Meckel's diverticulum medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Overview

Initially, the medical management of a symptomatic case of Meckel's diverticulum is directed toward management of clinical manifestations of complications. Intravenous lines for fluid and electrolyte therapy, nasogastric decompression for patients with symptoms and signs of intestinal obstruction, proton-pump inhibitors and Aluminum hydroxide for patients with gastrointestinal bleeding are preferred. The process of initial resuscitation in patients with lower gastrointestinal bleeding due to Meckel's diverticulum) is similar to the steps followed in any case of lower GI bleeding.

Medical Therapy

Initial Resuscitation in patients with lower gastrointestinal bleed due to Meckel's diverticula

The process of initial resuscitation in patients with lower gastrointestinal bleeding due to any pathology (including Meckel's diverticulum) is similar and includes the steps enlisted below.

Initial Evaluation

Role of Nasogastric tube (NGT)

Workup and Initial Management
Initial Evaluation
  • Airway, Breathing, Circulation
Supportive Therapy
  • Ensure patent and protected airway
  • 2 large-bore, peripheral intravenous lines
Blood transfusion

Assessment of severity of bleeding

Bleeding severity Vital signs Blood loss
Minor Normal <10%
Moderate Postural hypotension 10-20%
Severe Shock >25%

Fluid resuscitation

Blood transfusion

Indications for transfusion
Age Target Hematocrit
Elderly patient ( >45) 30%
Younger patient (<45) 25%
Patients with portal hypertension 28%

Triage and consultations

Evaluation setting Patient catagories
ICU Patients with high-risk features
Outpatient Patients with low-risk features
Regular Ward Most other patients can be admitted to a regular medical ward
  • : Low-risk features include a young, otherwise healthy patient with minor, self-limited rectal bleeding suspected to be from an anal source)
  • ♦: Requires continuous electrocardiogram monitoring and pulse oximetry.

Risk stratification

High-risk features

Medical Therapy

Pharmacotherapy is only used as an adjuvant therapy for patients with lower GI bleed due to Meckel's diverticulum. Epinephrine is used alone or in conjunction with other surgical techniques. Local injection of epinephrine stops bleeding by both pressure tamponade and the vasoconstrictor effect. In patients with re-bleeding, surgery should be considered.[21][16][17][18]

Dosage

Major contraindications

Complications

During vasopressin infusion, patients must be monitored for:

References

  1. Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, Mew D (2006). "Complications of Meckel's diverticula in adults". Can J Surg. 49 (5): 353–7. PMC 3207587. PMID 17152574.
  2. Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ (1994). "Surgical management of Meckel's diverticulum. An epidemiologic, population-based study". Ann. Surg. 220 (4): 564–8, discussion 568–9. PMC 1234434. PMID 7944666.
  3. Hong J, Park SB (2017). "A case of retroperitoneal abscess: A rare complication of Meckel's diverticulum". Int J Surg Case Rep. 41: 150–153. doi:10.1016/j.ijscr.2017.10.012. PMID 29078157.
  4. Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A (2017). "Meckel's diverticulum in the adult". J Visc Surg. 154 (4): 253–259. doi:10.1016/j.jviscsurg.2017.06.006. PMID 28698005.
  5. Cotter TG, Buckley NS, Loftus CG (2017). "Approach to the Patient With Hematochezia". Mayo Clin. Proc. 92 (5): 797–804. doi:10.1016/j.mayocp.2016.12.021. PMID 28473039.
  6. Rosat A, Pérez E, Oaknin HH, Mendiz J, Hernández G, Barrera M (2016). "Spontaneous hemoperitoneum caused by meckel's diverticulum in an elder patient". Pan Afr Med J. 24: 314. doi:10.11604/pamj.2016.24.314.10384. PMC 5267917. PMID 28154669.
  7. Rattan KN, Singh J, Dalal P, Rattan A (2016). "Meckel's diverticulum in children: Our 12-year experience". Afr J Paediatr Surg. 13 (4): 170–174. doi:10.4103/0189-6725.194671. PMC 5154221. PMID 28051045.
  8. Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC (2017). "The many faces of Meckel's diverticulum and its complications". J Med Imaging Radiat Oncol. 61 (2): 225–231. doi:10.1111/1754-9485.12505. PMID 27492813.
  9. Chabowski M, Szymanska-Chabowska A, Dorobisz T, Janczak D, Jelen M, Janczak D (2016). "A massive bleeding from a gastrointestinal stromal tumor of a Meckel's diverticulum". Srp Arh Celok Lek. 144 (3–4): 219–21. PMID 27483571.
  10. Srisajjakul S, Prapaisilp P, Bangchokdee S (2016). "Many faces of Meckel's diverticulum and its complications". Jpn J Radiol. 34 (5): 313–20. doi:10.1007/s11604-016-0530-x. PMID 26932405.
  11. Alfa-Wali M, Wardle S, Nizar S, Bloom IT (2016). "Atypical presentation of a Meckel's diverticulum". BMJ Case Rep. 2016. doi:10.1136/bcr-2016-214464. PMID 26884080.
  12. 12.0 12.1 Strate LL, Gralnek IM (2016). "ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding". Am. J. Gastroenterol. 111 (4): 459–74. doi:10.1038/ajg.2016.41. PMC 5099081. PMID 26925883.
  13. Barnert J, Messmann H (2009). "Diagnosis and management of lower gastrointestinal bleeding". Nat Rev Gastroenterol Hepatol. 6 (11): 637–46. doi:10.1038/nrgastro.2009.167. PMID 19881516.
  14. Barnert J, Messmann H (2008). "Management of lower gastrointestinal tract bleeding". Best Pract Res Clin Gastroenterol. 22 (2): 295–312. doi:10.1016/j.bpg.2007.10.024. PMID 18346685.
  15. Raphaeli T, Menon R (2012). "Current treatment of lower gastrointestinal hemorrhage". Clin Colon Rectal Surg. 25 (4): 219–27. doi:10.1055/s-0032-1329393. PMC 3577609. PMID 24294124.
  16. 16.0 16.1 Ghassemi KA, Jensen DM (2013). "Lower GI bleeding: epidemiology and management". Curr Gastroenterol Rep. 15 (7): 333. doi:10.1007/s11894-013-0333-5. PMC 3857214. PMID 23737154.
  17. 17.0 17.1 Beck DE, Margolin DA, Whitlow CB, Hammond KL (2007). "Evaluation and management of gastrointestinal bleeding". Ochsner J. 7 (3): 107–13. PMC 3096402. PMID 21603524.
  18. 18.0 18.1 Triadafilopoulos G (2012). "Management of lower gastrointestinal bleeding in older adults". Drugs Aging. 29 (9): 707–15. doi:10.1007/s40266-012-0008-1. PMID 23018607.
  19. Al-Jaghbeer M, Yende S (2013). "Blood transfusion for upper gastrointestinal bleeding: is less more again?". Crit Care. 17 (5): 325. doi:10.1186/cc13020. PMC 4056793. PMID 24063362.
  20. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C (2013). "Transfusion strategies for acute upper gastrointestinal bleeding". N. Engl. J. Med. 368 (1): 11–21. doi:10.1056/NEJMoa1211801. PMID 23281973.
  21. Liou TC, Lin SC, Wang HY, Chang WH (2006). "Optimal injection volume of epinephrine for endoscopic treatment of peptic ulcer bleeding". World J. Gastroenterol. 12 (19): 3108–13. PMC 4124392. PMID 16718798.

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