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CASE 3. Meckel’s Diverticulum. General Data. I.S. 6 mos old Female Filipino Roman Catholic Pandacan, Manila. CHIEF COMPLAINT:. Bloody stools. History of Present Illness. 4days PTC fever (T38.8C), Paracetamol drops no fever, cough, colds, vomiting good appetite and activity

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case 3

CASE 3

Meckel’s Diverticulum

general data
General Data
  • I.S.
  • 6 mos old
  • Female
  • Filipino
  • Roman Catholic
  • Pandacan, Manila
chief complaint

CHIEF COMPLAINT:

Bloody stools

history of present illness
History of Present Illness
  • 4days PTC fever (T38.8C),Paracetamol drops

no fever, cough, colds, vomiting

good appetite and activity

no consult

  • 2 days PTC persistence prompted consult with AMD, Dx: acute viral illness
  • 1 day PTC lysis of fever

2 episode of dark stools, irrritable, decrease in appetite

ER : SFA ileus; no recurrence of stools

Dx : AVI, resolving; t/c Milk Allergy

history of present illness1
History of Present Illness
  • Few hrs PTC 2 episode of voluminous maroon colored stools

Admitted

slide6

Review of System

  • General: (-) weight loss, anorexia, easy fatigability
  • HEENT: no trauma, no ear infection,
  • Neck: (-) limitation of motion, mass, adenopathy
  • Respiratory: (-) shortness of breath, easy fatigability, wheezing
  • Cardiology: (-) palpitation or cyanosis
  • Musculoskeletal: (-) swelling, deformities
past medical history
Past Medical History
  • No bronchial asthma
  • no Primary Tuberculosis infection
  • no known allergies
  • This is the patient’s first admission
family history
Family History
  • (+) Diabetes: maternal grandparents
  • (+) Hypothyroid : mother
  • No history of cancer
slide9

Birth and Nutritional History

  • Born to a 34 year old G3P2, non-smoker, non-alcoholic beverage drinker, with regular prenatal check up
  • Denied illness during pregnancy
  • Born Full term via Repeat Ceasarian section at Cardinal Santos Medical Center
  • No fetomaternal complications
  • No history of Breastfeeding
  • Enfapro 6oz/bottle x 12 bottles/day
  • Complimentary feeding (Cerelac): 6 mos old
developmental history
Developmental History
  • Presently, sits with support
upon arrival er
Upon arrival ER
  • S>(+) maroon colored stool
  • O>pale looking, irritable

HR 106 RR28

clear breath sounds

soft abdomen, non tender

good pulses

  • A>Lower GI bleed t/c Meckel’s Diverticulum
  • P>lab work up

PRBC 10cc/kg

post transfusion Hgb 10.6

laboratory examination
Laboratory Examination
  • CBC 7.7/23.4/9090/N16 L79 M5/170,000
  • Retic count 0.35
  • Stool Exam RBC 30-40
  • Fecal occult Blood Positive
  • PT 10.4 INR 0.83 181% PTT 41.8
  • Urinalysis <1.005 ph7.5
  • PBS: microcytic hypochromic
  • Na 139 K 4.6 Cl 102 Ca 9.3
laboratory exam
Laboratory Exam
  • SFA non specific, non obstructive gas pattern
  • Meckel's Diverticulum Scintigraphy which showed radioactive activity on the right lower quadrant which may represent ectopic gastric mucosa.
upon arrival at picu
Upon arrival at PICU
  • s/p Explore Laparotomy, Resection of Meckel’s diverticulum with end to end anastomosis
  • OR findings: 1.5cm Meckel’s Diverticulum approx 25cm from appendix
  • Estimated Blood Loss <20cc
  • s/p 160 PRBC (20cc/kg)
  • P> NPO
  • D5NR x 40cc/hr
  • Cefazolin 250mg/IV (125mkd)
  • Ranitidine 10mg/IV q8
  • Nubain 2mg q6
  • Ketorolac 10mg q6
second picu day
Second PICU Day
  • S> no bleeding
  • O>BP 90/60, afebrile
  • Stable VS
  • CBC 13.7/39/11680/N50 L40 M8 B1/268K
  • P> transfer to regular room
meckel s diverticulum1
Meckel’s Diverticulum
  • remnant of the embryonic yolk sac
  • Embyonal stage: omphalomesenteric duct connects the yolk sac to the gut, nutrition
  • 5th and 7th wk AOG: duct separates from the intestine
  • Yolk sac + lining epith similar to stomach
  • Partial or complete failure of involution of the omphalomesenteric duct results in various residual structures.
frequency
Frequency
  • Occurs in 2–3% of all infants
  • a 3–6 cm outpouching of the ileum along the antimesenteric border 50–75 cm from the ileocecal valve
  • 1st 2 years of life, 2.5yo
manifestations
Manifestations
  • Intermittent painless rectal bleeding
  • Stool: brick colored or currant jelly colored.
  • Bleeding: self-limited, contraction of the splanchnic vessels
  • r/o acute appendicitis
  • Diverticulitis can lead to perforation and peritonitis
diagnosis
Diagnosis
  • Meckel radionuclide scan: IV infusion of technetium-99m pertechnetate: mucus secreting ectopic gastric mucosa : visualization of the Meckel diverticulum
  • sensitivity enhanced scan : 85%
  • specificity : 95%.
  • Other methods of detection: abdominal ultrasound, superior mesenteric angiography, abdominal CT scan, and exploratory laparoscopy.