Laparoscopy for definitive diagnosis and treatment of gastrointestinal bleeding of obscure origin in children

doi:10.1053/jpsu.2000.9299

Journal of Pediatric Surgery

Volume 35, Issue 9, September 2000, Pages 1291-1293

https://doi.org/10.1053/jpsu.2000.9299 Get rights and content

Abstract

Background/Purpose: Gastrointestinal bleeding (GIB) in children with no identifiable source found after upper endoscopy and colonoscopy or GIB of obscure origin can pose a great management problem for pediatric surgeons. The recent advent of laparoscopy in children has provided a useful solution. Methods: The authors reviewed their experience of using laparoscopy in the management of 17 children (13 boys) with GIB of obscure origin over an 8-year period. The mean age was 9.8 years (range, 3 to 17 years). Results: In all patients, upper endoscopy and colonoscopy results did not show a bleeding source. Pertechnetate technetium Tc 99m scan showed positive uptake in 6 patients. Of these, 4 were found on laparoscopy to have a Meckel's diverticulum, 1 had intestinal duplication, and the remaining patient had nodular lymphoid hyperplasia at the terminal ileum. Ten patients had a negative pertechnetate scan. Of these, 3 had a Meckel's diverticulum, 1 had lymphoid hyperplasia, 1 had intestinal duplication, 1 had vascular enteritis, and 4 had normal findings on videolaparoscopy. Pertechnetate scan was not performed in 1 patient and, on laparoscopy, it turned out to be Meckel's diverticulum. Laparoscopic-assisted small bowel resection was performed successfully in all patients with Meckel's diverticulum, intestinal duplication, and nodular hyperplasia. Conversion to open surgery was required in the patient with extensive ileal vascular enteritis secondary to Henoech Scholein purpura. All patients, including the 4 with normal findings on laparoscopy, had made uneventful recovery without further episode of bleeding. Conclusion: Laparoscopy is a useful diagnostic as well as therapeutic tool in children with GIB of obscure origin. J Pediatr Surg 35:1291-1293. Copyright © 2000 by W.B. Saunders Company.

Section snippets

Materials and methods

Between 1991 and 1999, we had treated 17 children presenting with GIB of obscure origin. For children presenting with melaena or rectal bleeding, we routinely performed an initial esophagogastroduodenoscopy as an emergency and, if no lesion was found, colonoscopy. If there was no lesion identified on the endoscopy findings, a Meckel's scan would be performed. Irrespective of the result of the Meckel's scan, laparoscopy would be performed after obtaining an informed consent from parents. This

Results

Over an 8-year period, 17 children (13 boys) were treated at a mean age of 9.8 years (range, 3 to 17 years). All patients presented with either melaena or fresh rectal bleeding. Three patients also had abdominal pain. At presentation, 6 had hemoglobin level less than 10 g/L, whereas 2 had systolic blood pressure less than 100 mmHg. A Meckel's scan was performed in 16 of the 17 patients and was reported to be positive in only 6 patients. Of these, only 4 patients were found to have a Meckel's

Discussion

Although Meckel's diverticulum is the most common cause of severe lower GIB in children, occasionally other rarer pathologies including intestinal duplication or enteritis may present similarly while at the same time produce an indistinguishable false-positive Meckel's scan result.6, 8 This makes accurate preoperative identification of the exact cause of bleeding often difficult. In addition, a negative Meckel's scan result poses an equally difficult management dilemma in children with GIB of

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Cited by (71)

Clinical diagnostic predictive score for Meckel diverticulum
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Citation Excerpt :
Moreover, data has also shown that a false negative (99mTc)-pertechnetate scintigraphy can incur increased costs (true positive = $5012 ± 1992; false negative = $8554 ± 1506; P = 0.0001) [10]. A diagnostic surgery is a safe procedure with minimal complications which may be more cost effective and beneficial in the diagnosis of a bleeding MD [3, 4, 11, 15]. This scoring system can serve as an important diagnostic tool for MD.
Background/Purpose: Meckel diverticulum (MD) is present in 2% of the population. Many practitioner feel the diagnosis relies upon technetium-99 m pertechnetate scintigraphy. When negative, patients undergo additional invasive procedures delaying definitive therapy. This study aims to identify features of bleeding MD and generate a risk score, which could preclude unnecessary testing and facilitate earlier operation.
Methods: All patients <18-years-old who presented with hematochezia from 2005 to 2015 were identified. MD diagnosis was based on histopathology of operative tissue. Controls were patients with hematochezia undergoing colonoscopy. A points system was used generate a risk score.
Results: A total of 215 patients presented with hematochezia out of which 42 patients with MD were identified. Predictive variables included infant (OR 7, 95%CI 2–29) and toddler (OR 20, 95%CI 8–50) age groups, duration <6 days (OR 18, 95%CI 8–43), presence of large blood volume (OR 16, 95% CI 7–36), hemoglobin <7 g/dL (OR 6, 95% CI 3–15) and transfusion requirement (OR 16, 95% CI 7–38). A score of 6 or higher is highly suggestive of MD.
Conclusions: This scoring system identifies children with bleeding MD who may benefit from exploratory surgery without undergoing endoscopy. This novel scoring system can be applied to provide accurate clinical diagnosis, reduce unnecessary tests and allow prompt surgical management.
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2014, Clinical Pediatric Emergency Medicine
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The high false-negative rate has been contributed to inadequate amount of heterotopic gastric mucosa and high bleeding rates; however, angiography is usually negative unless the rate is greater than 0.5 mL/min, it is an invasive test with potential complications, and it is not used in the typical evaluation for Meckel's diverticulum.8 Because of the low sensitivity and high rate of false negatives when using the Meckel's scan, many have recommended proceeding directly to laparoscopy for both diagnosis and treatment when a Meckel's diverticulum or an obscure origin of gastrointestinal bleeding is suspected.9,12,13 However, recent evidence suggests that H2 receptor antagonists such as cimetidine or ranitidine can be used to augment and improve the sensitivity of the Meckel's scan when administered for 24 hours before imaging.14
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^*: Address reprint requests to W.T. Ng, Department of Surgery, Yan Chai Hospital, 711 Yan Chai St, Hong Kong, China.

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Laparoscopy for definitive diagnosis and treatment of gastrointestinal bleeding of obscure origin in children*

Abstract

Section snippets

Materials and methods

Results

Discussion

J Pediatr Surg

Gastroent Cl N Am

J Pediatr Surg

Am J Surg

J Pediatr Surg

Technetium pertechnetate scintigraphy to detect ectopic gastric mucosa in Meckel's diverticulum

Acta Radiologica: Diagnosis

Technetium-99m pertecnetate scan for ectopic gastric mucosa in children with gastrointestinal bleeding

J Form Med Ass

Ectopic gastric mucosa