitelline artery 26 Alex Herrera, HMS III Gillian Lieberman, MD Suggested Meckel’s Work-up • Barium stuides can be helpful, but… • Most sensitive and specific test is a Meckel’s scan! • If setting of acute GI bleeding, GI bleeding scan and/or angiography is indicated – Meckel’s scan may be falsely negative 27 Alex Herrera, HMS III Gillian Lieberman, MD Radiologic Work-up Algorithm Meckel’s Scan Findings suggestive of Meckel’s on KUB, Barium, CT, or U/S Self-limited GI bleed prompts suspicion of Meckel’s Acute GI hemorrhage GI Bleeding Scan Angiography Surgery Acute abdomen Indeterminate EGD/Colonoscopy + - + - 28 Alex Herrera, HMS III Gillian Lieberman, MD Patient Presentation, 8/22/04 JD is a 20 year old male who presents to an OSH with: • 10 episodes of blood per rectum over 24 hours • He becomes pale and diaphoretic after having another bloody stool while waiting in the ED • No history of aspirin or NSAID use PMH: non-contributory PE: significant for tachycardia to 122, BP 99/49, and gross blood on rectal exam. No abdominal tenderness or external hemorrhoids noted. 29 Alex Herrera, HMS III Gillian Lieberman, MD OSH Hospital Course Significant labs: Hct 24.2, WBC 13.5, normal PT, PTT, INR Diagnostics: • Colonoscopy showed dark red blood throughout colon without active bleeding site • EGD normal to 2nd portion of duodenum • 99mTc GI bleeding scan showed small focus of increased activity at region of terminal ileum • Meckel’s scan showed possible uptake at L5 level Therapeutics: • JD received IV fluids and 7 units of PRBCs over the course of his stay 30 Alex Herrera, HMS III Gillian Lieberman, MD Transfer to BIDMC, 8/30/04 JD was transferred to the BIDMC for further work-up. • On 8/31, JD underwent a Meckel’s scan and a GI bleeding scan. 31 Alex Herrera, HMS III Gillian Lieberman, MD Our Patient JD: Meckel’s Scan 8/31/04 Anterior View Bladder PACS, BIDMC • Negative Scan 32 Alex Herrera, HMS III Gillian Lieberman, MD JD: GI Bleeding Scan 8/31/04 Posterior View Spleen PACS, BIDMC • Negative Scan 33 Alex Herrera, HMS III Gillian Lieberman, MD Discharge • On 9/01, colonoscopy, EGD, and capsule endoscopy were negative. • JD was stabilized and discharged on 9/2 without a clear etiology for his GI bleeding. 34 Alex Herrera, HMS III Gillian Lieberman, MD Differential Diagnosis The differential diagnosis based on his course included: • Meckel’s diverticulum • AVM or angiodysplasia • IBD • Infectious ileitis/colitis • Neoplasia 35 Alex Herrera, HMS III Gillian Lieberman, MD 14 months later, 11/12/05 JD, now 21 years old, is admitted directly to the medical ICU with massive GI bleeding. A GI bleeding scan is performed on the same day… 36 Alex Herrera, HMS III Gillian Lieberman, MD Our patient JD: GI Bleeding Scan 11/12/05 Posterior View 0-60 min 60-90 min 90-120 min PACS, BIDMC Bleeding in terminal ileum 37 Alex Herrera, HMS III Gillian Lieberman, MD Findings and Differential Diagnosis • Tracer activity in center of pelvis at 90 minutes, corresponding to terminal ileum – Extends antegrade into ascending colon DDx for terminal ileum hemorrhage: • AVM or angiodysplasia • Meckel’s Colonoscopy was performed to localize and potentially treat (if found to be AVM) the lesion 38 Alex Herrera, HMS III Gillian Lieberman, MD JD: Colonoscopy, 11/12/04 • A clot and then fresh blood was seen coming from the ileocecal valve • Old blood was pooled throughout the colon • Angiography recommended to localize lesion and embolize possible AVM PACS, BIDMC 39 Alex Herrera, HMS III Gillian Lieberman, MD JD: SMA Arteriogram 11/13/05 PACS, BIDMC Negative arteriogram • Selective ileal arteriogram recommended 40 Alex Herrera, HMS III Gillian Lieberman, MD Selective Ileal Arteriogram 11/14/05 PACS, BIDMC Persistent vitelline artery 41 Alex Herrera, HMS III Gillian Lieberman, MD Conclusion JD underwent successful surgery to remove the Meckel’s diverticulum seen on ileal arteriography. Pathology demonstrated a 3cm Meckel’s diverticulum with diffuse gastric heterotopia. 42 Alex Herrera, HMS III Gillian Lieberman, MD Summary • Meckel’s diverticulum commonly presents as GI bleeding in the pediatric population • Meckel’s presents less commonly in adults, usually as obstruction or diverticulitis • 99mTc-Pertechnetate scan is the best test for diagnosing a Meckel’s diverticulum • For active GI bleeding, GI bleeding scan and/or angiography can aid diagnosis 43 Alex Herrera, HMS III Gillian Lieberman, MD References • Rossi P, Gourtsoyiannis N, Bezzi M, Raptopoulos V, Massa R, Capanna G, Pedicini V, Coe M. Meckel’s Diverticulum: Imaging Diagnosis. AJR Am J Roentgenol. 1996 Mar;166(3):567-73. • Bennett GL, Birnbaum BA, Balthazar EJ. CT of Meckel's diverticulitis in 11 patients. AJR Am J Roentgenol. 2004 Mar;182(3):625-9. • Baldisserotto M, Maffazzoni DR, Dora MD. Sonographic findings of Meckel's diverticulitis in children. AJR Am J Roentgenol. 2003 Feb;180(2):425-8. • Mitchell AW, Spencer J, Allison DJ, Jackson JE. Meckel's diverticulum: angiographic findings in 16 patients. AJR Am J Roentgenol. 1998 May;170(5):1329-33. • Pantongrag-Brown L, Levine MS, Buetow PC, Buck JL, Elsayed AM. Meckel's enteroliths: clinical, radiologic, and pathologic findings. AJR Am J Roentgenol. 1996 Dec;167(6):1447-50. • Eisenberg RL. GI Radiology: A Pattern Approach, 2nd edition. Philadelphia: Lippincott, 1990. 536- 538. • Levy AD, Hobbs CM. Meckel diverticulum: Radiologic features with pathologic Correlation. Radiographics. 2004 Mar-Apr;24(2):565-87. • Turkington JR, Devlin PB, Dace S, Madden M. An unusual cause of intermittent abdominal pain (2006: 5b). Inverted Meckel's diverticulum. Eur Radiol. 2006 Aug;16(8):1862-4. Epub 2006 Jun 3. • Ojha S, Menon P and Rao K. Meckels diverticulum with segmental dilatation of the ileum: radiographic diagnosis in a neonate. Pediatr Radiol. 2004 Aug;34(8):649-51. Epub 2004 Mar 12. • Nagi B, Kochhar R, Malik AK. Inverted Meckel diverticulum shown by enteroclysis. AJR Am J Roentgenol. 1991 May;156(5):1111-2. • http://gamma.wustl.edu 44 Alex Herrera, HMS III Gillian Lieberman, MD Acknowledgements I would like to thank: • Jacques Tham, MD • Anthony Parker, MD, PhD • Gillian Lieberman, MD • Pamela Lepkowski • Larry Barbaras Meckel’s Diverticulum Meckel’s Embryology Anatomy of Meckel’s Epidemiology Heterotopic tissue Clinical Presentation Clinical Presentation Companion Patient 1: Enterolith in Diverticulum on Plain Film Companion Patient 2: Inverted Meckel’s on SBFT Companion patient 3: Intussusception of Meckel’s on CT Scan Possible Imaging Modalities Abdominal Plain Film and Companion Patient 4 Ultrasound and Companion Patient 5 CT and Companion Patient 6 and 7 Possible Imaging Modalities Barium Studies: SBFT and Enteroclysis Companion patients 8 and 9: Mucosal Pattern of Meckel’s on SBFT Enteroclysis Meckel’s Scan Limitations of Meckel’s Scan Companion Patient 10: Meckel’s Scan GI Bleeding Scan Companion Patient 11: GI Bleeding Scan Angiography Companion Patient 12: Selective SMA and Ileal Arteriography Suggested Meckel’s Work-up Radiologic Work-up Algorithm Patient Presentation, 8/22/04 OSH Hospital Course Transfer to BIDMC, 8/30/04 Our Patient JD: Meckel’s Scan 8/31/04 JD: GI Bleeding Scan 8/31/04 Discharge Differential Diagnosis 14 months later, 11/12/05 Our patient JD: GI Bleeding Scan 11/12/05 Findings and Differential Diagnosis JD: Colonoscopy, 11/12/04 JD: SMA Arteriogram 11/13/05 Selective Ileal Arteriogram 11/14/05 Conclusion Summary References Acknowledgements
/
本文档为【Meckel\'s憩室】,请使用软件OFFICE或WPS软件打开。作品中的文字与图均可以修改和编辑, 图片更改请在作品中右键图片并更换,文字修改请直接点击文字进行修改,也可以新增和删除文档中的内容。
[版权声明] 本站所有资料为用户分享产生,若发现您的权利被侵害,请联系客服邮件isharekefu@iask.cn,我们尽快处理。 本作品所展示的图片、画像、字体、音乐的版权可能需版权方额外授权,请谨慎使用。 网站提供的党政主题相关内容(国旗、国徽、党徽..)目的在于配合国家政策宣传,仅限个人学习分享使用,禁止用于任何广告和商用目的。

历史搜索

    清空历史搜索