REVIEW
Meckel’s diverticulum: clinical features, diagnosis and management
Serdar Kuru and Kemal Kismet
Department of General Surgery. Ankara Education and Research Hospital. Ankara, Turkey
Received: 04/04/2018 · Accepted: 03/06/2018
Correspondence: Serdar Kuru. S.B. Ankara Egitim ve Arastirma Hastanesi Genel Cerrahi Klinigi. Sukriye Mh.
Ulucanlar Cd, 89. 06230 Altındag, Ankara. Turkey. e-mail: dokserkur@yahoo.com.tr
ABSTRACT
Meckel’s diverticulum is the most common anomalous
development of the gastrointestinal system that results
from an incomplete vitelline canal. A diagnosis is usual-
ly made during the clinical examination of presentations
such as unexplained gastrointestinal bleeding, obstruction,
inflammation or perforation. The purpose of this review is
to provide an adequate level of knowledge of the clinical
and diagnostic features as well as the management of
Meckel’s diverticulum. Diagnosis of Meckel’s diverticulum
may be challenging as the condition remains asymptomatic
or may mimic various diseases and obscure the clinical
picture. Life-threatening complications include bleeding,
obstruction, inflammation and perforation. Therefore, it is
essential that anatomical and pathophysiological character-
istics are known in detail in order to prevent complications
which will result in morbidity and mortality.
Key words: Meckel’s diverticulum. Diagnosis. Complica-
tions. Management.
INTRODUCTION
Meckel’s diverticulum is the most widespread congenital
abnormality of the gastrointestinal system (1). The reported
incidence is 0.6-4% in most studies and is known to devel-
op from incomplete obliteration of the omphalomesenter-
ic canal causing the creation of a true diverticulum in the
small bowel (2). The first descriptions of this condition were
recorded by Fabricus Heldanus in 1650 (3) and subsequently
by Levator and Ruysch in 1671 and 1730, respectively (4,5).
However, the name was attributed to the German compar-
ative anatomist Johann Friedrich Meckel, who established
the embryonic origin in 1809 (6).
Since Meckel’s diverticula are usually clinically asymptom-
atic, particularly in adults, it may be encountered during a
laparotomy performed for another reason. It may be less
frequently found as an incidental finding on diagnostic
imaging. Life-threatening complications, such as intestinal
obstruction, bleeding, inflammation and perforation may
also develop. While bleeding is life-threatening in child-
hood, intestinal obstruction is more common in adulthood.
However, the diagnosis of Meckel’s diverticulum is often
1130-0108/2018/110/11/726-732  •  REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
© Copyright 2018. SEPD y © ARÁN EDICIONES, S.L.
overlooked. Therefore, the aim of this study was to contrib-
ute to the management strategies by conducting a review
of the current literature, including the knowledge of the
clinical and diagnostic features and the management of
Meckel’s diverticulum.
CLINICAL FEATURES
The cells covering the vitelline channel are pluripotent.
Therefore, the vitelline channel contains heterotopic gas-
tric tissue (50%), pancreatic tissue (5%) and more rarely,
hepatobiliary tissue and duodenal, colonic, endometrial or
Brunner glands. Life-threatening and disturbing complica-
tions such as gastrointestinal hemorrhage (31%), inflamma-
tion (25%), intestine obstruction (16%), hernial involvement
(11%), intussusception (11%), fistula or umbilical sinus (4%)
and tumors (2%) occur as a result of the presence of het-
erotopic tissues (7,8).
As the majority of diverticula maintain a silent course, diag-
nosis is often made incidentally during a small intestine
contrast study, unrelated laparotomy or laparoscopy proce-
dures, or when complications result from the diverticulum
(9). Establishing a diagnosis of symptomatic Meckel diver-
ticulum is difficult preoperatively. Although symptoms can
appear at all ages, clinical manifestations are more wide-
spread in childhood (10). Higaki et al. (11) examined 776
patients and concluded that diagnosis in cases that present
with symptoms, with the exception of bleeding, was more
difficult than in those with per-rectal bleeding. The symp-
toms of complicated diverticulum may resemble symptoms
of various other intra-abdominal pathologies such as other
causes of small intestine obstruction, inflammatory bowel
disease, acute appendicitis or peptic ulcer disease. This may
make a differential diagnosis difficult (12).
The life-time risk of diverticulum complications including
bleeding, obstruction and diverticulitis is approximately 4%
Kuru S, Kismet K. Meckel’s diverticulum: clinical features, diagnosis and ma-
nagement. Rev Esp Enferm Dig 2018;110(10):726-732.
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 Meckel’s diverticulum: clinical features, diagnosis and management
to 6%; 40% of these complications are seen in children below
the age of ten years (13) (Table 1). The most general presen-
tation in childhood is bleeding, which has been reported
in approximately 50% of cases with symptoms related to
the diverticulum (10). The most widespread complication of
Meckel’s diverticulum in adults is bowel obstruction, where-
as this presentation occurs as the second most common
complication in childhood (9,10,14). Intestinal obstruction
resulting from Meckel’s diverticulum occurs via distinct
mechanisms such as: intussusception (15), volvulus (9,16),
abdominal wall hernia (9,17,18), Meckel’s diverticulitis (9),
entrapment of the bowel loop beneath the mesodiverticu-
lar band (9, 19) (Fig. 1), lithiasis of the diverticulum (9,20),
an ileum loop entrapped by a band stretching between the
Meckel’s diverticulum and the base of the mesentery (9),
phytobezoar formation, gallstone ileus, impacted meconium
in neonates and tumors (carcinoids, mesenchymal tumors,
lipomas, hamartomas and others) (9,21,22). The presenta-
tion of obstruction related to the diverticulum may resemble
other sources of small intestine obstruction.
The second most widespread complication in adults is
related to the inflammatory process. The combined rate of
diverticulitis and perforation is almost 20% and can often
not be differentiated from acute appendicitis until observed
via laparotomy (21). Acute inflammation of the Meckel’s
diverticulum is thought to be caused by obstruction of the
diverticular opening as a result of an enterolith, inflamma-
tory tissue, food, other parasites (Taenia saginata or Ascaris
lumbricoides), tumors or a foreign body (23-25). Obstruc-
tion leads to bacterial overgrowth and an inflammation sim-
ilar to acute appendicitis (26). Meckel’s diverticulitis can also
result from torsion of the diverticulum or peptic ulceration
due to heterotopic gastric tissue. If not treated, it generally
results in perforation and peritonitis (9).
DIAGNOSIS
Despite all the improvements, the most significant chal-
lenge is still the preoperative diagnosis of Meckel’s diver-
ticulum (2). The diverticulum is occasionally identified inci-
dentally on imaging studies and may be found during the
course of a laparotomy performed for other reasons. The
preferred diagnostic method is laparoscopy in doubtful cas-
es. However, laparoscopy is not an initial step of diagnostic
modalities as it is more invasive compared to conventional
imaging methods (10).
Radiological imaging
Plain X-ray, barium studies and computed tomography (CT)
scans are seldom beneficial for a preoperative diagnosis
of the diverticulum. The typical appearance of an intesti-
nal obstruction may be demonstrated by plain abdominal
radiographs. When distension develops in a diverticulum,
diagnosis may be established due to a gas-filled viscous
appearance in the right iliac fossa or middle abdomen
region. If a perforation develops as a complication, the
findings of pneumoperitoneum may be seen on upright
chest and plain abdominal radiographs. Characteristically,
the diverticulum is delineated as a contrast-filled out pouch-
ing which has a junctional fold pattern and is seated on the
anti-mesenteric margin of the small bowel (10).
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Ultrasonography, although not specific enough for imaging
this condition, may reveal a tubular diverticulum swollen
with fluid in a region away from the cecum, invagination,
segmental thickening of the bowel walls, swelling of diver-
ticular wall and pelvic abscess (27). Anomalous vessels may
be detected via Doppler ultrasonography (28). On CT scan,
differentiation of the Meckel’s diverticulum from the normal
small intestine is difficult in uncomplicated patients. How-
ever, CT may reveal a gas-filled structures or blind-ending
fluid in continuity with the small intestine (29). With regard
to uncomplicated patients such as those with intussuscep-
tion, CT imaging can be applied and the inverted divertic-
ulum is typically demostrated as an interior nucleus of fat
attenuation which is encircled by an annulus of soft tissue
attenuation (30). In cases where a lesion in the small intes-
tine is suspected, the alternative radiological examination
to conventional tomography is CT enteroclysis (31).
Angiography
The diagnosis of a bleeding diverticulum can usually be
made via a Meckel’s scan or mesenteric arteriography (32).
Angiograms of the arteria mesenterica superior may not
only display the location of the hemorrhage by extrava-
sation of focal radiopaque substance but also the reason
for the hemorrhage. The accuracy rate of angiography is
59% (10). Active signs of hemorrhage can be identifed on
high-resolution CT angiography. With regard to the detec-
tion of active gastrointestinal hemorrhage, CT angiography
was shown to have a specificity of 92% and sensitivity of
85% in a meta-analysis of 22 studies that included 672 cases
(33). Although another study of 124 patients reported a CT
angiography accuracy rate of 100% (34), the type of patients
and the context should be taken into consideration when
evaluating the accuracy of CT angiography.
Nuclear imaging
Technetium-99m pertechnetate scanning, a diagnostic tool
for Meckel’s diverticulum, is the most commonly used
non-invasive technique for diagnosis. Furthermore, patients
with gastrointestinal bleeding do not require general anaes-
thesia. This is a useful method due to its tendency to con-
centrate on ectopic gastric tissue (2). The reported specific-
ity is 95%, with a sensitivity of 80%-90% and an accuracy of
90% in children (35), whereas specificity is 9%, sensitivity
62.5% and accuracy 46% in adults. Thus, it is less reliable
in adults (36). However, both false-negative and false-pos-
itive scan results may occur due to technical problems or
the bladder overlapping the region of the diverticulum
(10). Pre-treatment with pentagastrin, which accelerates Tc
uptake or H-2-receptor antagonists and reduces Tc release
by the gastric mucosa, decreases the rate of false-negative
results (37).
Although the above-mentioned diagnostic tools have been
widely used for the diagnosis of Meckel’s diverticulum for
many years, new diagnostic methods such as capsule endos-
copy, double-balloon enteroscopy and magnetic resonance
(MR) enterography have emerged in recent years. After the
emergence of both capsule endoscopy and double-baloon
enteroscopy, the diagnosis of small intestine diseases has
dramatically developed over the past decade.
 728

Table 1. Complications of Meckel’s diverticulum: incidence, causes, presentation in child/adult and symptoms

Inflammatory process
Hemorrhage Intestinal obstruction Tumor
(diverticulitis and perforation)
Incidence 25%-50% 22%-50% 20% 0.5%-1.9%
The most common The second most common
Children
presentation complication
Adults The most common complication The second most common complication
Heterotopic mucosa Intussusception, volvulus, Littre’s Diverticulitis Perforation Malignant group Benign group
(gastric and pancreatic), hernia, mesodiverticular band, Obstructions due to fecalith Progression of diverticulitis, Carcinoids, Lipoma,
neoplasm (carcinoid tumors, stricture, enteroliths, band extending or foreign body or parasites, ulceration of adjacent ileal mesenchymal neuromuscular and
Cause adenocarcinomas, benign between the diverticulum and the peptic ulceration of the mucosa secondary to acid tumors, vascular hamartoma
mesenchymal tumors, base of the mesentery, tumors, ileal mucosa due to ectopic produced by ectopic gastric adenocarcinomas,
melanoma, lymphoma, impacted meconium, cecal volvulus, gastric mucosa, diverticular mucosa, trauma due to desmoplastic small
S. Kuru and K. Kismet

lipomas), phytobezoars gall stone ileus, phytobezoars torsion ingested foreign body, tumors round cell tumor
• Dark red or maroon stools • Cramping abdominal pain and • Abdominal pain or • Abdominal pain • Tumors can have various manifestations:
or stools with blood or obstipation (depending on the discomfort that ranges • Localized or generalized acute abdominal pain, perforation,
mucus (often in children) etiology of the obstruction and the from mild to severe tenderness with rebound bleeding, intussusception and intestinal
• Melena and crampy location and degree of obstruction) • Right lower quadrant and guarding due to obstruction making it an emergency
Symptoms abdominal pain (often in • Bloating tenderness, mimicking peritonitis situation
adults) • Nausea and vomiting acute appendicitis • Distention
• Chronic and insidious • Diarrhea • Fever • Fever
hemorrhage leading to • Constipation • Nausea and vomiting • Nausea and vomiting
anemia or iron deficiency

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 Meckel’s diverticulum: clinical features, diagnosis and management
Fig. 1. Intra-operative view: obstruction resulted from
trapping of the small intestine loop under the meso-
diverticular band of Meckel’s diverticulum.
The whole small intestine can be endoscopically reached by
both capsule endoscopy and double-baloon enteroscopy (38).
Capsule endoscopy and double-balloon enteroscopy
Capsule endoscopy is a novel technological tool for the
examination of the small bowel in a noninvasive and sim-
ple manner. It has been proved in a number of studies that
capsule endoscopy has the capability to detect small intes-
tine lesions in cases with obscure gastrointestinal hemor-
rhage. The entire small intestine can be examinated by both
double-baloon enteroscopy and capsule endoscopy. For the
detection of hemorrhagic lesions in the small bowel, oth-
er studies proved that the efficacy of both capsule endos-
copy and double-baloon enteroscopy is similar. However,
capsule endoscopy is contra-indicated and also difficult in
cases under ten years of age. Furthermore, it is relatively
simple to reach via the retrograde double-balloon enteros-
copy method, as the distance of the Meckel’s diverticulum
is generally closer than a meter from the ileocecal valve.
During capsule endoscopy, the capsule may pass rapidly
through the opening of the Meckel’s diverticulum and an
image may not be obtained. The management of cases with
an obscure gastrointestinal hemorrhage results in a con-
sumption of resources and time. Research has demostrat-
ed that initial double-balloon enteroscopy (compared with
push enteroscopy, angiography, intra-operative enterosco-
py and capsule endoscopy) is the most cost-effective meth-
od for cases with small intestine hemorrhage (38).
Gasbarrini et al. (39) first defined the use of double-bal-
loon enteroscopy for the detection of Meckel’s diverticu-
lum. The various clinical studies noted that double-balloon
enteroscopy is a reliable method for the study of small bow-
el pathology. The entire small intestine can be visualized
and treated and biopsies can also be performed using this
procedure (38). Konomatsu et al. (40) used double-balloon
enteroscopy for both diagnosis and treatment of bleeding
Meckel’s diverticulum. The most widespread indication
for double balloon enteroscopy is obscure gastrointes-
tinal hemorrhage. The detection ratio of obscure hemor-
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729
rhage using this techenique is 68.1%. However, due to the
potential adverse events, limitations and own unique set of
indications, experience is limited in children. Double-bal-
loon enteroscopy intervention may lead to complications
such as pancreatitis, pneumonia, bowel obstruction and
perforation. Acute pancreatitis, which occurs after 0.3% of
interventions, is a source of concern. However, this is not
an issue for those cases undergoing retrograde double-ba-
loon enteroscopy, as in cases undergoing the procedure for
the detection of Meckel’s diverticulum. Most studies have
shown that double balloon enteroscopy performed in child-
hood is a reliable and safe method (38). In the Leung’s study
(41), retrograde double-balloon enteroscopy was recom-
mended for children over 14 kg.
CT enterography and MR enterography
CT enterography not only maximizes the visibility of the
bowel structure and mucosa with the support of radiopaque
substances but also detects peri-enteral abnormalities. For
this reason, it has been proven to be more benifical than
conventional CT for the detection of lesions in the small
intestine. MR enterography, which allows the assessment of
bowel functionalities using MR fluoroscopy, is a novel tech-
nique without radiation. It unites the advantages of both
the morphological imaging of MR and the conventional
enterography. In this way, it can analyze both the morphol-
ogy and function of the small bowel. Its perfect soft tissue
contrast and three-dimensional imaging capability means
that changes around the intestinal canal and the mucosa
can be examined (42).
Diagnostic laparoscopy or laparotomy
Laparoscopy is an efficient and safe way of localizing the
lesion for the removal of the Meckel’s diverticulum. How-
ever, it is more invasive and therefore not recommended
as an initial step for diagnosis (10).
MANAGEMENT
As double-balloon enteroscopy can be used for therapeutic
interventions such as argon plasma coagulation, balloon
dilatation, polypectomy and performing biopsies, some
clinicians use it effectively for the endoscopic treatment of
bleeding Meckel’s diverticula (43). Double-ballon enterosco-
py has also been used for endoscopic full-thickness resec-
tion of inverted Meckel’s diverticulum (40,44).
Although endoscopic therapeutic procedures have been
used recently, the main treatment for Meckel’s diverticulum
is surgical resection. However, whether resection should
be applied to all incidentally detected Meckel’s diverticula
or not is still controversial. Elective surgery is not recom-
mended for cases where the diverticulum is discovered
incidentally on radiological imaging. In general, it is not
possible to determine the increased risk of complications
associated with incidentally detected Meckel’s diverticulum
by intraoperative palpation or inspection (2). Therefore, for
this reason, the intraoperative approach to asymptomatic
or incidentally encountered Meckel’s diverticulum remains
a matter of debate. Many surgeons advocate resection of an
730 S. Kuru and K. Kismet

incidentally encountered diverticulum due to the potential
for life-threatening complications that may develop (45).
The clinical circumstances of the case, the life-long risk of
complications and anatomic characteristics associated with
symptoms should be taken into account when asymptomat-
ic diverticula are encountered during an abdominal explo-
ration (15,46). Some surgeons use a risk score as a guide
to make a decision of the need for a resection. Robijn et al.
(46) recommend a scoring system based on the four risk
factors for decision-making using weighted criteria and a
more objective basis; these include: patient age < 45 years,
male gender, fibrous band presence and diverticula > 2 cm
long. When the risk score is ≥ 6 points, the resection of
asymptomatic Meckel’s diverticula is recomended.
Based on the data of the relevant literature, all incidentally
detected diverticula that meet any of the following criteria
should be removed.
• Patient age < 50 years (47).
• Male gender (47).
• Length of the diverticulum > 2 cm (47).
• Presence of abnormal tissue on histopathological ex-
amination (47).
• A broad-based diverticulum, which has been shown in
other studies to be prone to complications (46).
• The presence of fibrous bands attached to the divertic-
ulum may also be significat (46).
Symptomatic Meckel’s diverticula should be managed sur-
gically by laparotomy, laparoscopy or laparoscopy-assisted
approaches (19). Generally, a wedge resection is performed
of the diverticulum and sometimes an end-to-end anasto-
mosis is applied following the resection of an ileum seg-
ment. The extent of resection is determined according to
the intraoperative findings and any intraoperative compli-
cations. If the omphalomesenteric remnant is narrow-based
and there is no palpable mass within the lumen of the ile-
um, this diverticulum may be managed by a simple wedge
resection, followed by a primary closure of the remaining
defect (9,48). If the diverticulum base is broad, heterotopic
tissue is palpated or there are ischemic or inflammatory
alterations in the ileum adjoining the diverticulum, resec-
tion of the associated intestine and end-to-end anastomo-
sis should be applied. A segmental ileal resection must
be performed in cases of gastrointestinal bleeding, as the
hemorrhage is generally located in the adjoining ileum.
Depending on the size and location of benign tumors with-
in the diverticulum, simple diverticulectomy is sufficient,
whereas malignant tumors require wide resection of the
intestine and mesentery (45).
The treatment algorithm created by the authors of this
review for Meckel’s diverticula is shown in figure 2.
CONCLUSION
Meckel’s diverticulum, which contains all the layers of the
small intestine, is the most commonly seen congenital
abnormality of the gastrointestinal tract. Although present
in only a small percentage of the general population, the

The Treatment Algorithm of

Meckel's diverticulum

Asymtomatic Meckel's Symptomatic Meckel's

diverticulum diverticulum

Meckel's diverticulum Meckel's diverticulum Surgery

discovered incidentally on discovered incidentally during
imaging an operation (controvertial)

Non elective surgery Age < 50 years Age ≥ 50

Male sex
Diverticulum length ≥ 2 cm
The presence of abnormal
tissue
A broad-based diverticulum
(≥ 2 cm)
The presence of fibrous bands
attached to the diverticulum
(unless there is the presence
of medical comorbidities)
Female sex
Diverticulum length < 2 cm
A narrow-based diverticulum
(< 2 cm)
The absence of fibrous bands
attached to the diverticulum

Surgery No surgery

Fig. 2. The treatment algorithm of Meckel’s diverticulum (created by Serdar Kuru, MD).

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 Meckel’s diverticulum: clinical features, diagnosis and management
complications of this disorder can be severe. These include
intestinal obstruction, hemorrhage, intussusception, diver-
ticulitis and perforation causing peritonitis. It can be difficult
to diagnose a complicated Meckel’s diverticulum preopera-
tively as the radiological and clinical findings can resemble
features of other acute abdominal disorders. A good level of
knowledge of the clinical, embryological, radiological and
pathological features of Meckel’s diverticulum will enable
a rapid and proper diagnosis of patients, thereby allowing
treatment via a timely surgical intervention.
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