Who was Hilidanus

1. Who was Hilidanus A. Adegbesan,

2. Case 1 • 68 year old lady admitted with a 2 day history of diffuse abdominal pain and vomiting. • Acute onset intermittent sharp epigastric pain, rated 7/10 with no aggravating or relieving factors. • Bowel motion and flatus last passed 3 day previously • Poor appetite. • No recent alcohol ingestion as per patient.

3. Case History • Past Medical History: • PUD • Hiatus hernia • Chronic Kidney Disease • COPD • Past Surgical History • Hysterectomy • Cholecystectomy • Appendectomy

4. Case History • Family History • Nil significant • Social History • Ex smoker • ROS: • Nil significant

5. On Examination • Vital Signs: • BP 111/74 • HR 92 • Temp 36.2 • RR 16 • O2 SATS 100% on RA • Abdomen was not distended. Tenderness in epigastrium with mild guarding. No rebound. Bowel sounds exaggerated. Hernial orifices were intact.

6. Investigations • WCC 7.4; Hb 13.3; Plts 433; CRP 17 • Urea 42; Na 125; K 7.4; Creat 609 (baseline 60-120) • ABG: pH 7.38, pCO2 4.57, pO2 12.4, HCO3 20 • Amylase 160 • ECG: NSR; tachycardic; tented T waves • CXR: no free air under diaphragm. • PFA: prominent small bowel loops

7. Management • Initially admitted medically with • Acute on chronic renal failure • Dehydration • Upon surgical review: • Features of small bowel obstruction for conservative management.

8. Management • Day 1 post admission: • Abdomen now distended, non tender, BS present. PFA showed progression - ? small bowel obstruction 2o to adhesions. • Day 2 post admission: • Medical review re: acute renal failure, hyperkalaemia and hyponatraemia. • Surgical team review • To continue conservative management • NG tube and urinary catheter placed

9. Management • Day 5 post admission: • Renal failure indices resolved • Abdominal distension still persistent • Obstipated • PFA showed increasing bowel dilatation • NG tube active • Proceeded to laparotomy

10. Operative findings • Small bowel volvolus with fulcrum around meckel’s diverticulum adherent to pelvic sidewall. • Merckel’s diverticulum and adjacent small bowel were resected and sent for histology. • Side to side anastomosis

11. Post Operative • The post operative period was uneventful. • Histology • Gastric body type mucosa • No helicobacter pylori • No evidence of malignancy

12. Case 2 • 31 year old gentleman admitted with: • 1/7 history of sudden onset non-radiating colicky lower abdominal pain. • No associated nausea, vomiting or altered bowel habit. • No previous medical/surgical hx. • ROS – nil significant

13. On Examination • Vital Signs: • BP 115/68 • HR 93 • O2 SATS 99% on RA • Apyrexial 36.2oC • On examination: • Tenderness and guarding in lower abdomen • Reduced bowel sounds.

14. Investigations • Urinalysis • NAD • Bloods • WCC 13.4 (neuts 10.58), Hb 13.4, CRP 49, Amylase 107 • Sickle cell screen negative • CXR • No air under the diaphragm • PFA • Bowel gas pattern normal. No bowel distension or obstruction. No free air.

15. Investigations • CT Abdomen/Pelvis • Minor stranding of fat around a loop of small bowel in right lower quadrant (differential included inflammatory change around a meckel’s diverticulum) • Small nodes in the adjacent mesentery. • No evidence of large colonic diverticulitis and normal appearance of the appendix.

16. CT Abdo/Pelvis

17. Management • On admission: • IV fluids, co-amoxiclav and analgesia • Day 2 post admission: • Proceeded to Laparoscopy: • Operative findings: • Perforated merckel’s diverticulum which was resected at its base using Endo GIA and sent for histology • Appendix long and injected but not acutely inflamed - most likely not the cause of his symptoms but removed.

18. Histological Findings • Ectopic gastric tissue at the fundus of the meckel’s diverticulum. • The excised edge was free of ectopic gastric tissue

19. Introduction • A true congenital diverticulum, a congenital bulge in the small intestine. • It is a vestigial remnant of the omphalomesenteric duct • is the most frequent malformation of the gastrointestinal tract • It was first described by Fabricius Hildanus, German surgeon, in 1598 • Johann Friedrich Meckel, described the embryological origin of this type of diverticulum in 1809

20. Pathophysiology • It is a vestigial remnant of the omphalomesenteric (vitellointestinal) duct • Human embryos initially have convex umbilical loops of primitive gut that communicate freely with the yolk sac through the omphalomesenteric (vitellointestinal) duct • As development proceeds, the duct normally becomes occluded and disappears entirely by weeks 8-10 of gestation • Results from the failure of the vitelline duct to obliterate during the fifth week of fetal development

21. Pathophysiology • The following anomalies are caused by the persistence of the omphalomesenteric (vitellointestinal) duct

22. Epidemiology • Autopsy records show an incidence of about 2% in the general population. • For asymptomatic diverticula there is no gender predominance,. • For symptomatic diverticula some studies give a 3:1 male to female ratio, while others have detected little difference. • The risk of complications ranges from 4-25% in various studies.

23. Anatomic Considerations • Meckel's diverticulum is located in the distal ileum, on its antimesenteric border. usually within about 60-100 cm of the ileocecal valve • It can also be present as an indirect hernia, typically on the right side, where it is known as a "Hernia of Littre."

24. Anatomic consideration Topography of abdomen

25. Anatomic Considerations • A memory aid is the rule of 2's: • 2% (of the population) • 2 feet (from the ileocecal valve) • 2 inches (in length) • 2% are symptomatic • 2 types of common ectopic tissue (gastric 80% , pancreatic, colonic and other tissues 20%), • The most common age at clinical presentation is 2, and • males are 2 times as likely

26. Clinical features • Asymptomatic in majority of cases • Painless rectal bleeding, • Intestinal obstruction, • Volvulus and Intussusception. • Meckel's diverticulitis may present with all the features of acute appendicitis. • Epigastric pain & Bloating • Neoplasm - lipoma, leiomyoma, neurofibroma and angioma, leiomyosarcoma and carcinoid, which represent about 80% & adenocarcinoma and metastatic lesions

27. Diagnosis • A technetium-99m (99mTc) pertechnetate scan is commonly used to diagnose Meckel's diverticulum – Gastric tissue. • Abd CT • Barium studies to out rule enterocolitis and intussuception • Laparoscopy • A bleeding scan. • Selective arteriography • Wireless capsule endoscopy • Abd USS

28. Treatment • Surgical for symptomatic Merckel’s diverticulum • Incidental Meckel’s diverticulum in asymptomatic patients remains controversial – Narrow vs wide • Excision is carried out by performing a wedge resection of adjacent ileum and anastomosis • a primitive persistent right vitelline artery originating from the mesentery has been found during operation - Bleeding

29. Histology • Heterotropic gastric mucosa 62% • pancreatic tissue  6%, • Both pancreatic tissue and gastric mucosa were found in 5%, • Jejunal mucosa was found in 2%, • Brunner tissue was found in 2%, and • Both gastric and duodenal mucosa were found in 2%

30. Take home message • Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. • it is often difficult to diagnose • It may remain asymptomatic • it may mimic disorders such as Crohn's disease, appendicitis, peptic ulcer disease, obstruction and bleeding.

31. Thank you • Who should take credit for this clinical entity • Fabricius Hildanus,, in 1598 • Johann Friedrich Meckel, 1809