Bleeding Meckel's Diverticulum: Update Course 2015
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Key Takeaways
- Negative Meckel scan with hematochezia warrants colonoscopy followed by laparoscopy if colonoscopy is negative, ideally same anesthetic setting
- PPI therapy may stop bleeding from ectopic gastric mucosa in Meckel's diverticulum, allowing for semi-elective rather than emergency operation
- Ulcers in bleeding Meckel's are typically at the tip of the diverticulum, not adjacent bowel; resection removes acid source
- Laparoscopic stapling risks bowel narrowing from traction; exteriorizing through umbilicus allows relaxed marking of resection margins
- Small-bowel resection preferred over simple diverticulectomy when ulceration present to ensure complete removal of bleeding source
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All right, so 3-year-old male has been admitted to the hospital with hematochezia. You're consulted. When you see the patient, he's stable with no other medical conditions. So you order a MECel scan and that's negative. So what would you do next? What do you do after a negative Meckel for a bleeding, bright red blood per rectum? Negative Meckel, bright red blood per rectum. Do you do a colonoscopy? Do you do a laparoscopy? Was it done with or wherever, yeah, it was done the right way. So depending on your GI. I guess depending on your GI folks, I probably would do colonoscopy with the intent to do a laparoscopy if the colonoscopy is negative, but at the same setting, same anesthetic, if, if you could, I'm not, I, I would like to do it. I would like that's OK. So you have them suction out as you go. OK. All right, I like the idea. I just don't you not have GI fellows where they're playing around for an hour or two and filling the abdomen with air. He can answer that question. All right. Does anyone do something different? I start a PPI. Why? Because if it's a Meckel's, it will stop bleeding and then bleed again. Well, but I'm, I'm not saying that's the end of the therapy. Oh, but that's what I would do next. I would just say do PPIs work that far down. Yes, it will stop the bleeding. It should never be an emergency operation. Wow, I did not know that. I didn't know it stopped it. OK, now I know. Another thing I've learned today. Change my practice. 4:42. 1 hour and 2 minutes over. Every hour I'll learn something new. OK, we'll just keep going. Keep going with it. So you do laparoscopy. You encounter this, you. Determine that's the source of the bleeding. What would be your next step in the operation? Find the Meckel. How do you take it out? Laparoscopically. What do you do? I didn't see the base. If I could staple across the base, if it's a bleeding meckles and you have an ulcer on the bottom, I may do a small bowel resection. But if it's if it's bleeding, if it's bleeding meckles, I'll do a small bowel resection. Small bowel resection. I was so hoping you stop the bleeding with the PPI and you take out the meckles with the, then you don't do a bowel resection, OK. Go ahead, staple across it if it's, if it's the right, yeah, yeah, yeah, it looks beautiful. Depends on small base, yeah, you staple staple staple. Bill Gazetta taught me at the fellows course this year. That the ulcers are in the meckles. I always thought it was in the small bowel. It doesn't matter if you take out the mecky. It doesn't matter where they are because you're going to fix the ulcer anyway. What people say, unless you use Mac's PPI thing, is that you staple it off. You've taken away the source, but that bleeding ulcer is still there. So for the next day they're going to be bleeding still. Yeah, but you've taken away the source of the acid that's causing the ulcer, so you're bleeding. It's like doing a vagotomy for a gastric ulcer, right? But you take care of the ulcer or duodenal ulcer. Have, OK, have you proven you got is, I don't think you need to do a bowel cells out. I don't, and it's been a while since you did a vagotomy. Yeah, how do you know you got a do them all the time when I take out the esophagus because it's almost always always at the tip of the nuckles. OK. Next, who does it laparoscopically versus pulling the mechles out of the um So do I. What do you do? I haven't actually had to do one yet, believe it or not. Oh, I don't know. I just do it like an appy, probably. Yeah, it's exactly singley my way or an appy your way. My way, of course. You have two choices. Both are single site, either inside single site or outside single site. Let me tell you why I would push for open, and I have good pictures, but I can't show them on the air here technologically. I think that when you do it laparoscopically and you're pulling it up to staple, there's a tendency to, to go a little bit onto the bowel. So what I do is I pull it out through the umbilicus and I let it relax. I'm not pulling on it and I draw with a marker. So I see where the edge of the bowel is without pulling on it, because once you pull it distorts everything. But if it's a linear staple line, who cares because the bowel's going to dilate out anyway. So you're not worried about impinging it a little bit, not unless you made a huge stricture there. Can't rethink. We could you should teach you how to do a laparoscopic appendectomy. I know. I don't know, yeah, OK. What's next? Wow, we are finished an hour and a half over, but we have finished. So, uh, for the people who have survived and are still here, uh, this has been great. I thank you guys very much. This has been a, a.