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The Turkish Journal of Gastroenterology
2013, Volume 24, No 2, Pages 187-188
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Mesenteric Meckel’s diverticulum
Imtiaz WANI, Nawab KHAN, Sameer NAQASH, Nisar CHOUDRI, Khursheed WANI
Department of General Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
Summary
Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract (1). The usual location is on the antimesenteric border of the distal ileum, usually within about 60–100 cm of the ileocecal valve. On rare occasions, it may be located on the mesenteric border of the ileum, the so-called mesenteric Meckel’s diverticulum. This Meckel's diverticulum attached to the mesenteric border is a distinct variant of the Meckel's diverticulum and has been considered a “forgotten entity” (2,3). Existence of the mesenteric Meckel’s diverticulum underlines the need for a revision in the understanding and classification of the Meckel's diverticulum (Table 1) (4). A nine-year-old boy presented with right lower abdominal pain of 10 hours duration. There was a history of nausea and anorexia. On general physical examination, pulse of 98/min, blood pressure of 100/70 mmHg, and temperature of 39C were recorded. Systemic examination was normal. On abdominal examination, tenderness and rebound tenderness in the right iliac fossa were present. Upright X-ray of the abdomen was normal. Ultrasonography of the abdomen was consistent with the diagnosis of appendicitis. The patient underwent emergency appendectomy via gridiron incision. The appendix was retrocecal in position and inflamed and contained a single fecalith. An exploration of 100 cm of terminal ileum was done for presence of incidental Meckel’s diverticulum. At about 90 cm from the ileocecal junction, a diverticulum measuring 7x2.2 cm was identified. Careful dissection showed that this diverticulum was subserosal, intramesenteric, and had a narrow base with small mesodiverticulum arising from the mesenteric border of the ileum (Figure 1A, 1B). Diagnosis of Meckel’s diverticulum was made and diverticulectomy was done. Histopathology confirmed the diagnosis of Meckel’s diverticulum with no presence of an ectopic tissue. The postoperative period was uneventful. Mesenteric-sided Meckel's diverticulum was first reported by Chaffin (5) in 1941. This mesenteric location can be subserosal or intramesenteric, and can possess mesodiverticulum. When intramesenteric, transillumination is required for its demonstration. Persistence of a very short vitelline artery that creates a mesodiverticular band from the mesentery to the tip of the diverticulum, which diverts the diverticulum away from the antimesenteric border during rapid growth, leads to mesenteric Meckel’s diverticulum. Meckel’s diverticulum should be classified (Wani and Nawab’s classification) as antimesenteric or mesenteric. Encountering asymptomatic mesenteric Meckel’s diverticulum is a very rare situation and treatment is a conflicting point. Existence of an inflammatory process may obviate the successful management of a diverticulum requiring diverticulectomy or resection and anastomosis. The lack of knowledge regarding mesenteric Meckel’s diverticulum and the differential diagnosis of ileal duplication, hypertrophic ileal tuberculosis, gut lymphoma gastrointestinal stromal tumor (GIST), lymphoma, adenocarcinoma, and metastatic deposit may require diverticulectomy for confirmation of the diagnosis. Prophylactic resection of the asymptomatic incidental mesenteric Meckel’s diverticulum had been recommended by Segal (3). This rare localization deserves more attention and is more alarming than a usual antimesenteric location because it may erode the mesentery and rupture into the mesenteric vasculature during the inflammatory process (6)
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    2. Seitun S, Vito LD, Rossi UG, et al. Perforated Meckel's diverticulitis on the mesenteric side: MDCT findings. Abdom Imaging 2012; 37: 288-91.
    3. Segal SD, Albrecht DS, Belland KM. Rare mesenteric location of Meckel’s diverticulum, a forgotten entity: a case study aboard USS Kitty Hawk. Am Surg 2004; 70: 985-8.
    4. Manukyan MN, Kebudi A, Midi A. Mesenteric Meckel's diverticulum: a case report. Acta Chir Belg 2009; 109: 510-2.
    5. Holiinshead WH. The jejunum, ileum, and colon. In: Hollinshead WH, ed. Anatomy for surgeons: volume 2. New York: Harper and Row, 1971.
    6. Sarioglu-Buke A, Corduk N, Koltuksuz U, et al. An uncommon variant of Meckel's diverticulum. Can J Surg 2008; 51: E46-E47.
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