Double-Balloon Enteroscopy for the Diagnosis of Meckel's Diverticulum in a 50-Year-Old Man With Obscure Gastrointestinal Bleeding

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A 50-year-old man presented to an outside facility with a 5-day history of intermittent hematochezia. This was associated with symptoms of fatigue, dyspnea on exertion, and headache. Blood work revealed hemoglobin of 7.9 gm/dL, and he was transfused 4 units of packed red blood cells. Esophagogastroduodenoscopy and colonoscopy were nonrevealing, and the patient was transferred to our facility for further care. Repeat esophagogastroduodenoscopy and colonoscopy with intubation of the terminal ileum were nondiagnostic and without evidence of bleeding. Patient had recurrent hematochezia, and a red blood cell scan demonstrated a focal area of mild increased activity to the left of the midline just above the level of the aortic bifurcation. Subsequent mesenteric angiogram and capsule endoscopy (CE) were nondiagnostic. A retrograde double-balloon enteroscopy (DBE) was performed and showed a Meckel's diverticulum (MD) at 100 cm proximal to the ileocecal valve (Figure A, arrow). The patient subsequently underwent a laparoscopy with removal of an MD at approximately 60 cm proximal to the valve (Figure B). Pathology revealed a 2.3 × 1.5 cm MD (Figure C) with a focus of gastric mucosa without ulceration. The postoperative course was uneventful, and patient was discharged home 2 days later in good condition. He continues to do well without any evidence of recurrent gastrointestinal bleeding (GIB) 1 year after surgery.

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MD is the most common congenital anomaly of the GI tract and occurs in 2%–4% of the population.¹ Although GIB is its most common complication in the pediatric population, this occurs rarely in adults and more scarcely in older adults.¹ Preoperative diagnosis of obscure GIB (OGIB) caused by MD in older adults is a clinical challenge for a number of reasons. First, it is infrequent and, thus, often not considered in the differential diagnosis. Second, the yield of the technetium pertechnetate scan in patients older than 40 years of age is reduced, with reported sensitivity and positive predictive values of 62.5% and 60.0%, respectively.²

CE and DBE have advanced our ability to diagnose and/or treat patients presenting with OGIB. Manner et al³ reported their experience with the use of DBE to diagnose MD in 3 patients (aged 22, 32, and 34 years, respectively) with OGIB, 2 of whom had an unrevealing technetium pertechnetate scan. It was suggested by these authors that DBE might be the diagnostic modality of choice in young adults with OGIB and suspected diagnosis of MD.

Only 7 subjects with MD who were at least 50 years of age and who presented with GIB have been described in the literature. Five were diagnosed during laparotomy for OGIB, and 2 were diagnosed preoperatively with CE. CE might have a low accuracy for MD because of the orientation of the diverticulum (opening tangential to the main lumen) and absence of ulcerations at the time of the study. DBE was able to diagnose the MD, and the patient was referred promptly for laparoscopy.

Clinicians should be cognizant that MD might be the source of OGIB even in older adults. A high index of suspicion is warranted to avoid extensive explorations. DBE might be the modality of choice to diagnose and localize MD in these patients.

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References 

1. Sagar J, Kumar V, Shah DK. Meckel's diverticulum: a systematic review. J R Soc Med. 2006;99:501–505
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2. Schwartz MJ, Lewis JH. Meckel's diverticulum: pitfalls in scintigraphic detection in the adult. Am J Gastroenterol. 1984;79:611–618
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3. Manner H, May A, Nachbar L, et al. Push-and-pull enteroscopy using the double-balloon technique (double-balloon enteroscopy) for the diagnosis of Meckel's diverticulum in adult patients with GI bleeding of obscure origin. Am J Gastroenterol. 2006;101:1152–1154
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