Life-threatening gastrointestinal haemorrhage from a large Meckel's diverticulum

Description

A 16-year-old patient was admitted to the emergency department one morning following a collapse with a short history of haematochezia (bleeding per rectum). There was no history of trauma or change in bowel habit and no relevant medical history or drug history. On admission, haemoglobin was 95 g/l. The patient was tachycardic (heart rate 140 beats/min), and hypotensive (blood pressure 85/60 mm Hg) but responded well to initial resuscitation with intravenous crystalloid and 2 units of packed red blood cells. As the patient had stabilised, a CT angiography scan of the abdomen was performed but showed no evidence of active bleeding, a previous bleeding site or any other pathology. The patient was transferred to the intensive care unit for close monitoring and further crystalloid and red blood cell transfusion. The decision was made to observe the patient overnight and perform a technetium Tc99m scan the following morning to determine whether a Meckel's diverticulum was present. However, during the course of the evening, the patient passed a further 400 ml of dark rectal blood. Haemoglobin dropped from 102 g/l, after a total of 4 units of packed red cells, to 69 g/l and the patient became haemodynamically unstable with a blood pressure of 75/40 and heart rate of 115. A decision was made to proceed to laparotomy. On laparotomy, a 20 cm Meckel's diverticulum was found approximately 80 cm from the ileocaecal valve and was excised with a limited small bowel resection and stapled anastomosis. On opening the specimen, the diverticulum was full of fresh blood with visible ectopic gastric mucosa and omphalomesenteric artery (figures 1 and 2). Postoperatively, the patient made an uncomplicated recovery and was discharged 4 days later.

Figure 1.

Excised Meckel's diverticulum (intraluminal view) with visible omphalomesenteric (vitelline) artery (arrowed).

Figure 2.

Excised Meckel's diverticulum (external).

Learning points.

• Gastrointestinal haemorrhage is rare in adolescent males but may represent bleeding from a Meckel's diverticulum.¹

• Haemodynamic compromise in children and adolescents occurs late and indicates significant intravascular volume depletion.

• Major gastrointestinal haemorrhage with haemodynamic instability should prompt consideration of urgent intervention by endoscopic, radiological or surgical means.