Clin J Gastroenterol (2012) 5:298–301 DOI 10.1007/s12328-012-0313-6
CASE REPORT
Perforation of Meckel’s diverticulum with enteroliths Takeshi Nishikawa • Yoshiki Takei Nelson H. Tsuno • Mamoru Maeda
•
Received: 23 December 2011 / Accepted: 14 May 2012 / Published online: 9 June 2012 Ó Springer 2012
Abstract Perforation of Meckel’s diverticulum with enteroliths is a rare complication. Here, we report a case of perforation of Meckel’s diverticulum with enteroliths, which could be accurately diagnosed by the preoperative computed tomography (CT). A 46-year-old man with acute onset of severe abdominal pain, and a localized muscle guarding in the right hypochondrium, had a solitary stone detected in the right abdomen by the radiography. The abdominal CT revealed a saclike outpouching of the small intestine, containing air/fluid levels and an enterolith, with surrounding free air and mesenteric inflammatory change in the right paraumbilical area. He was diagnosed as the perforation of Meckel’s diverticulum with enterolith, and the emergency operation was indicated. The perforated Meckel’s diverticulum was identified approximately 90 cm proximal to the ileocecal valve. The diverticulum was transected at the base, and removed. The patient’s postoperative course was uneventful. This case strongly suggested the ability of CT enterography to accurately diagnose pathologies involving the small intestine, such as the perforation of Meckel’s diverticulum, which open premises for its use in the diagnosis of acute abdomen preoperatively. Keywords Meckel’s diverticulum Perforation Enterolith Computed tomography (CT) enterography
T. Nishikawa (&) Y. Takei M. Maeda Department of Surgery, The Fraternity Memorial Hospital, 2-1-11 Yokoami, Sumida-ku, Tokyo 130-8587, Japan e-mail: [email protected] T. Nishikawa N. H. Tsuno Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
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Introduction Meckel’s diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract, occurring in approximately 2 % of the general population. When present, there is an estimated 4–16 % lifetime risk of becoming symptomatic, including hemorrhage, intussusceptions, inflammation and, occasionally, perforation [1, 2]. Formation of enteroliths in the diverticulum is an uncommon condition. Here, we present a rare case of perforation of the Meckel’s diverticulum with enteroliths. Computed tomography (CT) revealed a saclike outpouching of the small intestine, which contained the enteroliths, with surrounding free air and inflammatory change of the mesentery. Taking these findings, we could correctly diagnose the condition prior to surgical treatment.
Case report A 46-year-old man with no prior abdominal surgery presented to our department with acute onset of severe abdominal pain. Physical examination of the patient revealed abdominal tenderness and a localized muscle guarding in the right hypochondrium. The vital signs were stable, with a blood pressure (BP) of 106/75, and a heart rate (HR) of 90/min, but the body temperature was 38.3 °C. The blood test revealed a raised white blood cell count of 1.36 9 104/ll, and a high C-reactive protein level at 2.56 mg/dl. The patient had normal renal function and a normal hemoglobin level. The abdominal radiography showed a solitary stone with peripheral calcification and a lucent center, in the right abdomen (Fig. 1). Abdominal CT confirmed the presence of an enterolith at the saclike outpouching of the small
Clin J Gastroenterol (2012) 5:298–301
299
Fig. 1 A solitary stone with peripheral calcification and a lucent center was identified on the abdominal radiography (arrowhead)
intestine, containing air/fluid levels, with surrounding free air and mesenteric inflammatory change in the right paraumbilical area (Fig. 2a, b). Taking the results of the physical, laboratory and radiographic examinations, the patients was diagnosed as the perforation of Meckel’s diverticulum with an enterolith, and an emergency operation was indicated. Laparotomy was performed through a middle median incision, and the perforated Meckel’s diverticulum, containing the enterolith, was identified approximately 90 cm proximal to the ileocecal valve (Fig. 3). The diverticulum was easily dissected from the mesentery and transected at its base. The patient’s postoperative course was uneventful. The macroscopic findings of the surgical specimen confirmed a narrow-necked diverticulum lined by noninflamed small bowel mucosa containing two enteroliths (Fig. 4a). A gross loupe view showed the micro-perforation at the site of the inflammation (Fig. 4b). Microscopic examination revealed severe mucosal inflammation and hemorrhage with surrounding ectopic gastric mucosa (Fig. 4c) and around the perforation (Fig. 4d).
Fig. 2 a Enhanced axial CT (2 mm interval) demonstrated an enterolith (arrow) in the diverticulum which contained air/fluid levels, with surrounding free air and mesenteric inflammatory change (arrowhead). b Multiplanar reconstructed (MPR) CT demonstrated the presence of an enterolith at the saclike outpouching of the small intestine (arrowhead). The white arrow shows the oral side of the small intestine, and the black arrow, the anal side
Discussion Meckel’s diverticulum, a remnant of the vitelline duct which normally disappears by the seventh to eighth week of gestation, is the most common malformation of the gastrointestinal tract, occurring in 2 % of the population, typically within 2 feet of the ileocecal valve on the antimesenteric side and is 2 inches long [3]. Meckel’s diverticulum was first described by Johannes Meckel in 1809 [4]. Despite the fact
Fig. 3 Surgical appearance of the Meckel’s diverticulum (arrow), approximately 90 cm proximal to the ileocecal valve
that this condition is relatively common, only about 4–16 % of cases will develop complications, which include hemorrhage, intussusceptions, inflammation and, occasionally,
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Fig. 4 a Macroscopic findings of the surgical specimen showed narrow-necked diverticulum containing two enteroliths. b A gross loupe view of the resected specimen from the line in a. It revealed an inflammatory change of mucosa and the perforation at the site of the inflammation (arrow). c Microscopic findings of mucosal
inflammation and hemorrhage (arrow) with surrounding gastric ectopic mucosa (arrowhead) (H&E 940). d Microscopic findings revealed the infiltration of inflammatory cells and hemorrhage at the site of the perforation in b
perforation, which was the case in the present patient [1, 2]. Complications are much more common in males, and the incidence of complications decreases with age, with the majority occurring in the pediatric population. The most common presentation in children is bleeding, whereas inflammation and obstruction predominate in adults [5]. Only a few cases of perforation in adults with enterolith formation at the site of the diverticulum have been reported in the literature [6, 7]. The incidence of enteroliths was found to be about 0.3–10 % of all cases of Meckel’s diverticulum [8, 9]. One possible explanation of this rarity is that most Meckel’s diverticula have wide necks and contain smooth muscle capable of peristalsis [10]. Therefore, stagnation and stasis of the intestinal contents is unlikely. The pathogenesis of stone formation in Meckel’s diverticulum is unclear. It may be related to stasis resulting from poor coordination of the peristaltic wave at the site of the Meckel’s diverticulum [9, 11]. Also, superimposed inflammation and edema of the neck of the diverticulum could narrow the opening and decrease drainage, leading to precipitation and nidus formation of the enterolith. Approximately one-third of enteroliths are radiopaque and
therefore demonstrable radiographically, like in our present case [12]. Preoperatively, we diagnosed the presence of only one enterolith, which was possibly dependent on the fact that the 2 enteroliths were very closely located in the narrow lumen of the diverticulum. Diverticulitis occurs in 30 % of symptomatic Meckel’s diverticulum, and secondary perforation in 15 % [13, 14]. In one study, only one patient [1.4 % (0.02 % of population)] had diverticulitis secondary to an enterolith [14]. Three major pathologic mechanisms are considered to be responsible for the perforation of Meckel’s diverticulum: (1) Elevated pressure of the diverticulum due to stasis of the intestinal contents resulting from poor coordination of the peristaltic wave at the site of the Meckel’s diverticulum, (2) mechanical stimuli against the intestinal wall due to enteroliths, and (3) ulceration that occurs secondary to acid secretion from ectopic gastric mucosa [7]. The pathogenic role of Helicobacter pylori in the development of gastritis in the ectopic gastric mucosa is still debatable [15, 16]. Due to the rarity of cases in adults, it is still misdiagnosed or not diagnosed preoperatively. In a study of 776 patients, Kusumoto et al. [17] found that an accurate
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preoperative diagnosis could be made only in 11 % of patients presenting with symptoms other than bleeding, compared to 88 % in bleeding patients. Previously, CT scan was rarely used as primary imaging modality in patients with suspect of Meckel’s diverticulum, because significant experience has not yet been gained with CT scan for the confident diagnosis of pathologies of the small bowel [18, 19]. A recent innovation of CT enterography has resulted in better visualization of small bowel and consequent higher sensitivity in the diagnosis of Meckel’s diverticulum [20]. Meckel’s diverticulum is demonstrated as a blind-ending fluid- or gasfilled structure in continuity with small bowel. Also in this case, CT revealed the perforation of Meckel’s diverticulum as the saclike outpouching of the small intestine, containing the enteroliths, with surrounding free air and mesenteric inflammatory change. So we could correctly diagnose the condition preoperatively. In conclusion, we experienced a rare case of perforation of Meckel’s diverticulum with the enteroliths, which could accurately be diagnosed by the CT enterography. This case strongly suggested that the recent innovation of CT is a promising tool for the accurate diagnosis of the perforated Meckel’s diverticulum, which present as a blind-ending fluid- or gas-filled structure in continuity with small bowel, prior to indication of surgical treatment. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Sager J, Kumar V, Shah DK. Meckel’s diverticulum: a systemic review. J R Soc Med. 2006;99:501–5. 2. Kloss BT, Broton CE, Sullivan AM. Perforated Meckel diverticulum. Int J Emerg Med. 2010;3:455–7. 3. Higginson AP, Hall RI. Meckel’s diverticulitis due to an obstructing enterolith: ultrasound and CT appearances. Clin Radiol. 2001;56:593–5.
301 4. Arnold JF, Pellicane JV. Meckel’s diverticulum: a ten-year experience. Am Surg. 1997;63:354–5. 5. Yagci G, Cetiner S, Tufan T. Perforation of Meckel’s diverticulum by a chicken bone, a rare complication: report of a case. Surg Today. 2004;34:606–8. 6. Loh D. Perforated Meckel’s diverticulum caused by faecolith. ANZ J Surg. 2008;78:518–9. 7. Oya S, Miyata K, Yuasa N, Takeuchi E, Goto Y, Miyake H, et al. A case of perforated Meckel’s diverticulum with true enterolith. Jpn J Gastroenterol Surg. 2009;42:561–565 (in Japanese with English abstract). 8. Lai HC. Intestinal obstruction due to Meckel’s Enterolith. Pediatr Neonatol. 2010;51:139–40. 9. Pantongrag-Brown L, Levine MS, Buetow PC, Buck JL, Elsayed AM. Meckel’s enteroliths: clinical, radiologic, and pathologic findings. Am J Roentgenol. 1996;167:1447–50. 10. Sharma G, Benson CK. Enteroliths in Meckel’s diverticulum: report of a case and review of the literature. Can J Surg. 1970; 13:54–8. 11. Barr H. Calculi in Meckel’s diverticulum. Br J Surg. 1984;71: 478–9. 12. Athey GN. Unusual demonstration of a Meckel’s diverticulum containing enterolith. Br J Radiol. 1980;53:365–8. 13. Fa-Si-Oen PR, Roumen RM, Croiset van Uchelen FA. Complications and management of Meckel’s diverticulum: a review. Eur J Surg. 1999;165:674–8. 14. Mackey WC, Dineen P. A fifty year experience with Meckel’s diverticulum. Surg Gynecol Obstet. 1983;156:56–64. 15. Fich A, Talley NJ, Shorter RG, Phillips SF. Does Helicobacter pylori colonize the gastric mucosa of Meckel’s diverticulum? Mayo Clin Proc. 1990;65:187–91. 16. Hill P, Rode J. Helicobacter pylori in ectopic gastric mucosa in Meckel’s diverticulum. Pathology. 1998;30:7–9. 17. Kusumoto H, Yoshida M, Takahashi I, Anai H, Maehara Y, Sugimachi K. Complications and diagnosis of Meckel’s diverticulum in 776 patients. Am J Surg. 1992;164:382–3. 18. Malik AA, Shams-ul-Bari, Wani KA, Khaja AR. Meckel’s divertculum-revisited. Saudi J Gastroenterol. 2010;16:3–7. 19. Rossi P, Gourtsoyiannis N, Bezzi M, Raptopoulos V, Massa R, Capanna G, Pedicini V, Coe M. Meckel’s diverticulum: imaging diagnosis. AJR. 1996;166:567–73. 20. Elsayes KM, Menias CO, Harvin HJ, Francis IR. Imaging manifestations of Meckel’s diverticulum. AJR. 2007;189:81–8.
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CASE REPORT
Perforation of Meckel’s diverticulum with enteroliths Takeshi Nishikawa • Yoshiki Takei Nelson H. Tsuno • Mamoru Maeda
•
Received: 23 December 2011 / Accepted: 14 May 2012 / Published online: 9 June 2012 Ó Springer 2012
Abstract Perforation of Meckel’s diverticulum with enteroliths is a rare complication. Here, we report a case of perforation of Meckel’s diverticulum with enteroliths, which could be accurately diagnosed by the preoperative computed tomography (CT). A 46-year-old man with acute onset of severe abdominal pain, and a localized muscle guarding in the right hypochondrium, had a solitary stone detected in the right abdomen by the radiography. The abdominal CT revealed a saclike outpouching of the small intestine, containing air/fluid levels and an enterolith, with surrounding free air and mesenteric inflammatory change in the right paraumbilical area. He was diagnosed as the perforation of Meckel’s diverticulum with enterolith, and the emergency operation was indicated. The perforated Meckel’s diverticulum was identified approximately 90 cm proximal to the ileocecal valve. The diverticulum was transected at the base, and removed. The patient’s postoperative course was uneventful. This case strongly suggested the ability of CT enterography to accurately diagnose pathologies involving the small intestine, such as the perforation of Meckel’s diverticulum, which open premises for its use in the diagnosis of acute abdomen preoperatively. Keywords Meckel’s diverticulum Perforation Enterolith Computed tomography (CT) enterography
T. Nishikawa (&) Y. Takei M. Maeda Department of Surgery, The Fraternity Memorial Hospital, 2-1-11 Yokoami, Sumida-ku, Tokyo 130-8587, Japan e-mail: [email protected] T. Nishikawa N. H. Tsuno Department of Surgical Oncology, The University of Tokyo, Tokyo, Japan
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Introduction Meckel’s diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract, occurring in approximately 2 % of the general population. When present, there is an estimated 4–16 % lifetime risk of becoming symptomatic, including hemorrhage, intussusceptions, inflammation and, occasionally, perforation [1, 2]. Formation of enteroliths in the diverticulum is an uncommon condition. Here, we present a rare case of perforation of the Meckel’s diverticulum with enteroliths. Computed tomography (CT) revealed a saclike outpouching of the small intestine, which contained the enteroliths, with surrounding free air and inflammatory change of the mesentery. Taking these findings, we could correctly diagnose the condition prior to surgical treatment.
Case report A 46-year-old man with no prior abdominal surgery presented to our department with acute onset of severe abdominal pain. Physical examination of the patient revealed abdominal tenderness and a localized muscle guarding in the right hypochondrium. The vital signs were stable, with a blood pressure (BP) of 106/75, and a heart rate (HR) of 90/min, but the body temperature was 38.3 °C. The blood test revealed a raised white blood cell count of 1.36 9 104/ll, and a high C-reactive protein level at 2.56 mg/dl. The patient had normal renal function and a normal hemoglobin level. The abdominal radiography showed a solitary stone with peripheral calcification and a lucent center, in the right abdomen (Fig. 1). Abdominal CT confirmed the presence of an enterolith at the saclike outpouching of the small
Clin J Gastroenterol (2012) 5:298–301
299
Fig. 1 A solitary stone with peripheral calcification and a lucent center was identified on the abdominal radiography (arrowhead)
intestine, containing air/fluid levels, with surrounding free air and mesenteric inflammatory change in the right paraumbilical area (Fig. 2a, b). Taking the results of the physical, laboratory and radiographic examinations, the patients was diagnosed as the perforation of Meckel’s diverticulum with an enterolith, and an emergency operation was indicated. Laparotomy was performed through a middle median incision, and the perforated Meckel’s diverticulum, containing the enterolith, was identified approximately 90 cm proximal to the ileocecal valve (Fig. 3). The diverticulum was easily dissected from the mesentery and transected at its base. The patient’s postoperative course was uneventful. The macroscopic findings of the surgical specimen confirmed a narrow-necked diverticulum lined by noninflamed small bowel mucosa containing two enteroliths (Fig. 4a). A gross loupe view showed the micro-perforation at the site of the inflammation (Fig. 4b). Microscopic examination revealed severe mucosal inflammation and hemorrhage with surrounding ectopic gastric mucosa (Fig. 4c) and around the perforation (Fig. 4d).
Fig. 2 a Enhanced axial CT (2 mm interval) demonstrated an enterolith (arrow) in the diverticulum which contained air/fluid levels, with surrounding free air and mesenteric inflammatory change (arrowhead). b Multiplanar reconstructed (MPR) CT demonstrated the presence of an enterolith at the saclike outpouching of the small intestine (arrowhead). The white arrow shows the oral side of the small intestine, and the black arrow, the anal side
Discussion Meckel’s diverticulum, a remnant of the vitelline duct which normally disappears by the seventh to eighth week of gestation, is the most common malformation of the gastrointestinal tract, occurring in 2 % of the population, typically within 2 feet of the ileocecal valve on the antimesenteric side and is 2 inches long [3]. Meckel’s diverticulum was first described by Johannes Meckel in 1809 [4]. Despite the fact
Fig. 3 Surgical appearance of the Meckel’s diverticulum (arrow), approximately 90 cm proximal to the ileocecal valve
that this condition is relatively common, only about 4–16 % of cases will develop complications, which include hemorrhage, intussusceptions, inflammation and, occasionally,
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300
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Fig. 4 a Macroscopic findings of the surgical specimen showed narrow-necked diverticulum containing two enteroliths. b A gross loupe view of the resected specimen from the line in a. It revealed an inflammatory change of mucosa and the perforation at the site of the inflammation (arrow). c Microscopic findings of mucosal
inflammation and hemorrhage (arrow) with surrounding gastric ectopic mucosa (arrowhead) (H&E 940). d Microscopic findings revealed the infiltration of inflammatory cells and hemorrhage at the site of the perforation in b
perforation, which was the case in the present patient [1, 2]. Complications are much more common in males, and the incidence of complications decreases with age, with the majority occurring in the pediatric population. The most common presentation in children is bleeding, whereas inflammation and obstruction predominate in adults [5]. Only a few cases of perforation in adults with enterolith formation at the site of the diverticulum have been reported in the literature [6, 7]. The incidence of enteroliths was found to be about 0.3–10 % of all cases of Meckel’s diverticulum [8, 9]. One possible explanation of this rarity is that most Meckel’s diverticula have wide necks and contain smooth muscle capable of peristalsis [10]. Therefore, stagnation and stasis of the intestinal contents is unlikely. The pathogenesis of stone formation in Meckel’s diverticulum is unclear. It may be related to stasis resulting from poor coordination of the peristaltic wave at the site of the Meckel’s diverticulum [9, 11]. Also, superimposed inflammation and edema of the neck of the diverticulum could narrow the opening and decrease drainage, leading to precipitation and nidus formation of the enterolith. Approximately one-third of enteroliths are radiopaque and
therefore demonstrable radiographically, like in our present case [12]. Preoperatively, we diagnosed the presence of only one enterolith, which was possibly dependent on the fact that the 2 enteroliths were very closely located in the narrow lumen of the diverticulum. Diverticulitis occurs in 30 % of symptomatic Meckel’s diverticulum, and secondary perforation in 15 % [13, 14]. In one study, only one patient [1.4 % (0.02 % of population)] had diverticulitis secondary to an enterolith [14]. Three major pathologic mechanisms are considered to be responsible for the perforation of Meckel’s diverticulum: (1) Elevated pressure of the diverticulum due to stasis of the intestinal contents resulting from poor coordination of the peristaltic wave at the site of the Meckel’s diverticulum, (2) mechanical stimuli against the intestinal wall due to enteroliths, and (3) ulceration that occurs secondary to acid secretion from ectopic gastric mucosa [7]. The pathogenic role of Helicobacter pylori in the development of gastritis in the ectopic gastric mucosa is still debatable [15, 16]. Due to the rarity of cases in adults, it is still misdiagnosed or not diagnosed preoperatively. In a study of 776 patients, Kusumoto et al. [17] found that an accurate
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preoperative diagnosis could be made only in 11 % of patients presenting with symptoms other than bleeding, compared to 88 % in bleeding patients. Previously, CT scan was rarely used as primary imaging modality in patients with suspect of Meckel’s diverticulum, because significant experience has not yet been gained with CT scan for the confident diagnosis of pathologies of the small bowel [18, 19]. A recent innovation of CT enterography has resulted in better visualization of small bowel and consequent higher sensitivity in the diagnosis of Meckel’s diverticulum [20]. Meckel’s diverticulum is demonstrated as a blind-ending fluid- or gasfilled structure in continuity with small bowel. Also in this case, CT revealed the perforation of Meckel’s diverticulum as the saclike outpouching of the small intestine, containing the enteroliths, with surrounding free air and mesenteric inflammatory change. So we could correctly diagnose the condition preoperatively. In conclusion, we experienced a rare case of perforation of Meckel’s diverticulum with the enteroliths, which could accurately be diagnosed by the CT enterography. This case strongly suggested that the recent innovation of CT is a promising tool for the accurate diagnosis of the perforated Meckel’s diverticulum, which present as a blind-ending fluid- or gas-filled structure in continuity with small bowel, prior to indication of surgical treatment. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Sager J, Kumar V, Shah DK. Meckel’s diverticulum: a systemic review. J R Soc Med. 2006;99:501–5. 2. Kloss BT, Broton CE, Sullivan AM. Perforated Meckel diverticulum. Int J Emerg Med. 2010;3:455–7. 3. Higginson AP, Hall RI. Meckel’s diverticulitis due to an obstructing enterolith: ultrasound and CT appearances. Clin Radiol. 2001;56:593–5.
301 4. Arnold JF, Pellicane JV. Meckel’s diverticulum: a ten-year experience. Am Surg. 1997;63:354–5. 5. Yagci G, Cetiner S, Tufan T. Perforation of Meckel’s diverticulum by a chicken bone, a rare complication: report of a case. Surg Today. 2004;34:606–8. 6. Loh D. Perforated Meckel’s diverticulum caused by faecolith. ANZ J Surg. 2008;78:518–9. 7. Oya S, Miyata K, Yuasa N, Takeuchi E, Goto Y, Miyake H, et al. A case of perforated Meckel’s diverticulum with true enterolith. Jpn J Gastroenterol Surg. 2009;42:561–565 (in Japanese with English abstract). 8. Lai HC. Intestinal obstruction due to Meckel’s Enterolith. Pediatr Neonatol. 2010;51:139–40. 9. Pantongrag-Brown L, Levine MS, Buetow PC, Buck JL, Elsayed AM. Meckel’s enteroliths: clinical, radiologic, and pathologic findings. Am J Roentgenol. 1996;167:1447–50. 10. Sharma G, Benson CK. Enteroliths in Meckel’s diverticulum: report of a case and review of the literature. Can J Surg. 1970; 13:54–8. 11. Barr H. Calculi in Meckel’s diverticulum. Br J Surg. 1984;71: 478–9. 12. Athey GN. Unusual demonstration of a Meckel’s diverticulum containing enterolith. Br J Radiol. 1980;53:365–8. 13. Fa-Si-Oen PR, Roumen RM, Croiset van Uchelen FA. Complications and management of Meckel’s diverticulum: a review. Eur J Surg. 1999;165:674–8. 14. Mackey WC, Dineen P. A fifty year experience with Meckel’s diverticulum. Surg Gynecol Obstet. 1983;156:56–64. 15. Fich A, Talley NJ, Shorter RG, Phillips SF. Does Helicobacter pylori colonize the gastric mucosa of Meckel’s diverticulum? Mayo Clin Proc. 1990;65:187–91. 16. Hill P, Rode J. Helicobacter pylori in ectopic gastric mucosa in Meckel’s diverticulum. Pathology. 1998;30:7–9. 17. Kusumoto H, Yoshida M, Takahashi I, Anai H, Maehara Y, Sugimachi K. Complications and diagnosis of Meckel’s diverticulum in 776 patients. Am J Surg. 1992;164:382–3. 18. Malik AA, Shams-ul-Bari, Wani KA, Khaja AR. Meckel’s divertculum-revisited. Saudi J Gastroenterol. 2010;16:3–7. 19. Rossi P, Gourtsoyiannis N, Bezzi M, Raptopoulos V, Massa R, Capanna G, Pedicini V, Coe M. Meckel’s diverticulum: imaging diagnosis. AJR. 1996;166:567–73. 20. Elsayes KM, Menias CO, Harvin HJ, Francis IR. Imaging manifestations of Meckel’s diverticulum. AJR. 2007;189:81–8.
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