Diagnostic Laparoscopy and Small Bowel Resection for a Large Meckel's Diverticulum in Adult with Persistent GI Bleed

Symptomatic Meckel’s diverticulum is a diagnosis most commonly associated with male children under two years old. It typically presents with painless hematochezia and is diagnosed with a Meckel’s scan, which uses Technetium-99 to detect ectopic gastric tissue. In an adult with gastrointestinal bleeding, the differential is far broader, including an extensive and at times, inconclusive, work-up. Here, we describe a diagnostic laparoscopy for suspicion of Meckel’s diverticulum in a young adult male whose work-up showed evidence of small bowel bleeding without a definitive source. A large 6.2-cm, broad-based Meckel’s diverticulum was identified about 90 cm proximal to the ileocecal valve and resected via small bowel resection.

Laparoscopy; Meckel’s diverticulum; small bowel resection; gastrointestinal bleeding.

An otherwise healthy 20-year-old male presented to the Emergency Department after he fainted while exercising. He had three days of multiple melanotic stools, lightheadedness, and shortness of breath. He denied recent trauma, daily NSAID use, frequent alcohol use, other drug use, and family history of bleeding or gastrointestinal disorders aside from polyps and colon cancer at an advanced age. He received a blood transfusion for symptomatic anemia in the setting of gastrointestinal bleed of unknown etiology and was admitted for further workup.

Over the next several months, he presented to the Emergency Department four times with the same symptoms and underwent extensive inpatient and outpatient work-up to determine the source of gastrointestinal bleeding. All laboratory values were normal, including a Coombs test. The imaging and procedures in chronological order included:

1. Upper endoscopy (negative).
2. CT angiogram of abdomen and pelvis (negative).
3. Colonoscopy (negative).
4. CT enterography (negative).
5. Video capsule endoscopy (negative for bleeding, positive for mild NSAID gastropathy).
6. Meckel’s scan (negative).
7. Repeat video capsule endoscopy (plume of blood in terminal ileum and blood in colon, but no source).
8. Double-balloon retrograde enteroscopy (negative, although two red spots cauterized and a tattoo placed at the most distal scope point).

Given high suspicion for the source being within the distal small bowel, he was taken to the operating room electively for a planned diagnostic laparoscopy, possible laparoscopic-assisted enteroscopy, and possible small bowel resection with general surgery and gastroenterology.

Intraoperatively, the abdomen was insufflated after insertion of the Veress needle at Palmer’s point. Four 5-mm ports were placed. After lysis of adhesions, the small bowel was run from the ileocecal valve proximally, where a large ~10-cm ileal diverticulum with a broad base was identified about 90 cm proximal to the ileocecal valve (about 10 cm proximal to the tattoo). Given the large size and broad base, the decision was made to proceed with a small bowel resection rather than a simple diverticulectomy. An intracorporeal stapled side-to-side functional end-to-end primary small bowel anastomosis was performed. The common enterotomy was closed with a running 2-0 V-Loc in two layers, and the mesenteric defect was closed with a figure-of-eight 2-0 Vicryl suture. The patient recovered well and was discharged on postoperative day two after slow diet advancement. Pathology revealed an approximately 6.2-cm long Meckel’s diverticulum with a 2.5-cm base. No ulcers or heterotopic mucosa were noted in the pathology report.

Physical exam revealed a well-nourished, healthy-appearing male in no apparent distress with normal vital signs. No abdominal tenderness on exam.

The differential diagnosis for a young adult with gastrointestinal bleeding is broad and a detailed clinical history is critical. Etiologies are typically divided into upper and lower sources of bleeding depending on whether the bleeding originates proximal or distal to the ligament of Treitz. Causes of gastrointestinal bleeding include peptic ulcer disease, inflammatory bowel disease (specifically Crohn’s), angiodysplasia, Dieulafoy lesions, tumors, foreign body ingestions, Meckel’s diverticulum, and many others.¹ Meckel’s diverticulum, a true diverticulum, is the most common gastrointestinal congenital malformation.² It is found in 1–2% of the population and males are about 2 times more likely to be symptomatic.³ Typically it is diagnosed in children less than 2 years of age and is rarely symptomatic in adults.² In fact, only 4–6% of the population with Meckel’s diverticulum will be symptomatic.^3,4 Diagnosis is challenging because it can easily be overlooked on CT abdomen and pelvis and instead, mistaken for a normal loop of bowel, unless an intestinal obstruction or foreign body retention is present.² A Meckel’s scan is the gold standard for diagnosis in children with a sensitivity of 85% and specificity of 95%, but is much less accurate in adults.² It identifies ectopic gastric mucosa, which is ultimately shown on pathology in about 98% of resected Meckel's diverticulum.¹ The gastric mucosa causes an ulcer on the mesenteric side of the ileal lumen and results in painless bleeding.³ Those diverticula without heterotopic mucosa are less likely to be symptomatic and subsequently resected. Within the last decade, balloon-assisted enteroscopy has emerged as a useful non-operative diagnostic procedure because most Meckel’s diverticulum are within 100 cm of the ileocecal valve, which is accessible via this advanced endoscopic procedure.² Ultimately, diagnostic laparoscopy should be pursued if the index of suspicion is high.

As stated in the case overview, the patient underwent an exhaustive work up for gastrointestinal bleeding with both non-invasive and invasive studies. Most notably, Meckel’s scan was negative, video capsule endoscopy showed blood in the terminal ileum and colon without source, and double-balloon retrograde enteroscopy also showed evidence of blood in the terminal ileum without source. Although a Meckel’s Technetium-99 scan is the imaging of choice used to diagnose symptomatic Meckel’s diverticulum, it is not without limitations. It can be influenced by factors such as medications, and the lower diagnostic accuracy in adults is well-documented.^2,5

A symptomatic Meckel’s diverticulum can be removed either by small bowel resection or diverticulectomy. If only performing a diverticulectomy, the surgeon must first inspect the intestinal mucosa for an ulcer and then suture the bowel closed in a transverse fashion to avoid narrowing the lumen.³ Classically, a diverticulum with a broad base was removed via small bowel resection to fully remove the abnormal tissue and prevent narrowing of the intestinal lumen. Newer studies have shown no difference in outcomes for those undergoing diverticulectomy or segmental resection regardless of the base width.^6,7 That said, laparoscopic diverticulectomy versus small bowel resection is a decision specific to each surgeon, patient, and clinical picture.⁷  

Resection of an asymptomatic Meckel’s diverticulum discovered incidentally during an unrelated operation (e.g. appendectomy) has remained controversial. The risk-benefit of resection is nuanced and no clear guidelines have been established. Historically, the consensus was that the risk of complications from prophylactic resection is greater than the risk of future diverticulum-related complications.³ However, a recently published systematic review by Yganik et al. suggests otherwise.⁸ They looked at over two decades of studies on the management of incidentally found Meckel’s diverticulum and found that the evidence may slightly favor resection.⁸ Other studies concur that while routine resection is not indicated, it may be appropriate to consider diverticulectomy in a patient with multiple risk factors for future symptomatic Meckel’s diverticulum.⁹

Meckel’s diverticulum is often challenging to diagnose in adult patients. A Meckel’s scan has significantly lower sensitivity in adults and the diverticulum may be too proximal to identify with endoscopy. In such cases, when non-operative work-up remains inconclusive but clinical suspicion persists—particularly in the setting of unexplained gastrointestinal bleeding—diagnostic laparoscopy becomes an essential next step. As demonstrated in this case, despite multiple negative studies including upper endoscopy, colonoscopy, CT angiogram, Meckel’s scan, and both capsule and double-balloon enteroscopy, laparoscopy enabled direct visualization of the bowel and ultimately led to diagnosis. The small bowel was carefully run from the ileocecal valve proximally, revealing a large, broad-based Meckel’s diverticulum approximately 90 cm upstream—just beyond the reach of prior endoscopy. This case highlights the unique diagnostic value of laparoscopy in evaluating the distal small bowel when all other modalities have failed, particularly in young adults with obscure but persistent GI bleeding. The decision to perform diverticulectomy versus segmental resection is at the discretion of the surgeon. Both options are curative and with complete diverticulectomy without narrowing of the intestinal lumen, studies suggest that outcomes are similar.

The surgical field was visualized by an Olympus high-resolution video endoscopy system, including two high-resolution color monitors. Olympus laparoscopic tools were used for mobilization. A linear Ethicon Endo GIA 60 stapler with a white load was used to transect the small bowel, followed by an Ethicon Harmonic scalpel to divide the mesentery. The ileo-ileostomy was created using a linear Endo GIA 60 stapler with a blue load and the common channel was closed using a 2-0 V-Loc suture.

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.