A 19-year-old woman was referred to our hospital because of
recurrent obscure gastrointestinal bleeding. Abdominal computed tomography
revealed one heterogeneous lesion with soft tissue and accumulation of fluid
over the distal ileum ([Fig. 1]).
Fig. 1 Abdominal computed
tomography revealed one heterogeneous lesion with soft tissue and accumulation
of fluid over the distal ileum (arrow).
Physical examinations showed mild tenderness in the right lower
quadrant region of abdomen, and laboratory data revealed microcytic anemia.
Single-balloon enteroscopy with an anal approach showed one ulcerated
pedunculated polyp (about 2 cm in size) with a long stalk located at
around the distal ileum ([Fig. 2 a, b]; [Video
1]).
Fig. 2 a, b Enteroscopy showed
one ulcerated polyp with a long stalk located at around the distal ileum. The
arrow indicates the long stalk of the polyp. c The
specimen of resected polyp.
Video
1 Single-balloon enteroscopy
with an anal approach revealed one elongated pedunculated polyp with ulceration
over the distal ileum.
Polypectomy was performed during enteroscopy ([Fig. 2 c]). One diverticular-like orifice
occurred after polypectomy, and one small hole on the tip of this diverticulum
was visualized. The woman received emergent laparotomy because of iatrogenic
gut perforation. The operation disclosed one diverticulum with iatrogenic
perforation about 60 cm from the ileocecal valve ([Fig. 3 a]).
Fig. 3 a Operation findings
disclosed one diverticulum with perforation about 60 cm from the
ileocecal valve. b Pathologic examinations showed
ectopic pancreatic tissue within the resected polyp. The arrow indicates the
islets of Langerhans. c Pathologic examinations revealed
ectopic gastric tissue within the resected polyp. The arrow indicates the
gastric glands with parietal cells.
Segmental resection of the ileum was performed. The pathologic
examination of specimens from laparotomy and polypectomy confirmed the
diagnosis of Meckel’s diverticulum with ectopic pancreatic tissue ([Fig. 3 b]) and gastric tissue ([Fig. 3 c]) with ulceration.
Meckel’s diverticulum is the most common congenital anomaly of
the gastrointestinal tract
(1 % – 3 % of the population);
it is generally asymptomatic. Bleeding is the most common complication,
especially in children. However, accurate diagnosis remains difficult. In
addition to conventional Technetium-99 m pertechnetate scintigraphy,
capsule or balloon-assisted enteroscopy is another diagnostic tool to directly
observe the diverticulum [1]
[2]
[3]. Inverted Meckel’s diverticulum is extremely rare,
especially that containing both pancreatic and gastric tissues
[4]
[5]. In the present case, the
inverted Meckel’s diverticulum with ectopic tissues was clearly viewed by
single-balloon enteroscopy, but this lesion mimicked an ulcerated pedunculated
polyp. Polypectomy caused subsequent gut perforation. Therefore, inverted
Meckel’s diverticulum should be considered and treated carefully in a
patient with an elongated pedunculated polyp in the distal ileum.
Endoscopy_UCTN_Code_CPL_1AI_2AD
