AJR:189, July 2007 81

AJR 2007; 189:81–88

0361–803X/07/1891–81

© American Roentgen Ray Society

Elsayes et al.Imaging of Meckel’s Diverticulum

A b d o m i n a l I m ag i n g • P i c t o r i a l E s s ay

Imaging Manifestations of Meckel’s Diverticulum

Khaled M. Elsayes1

Christine O. Menias2

Howard J. Harvin2

Isaac R. Francis1

Elsayes KM, Menias CO, Harvin HJ, Francis IR

Keywords: abdominal imaging, congenital malformation, diverticulum, Meckel’s diverticulum

DOI:10.2214/AJR.06.1257

Received September 22, 2006; accepted after revision January 15, 2007.

1Department of Radiology, University of Michigan Health Center at Ann Arbor, Ann Arbor, MI 48100-0030. Address correspondence to K. M. Elsayes (kelsayes@med.umich.edu).

2Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO.

CMEThis article is available for CME credit. See www.arrs.org for more information.

OBJECTIVE. Meckel’s diverticulum is the most common congenital anomaly of the gas-trointestinal tract, found in 2% of the population in autopsy studies. Most patients remainasymptomatic during their lifetime. Complications of Meckel’s diverticulum are reported to oc-cur in approximately 4–40% of patients and include inflammation (diverticulitis), hemorrhage,intussusception, small-bowel obstruction, stone formation, and neoplasm. The purpose of thisarticle is to familiarize the radiologist with the current imaging of Meckel’s diverticulum andits presenting complications. The spectrum of diagnostic findings on various imaging tech-niques will be reviewed.

CONCLUSION. Meckel’s diverticulum and its complications are a serious health prob-lem. Familiarity of the radiologist with the appearance of this pathologic entity enables an ac-curate diagnosis in emergent settings.

eckel’s diverticulum is the mostcommon congenital anomaly ofthe gastrointestinal tract. It is seenin 2% of the population, and it is

caused by failure of the omphalomesentericduct to regress. The point of attachment of aMeckel’s diverticulum to the bowel varies.Most (75%) Meckel’s diverticula are foundwithin 100 cm of the ileocecal valve [1].Meckel’s diverticulum occurs with equal fre-quency in both sexes, but symptoms from com-plications are more common in male patients.Meckel’s diverticula are typically asympto-matic and usually are found incidentally, witha lifetime risk of complications reported to be4–40% [2]. Heterotopic gastric and pancreaticmucosa are frequently found histologically inthe diverticula of symptomatic patients [2].The most common complications are hemor-rhage from peptic ulceration, small-intestinalobstruction, and diverticulitis [3].

The purpose of this article is to familiarize theradiologist with the current imaging of Meckel’sdiverticulum and its presenting complications.The spectrum of diagnostic findings on variousimaging techniques will be reviewed.

Embryology and AnatomyMeckel’s diverticulum was named after

Johann Friedrich Meckel, who described itsanatomy and embryology in 1809 [4].Meckel’s diverticulum is a remnant of the

omphalomesenteric or vitelline duct, whichconnects the yolk sac to the midgut throughthe umbilical cord. This duct is typicallyobliterated by the 5th–8th week of gestation.Failure of duct closure results in diverticu-lum (90% of cases), omphalomesenteric fis-tula, enterocyst, or a fibrous band.

Meckel’s diverticulum arises from the anti-mesenteric border of the distal small bowel,typically 40–100 cm from the ileocecal valve,with a typical length of up to 5 cm and diam-eter of up to 2 cm. Blood supply to this diver-ticulum typically comes from the omphalo-mesenteric artery (a remnant of the primitivevitelline artery arising from an ileal branch ofthe superior mesenteric artery).

Meckel’s diverticula are lined with hetero-topic mucosa in up to 60% of cases in the fol-lowing manner: gastric mucosa, 62%; pancre-atic, 6%; both gastric and pancreatic, 5%,jejunal, 2%; Brunner’s glands, 2%; and gas-tric and duodenal, 2% [5].

Imaging Findings and Usefulness of Various Imaging Techniques

Various imaging techniques have beenused for diagnosing Meckel’s diverticulum.Conventional radiographic examination is oflimited value and is usually unrevealing.However, it may show enteroliths, findings ofbowel obstruction, and the presence of gas ora gas–fluid level in the diverticulum.

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Conventional barium studies (small-bowelfollow-through study, enteroclysis, or retro-grade ileal opacification by means of bariumenema) have been largely replaced by otherimaging techniques for evaluation of patientswith acute symptoms.

Meckel’s diverticulum is not often seen onroutine barium studies because of its small os-tium, filling with intestinal contents, and peri-stalsis with rapid emptying. Meticulous ex-amination with enteroclysis has been reportedto be more sensitive [6].

On barium studies, Meckel’s diverticulumappears as a blind-ending pouch arising fromthe antimesenteric side of the distal ileum(Fig. 1). Filling defects in the diverticulummay suggest gastric mucosa or tumor [3].

Meckel’s diverticulum may be inverted,serving as lead point for intussusception, andappears as a soft polypoid filling defect [7].

SonographyAlthough of limited value, sonography has

been used for the investigation of Meckel’sdiverticulum [8]. High-resolution sonographyusually shows a fluid-filled structure in the rightlower quadrant having the appearance of ablind-ending, thick-walled loop of bowel, withthe typical gut signature and a clear connectionto a peristaltic, normal small-bowel loop(Fig. 2). The echo-free contents should not becompressed or expressed into the connectingbowel loop [8]. Hyperechoic mucosa (“gut sig-nature”) is always detected, and enteroliths arevisualized as shadowing echogenic foci [8].

CTOn CT, Meckel’s diverticulum is difficult to

distinguish from normal small bowel in uncom-plicated cases. However, a blind-ending fluid-or gas-filled structure in continuity with smallbowel may be seen. CT may also show entero-liths, intussusception, diverticulitis, and small-bowel obstruction. A recent innovation of CTenterography has resulted in better visualiza-tion of small bowel and consequent higher sen-sitivity in the diagnosis of Meckel’s diverticu-lum [9] (Fig. 3). CT enterography combines theimproved spatial and temporal resolution ofMDCT with large volumes of ingested neutralenteric contrast material to permit visualizationof the small-bowel wall [9].

Angiography can show the persistent om-phalomesenteric artery in most individualswith a Meckel’s diverticulum who present withchronic gastrointestinal bleeding (Fig. 4).However, the recognition of a persistent vitel-lointestinal artery may be difficult because of

overlying vessels, and superselective catheter-ization of distal ileal arteries may be necessary.The omphalomesenteric artery typically arisesfrom mid or distal branches of the superior me-senteric artery. Ectopic gastric mucosa mayshow a dense blush (Fig. 4). Extravasation ofcontrast material in cases of active bleedingtypically requires bleeding > 0.5 mL/min inorder to be visualized [10].

ScintigraphyScintigraphy with 99mTc-Na-pertechnetate

has only minor diagnostic value and a limitedsensitivity of 60% in diagnosing Meckel’s di-verticulum [11]. However, it aids in the diag-nosis of diverticula with ectopic gastric mu-cosa. Pertechnetate is taken up by mucin-secreting cells of the gastric mucosa and ec-topic gastric tissue. Higher sensitivity in pedi-atric (85–90%) than in adult (60%) patients isnoticed [11]. This could be due to earliersymptoms (such as hemorrhage) in patientswith ectopic gastric mucosa (Fig. 5).

Imaging of Complications of Meckel’s Diverticulum

Reported complication rates range from4% to 40%, with complications includingbleeding, bowel obstruction, enterolith for-mation, retention of foreign bodies, inflam-mation (diverticulitis or ulceration), and neo-plasm [2, 5, 12]. Detection of heterotopicgastric mucosa is of paramount significancebecause it can result in serious complicationssuch as bleeding. CT and scintigraphy play animportant role in the diagnosis of heterotopicmucosa (Figs. 5 and 6).

HemorrhageHemorrhage accounts for up to 30% of

symptomatic Meckel cases [12]. Hemorrhageusually occurs secondary to ectopic gastricmucosa. Hemorrhage has been reported to bemore common and more severe during child-hood. Angiography is usually used to diag-nose hemorrhage secondary to the bleedingMeckel’s diverticulum (Fig. 4).

Bowel ObstructionBowel obstruction accounts for up to 40%

of symptomatic Meckel’s diverticula [12](Fig. 7). Obstruction can be caused by trap-ping of a bowel loop by a mesodiverticularband, a volvulus of the diverticulum around amesodiverticular band (Fig. 8), and intussus-ception, as well as by an extension into a her-nia sac (Littre’s hernia). Obstruction has beenfound to occur more frequently with a giant

Meckel’s diverticulum. MDCT is a sensitivetechnique for diagnosing small-bowel ob-struction [13]. Ileocolonic intussusceptioncan rarely occur secondary to an invaginatedMeckel’s diverticulum. In these cases, CT re-veals dilated loops of proximal small bowelwith an intraluminal mass seen in the ascend-ing colon. This intracolonic mass is an intus-suscepted ileum [14] (Fig. 9).

Enterolith FormationEnterolith formation is an uncommon com-

plication of Meckel’s diverticulum despite di-verticula being the most likely sites of a small-bowel enterolith. Enteroliths can be seen in3–10% of Meckel’s diverticula [12]. Entero-liths are thought to form as a result of stasis.Approximately 50% of enteroliths can be seenon radiography. However, unenhanced CTshould be more valuable in detecting an en-terolith (Figs. 10 and 11).

InflammationDiverticulitis accounts for up to 30% of

symptomatic cases [12]. Diverticulitis com-monly occurs secondary to acid secretion fromectopic gastric mucosa. It also can occur due toobstruction by enteroliths, foreign bodies, orneoplasm. Scintigraphy has been used for diag-nosing Meckel’s diverticulitis secondary to het-erotopic gastric mucosa and usually shows a fo-cal high uptake indicative of heterotopic gastricmucosa with an adjacent region of low-gradetracer localization attributable to the inflamma-tory mass [15]. CT is a sensitive technique fordiagnosing Meckel’s diverticulitis, which usu-ally appears as a blind-ending pouch of variablesize with mural thickness and containing fluid,air, or particulate material with surroundingmesenteric inflammation [16] (Figs. 10 and 12).

NeoplasmNeoplasms arising in Meckel’s diverticula

are rare, accounting for up to 3% of compli-cated cases [14]. The most frequently re-ported neoplasm complicating a Meckel’s di-verticulum is carcinoid tumor. Other reportedtumors include leiomyoma (Fig. 13), leiomy-osarcoma [17], angioma, neuroma, lipoma,carcinosarcoma, and adenocarcinoma [18,19]. These tumors have nonspecific imagingfeatures, including a sessile or lobulated fill-ing defect. Malignant neoplasms may infil-trate the adjacent mesenteric fat [19].

PerforationMeckel’s diverticulum can rarely be compli-

cated by perforation, which is a serious health

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event. Perforation is usually secondary to in-flammatory diverticulitis, gangrene, and pepticulceration [20–22]. Perforation can be sug-gested by the presence of free intraperitonealair in the setting of Meckel’s diverticulum.This can be further detected on CT (Fig. 14).

ConclusionMeckel’s diverticulum and its complica-

tions are a serious health problem. Familiarityof the radiologist with the appearance of thispathologic entity enables an accurate diagno-sis in emergent settings.

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Fig. 1—Image from small-bowel follow-through examination shows filling of blind-ending diverticulum (arrow) in right lower quadrant in 17-year-old girl with chronic abdominal pain.

Fig. 2—Sonogram in 30-year-old woman shows blind-ending thickened loop with gut signature correlating with inflamed Meckel’s diverticulum (short arrow) in right lower quadrant. Note cecum (long arrow) and iliac vessels (arrowhead).

Fig. 3—37-year-old man with occult gastrointestinal bleeding. Axial image from CT enterography examination shows increased enhancement in Meckel’s diverticulum (arrow). Surgical pathology confirmed ectopic gastric mucosa.

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A B

Fig. 4—17-year-old girl with abdominal pain and rectal bleeding.A and B, Selective angiograms of superior mesenteric artery show focal region of pooling surrounding Meckel’s diverticulum with contrast blush (arrow).

A B

Fig. 5—26-year-old woman with Meckel’s diverticulum. A–D, Technetium-99m-labeled heat-damaged RBC scans show focus of intense activity (arrows, B–D) in right lower quadrant on initial flow study. Operative findings confirmed hemorrhagic Meckel’s diverticulum.

C D

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Fig. 6—26-year-old woman. Axial contrast-enhanced CT scan shows blind-ending Meckel’s diverticulum with thickened mucosal folds (arrow). Pathology confirmed ectopic gastric mucosa in Meckel’s diverticulum.

A B

Fig. 7—23-year-old man. A and B, Axial contrast-enhanced CT images show blind-ending fluid-filled structure (arrow, A) resulting in small-bowel obstruction. Operative findings confirmed Meckel’s diverticulum.

A B

Fig. 8—21-year-old woman with right lower quadrant pain and neutrophilia. A and B, Axial CT scans show U-shaped loop of bowel in pelvis, suggesting volvulus of diverticulum around mesodiverticular band (arrow). Operative findings confirmed torsion of Meckel’s diverticulum.

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A B

Fig. 9—13-year-old boy with right lower quadrant abdominal pain.A and B, CT scans reveal long-segment enteroenteric intussusception due to inverted Meckel’s diverticulum (arrow, A).

A B

Fig. 10—31-year-old woman. A and B, Axial CT scans show enterolith (arrow, A) in dilated infected Meckel’s diverticulum. Note adjacent infiltration of ileocolic mesentery, suggesting superim-posed diverticulitis (arrows, B).

A B

Fig. 11—28-year-old woman with vomiting and abdominal pain.A, Axial CT scan reveals distended fluid-filled diverticulum (arrow) with narrowed neck.B, CT scan shows enteroliths (arrow) in neck of diverticulum. Operative findings confirmed obstructed Meckel’s diverticulum containing enterolith.

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A

B

C

Fig. 12—28-year-old man with 1 week of epigastric pain that subsequently localized to right lower quadrant.A–C, CT scans show inflammatory process in right lower quadrant (arrows, A) with small abscess (arrow, B and C). Operative exploration confirmed perforated Meckel’s diverticulitis.

Fig. 13—37-year-old woman with melena. Technetium-99m-labeled RBC study shows bleeding in right lower quadrant (arrow). Operative findings confirmed Meckel’s diverticulum with ulcerated leiomyoma (thought to be cause of bleeding).

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A B C

Fig. 14—34-year-old man. A–C, Serial CT slices through lower abdomen show perforated Meckel’s diverticulum (black arrow, B). Extraluminal gas (arrow, A), and inflammatory changes (white arrow, B) are seen adjacent to diverticulum. Operative findings confirmed imaging findings.

F O R Y O U R I N F O R M A T I O N

This article is available for CME credit. See www.arrs.org for more information.

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