An obscure addendum of human anatomy discerned during elective or emergent abdominal surgery is exemplified as Meckel’s diverticulum. Meckel ‘s diverticulum is located on the ileum and configures a frequent, benign, congenital malformation of gastrointestinal tract. Persistence or defective atrophy of the embryonic omphalo-mesenteric or a vitelline duct describes Meckel’s divertculum^[1,2]. German anatomist “Johann Friedrich Meckel” aptly connoted the entity in early 19th century which subsequently adopted a nomenclature of Meckel’s diverticulum^[1]. Majority of the lesions remain asymptomatic. When Meckel’s diverticulum is devoid of a pre-emptive surgical eradication, severe complications such as haemorrhage or perforation arise. Detection of the diverticulum is incidental and enhanced imaging studies such as Computerized Tomography (CT) along with the evolution of laproscopic surgical techniques augments the discernment of the anomaly. Thus, epidemiological incidence of the malformation requires evaluation. An estimated three fourths (74%) instances with systemic symptoms of surgically extracted Meckel’s diverticulum are constituted by males^[2,3].

Embryogenesis of Meckel’s Diverticulum

Foetal omphalo-mesenteric duct usually conjoins with the yolk sac to intestinal tract and generally is obliterated during 5^th to 7^th week of gestation. In instances of disrupted development and duct obliteration, congenital anomalies emerge such as residual fibrous cords, umbilical sinus, omphalo-mesenteric fistula, enterocyst and frequent congenital anomaly of Meckel’s diverticulum^[3,4].

Disease Prevalence: Estimated incidence of Meckel’s diverticulum varies amidst 0.3% to 2.9% within the general population. Proportionate discernment of Crohn’s disease permits the detection of Meckel‘s diverticulum as a comprehensive intestinal examination for Crohn’s disease is a pre-requisite and appropriately assesses the presence of Meckel’s diverticulum.Meckel’s diverticulum depicts a male predominance with a M: F ratio varying from 1.5:1 to 4.1: 1. Constitutional symptoms of Meckel’s diverticulum predominate in males during childhood, though the condition can emerge at any age. Surgical intervention for Meckel’s diverticulum is commonly required below 5 years of age in an estimated half (50%) the instances and incidence of symptomatic disease declines in due course^[2,3].

Lifetime probability of Meckel‘s diverticulum developing systemic symptoms and complications collates at an estimated 4.2% - 9.0%. Constitutional symptoms of Meckel’s diverticulum comprise of gastro-intestinal haemorrhage, intestinal obstruction, and intestinal inflammation with a co-existent or absent intestinal perforation along with presence of an ectopic gastric mucosa. Ectopic tissue and adjunctive symptoms of Meckel’s diverticulum may or may not induce an intestinal perforation^[2]. Aberrant gastric tissue constitutes a frequent form of ectopic tissue discerned within Meckel’s diverticulum followed in frequency by anomalous pancreatic tissue.

Disease Characteristics: Meckel’s diverticulum is situated within 7 centimetres to 200 centimetre distance from ileo-caecal valve on the anti mesenteric border of the ileum. Mean distance is estimated at 52.4 centimetres from the ileocaecal valve. Diverticulum ranges from 0.41 centimetre to 11 centimetres in length with an estimated mean length of 3.05 centimetres and a diameter of 0.3 centimetre to 7.0 centimetres with a mean diameter of 1.58 centimetres^[2]. Systemic symptoms of Meckel’s diverticulum frequently elucidate clinical aspects of intestinal obstruction , gastro-intestinal haemorrhage and inflammation of the diverticulum with or without an intestinal perforation^[3,5].

Meckel’s diverticulum enunciates an intestinal obstruction on account of intussusceptions or diverticular invagination into the small intestinal lumen. Volvulus of small intestine while circumscribing the diverticular axis augments possible intestinal obstruction.

Gastro-intestinal haemorrhage appears as a painless bleeding per rectum and is often secondary to acid generated from ectopic gastric mucosa situated within the Meckel’s diverticulum. Gastric acid secretion damages the intestinal lumen and induces a mucosal ulceration with haemorrhage^[5,6].

Inflamed Meckel’s diverticulum demonstrates an inflammatory infiltrate confined to the diverticulum itself or an accompanying perforation of the diverticular wall with exemplification of peritonitis. Commonly, greater than half (50%) the instances of Meckel’s diverticulum delineates systemic symptoms. Intestinal obstruction arises in an estimated half (46.7%) the instances, gastro-intestinal haemorrhage in one fourth (25.3%) and inflammation of the bowel is elucidated with roughly one fifth (19.5%) of individuals. Combined complications of intestinal obstruction, gastro-intestinal haemorrhage and intestinal inflammation incorporate three fourths to all (69.5% to 100%) of the constitutional symptoms of Meckel’s diverticulum .

Umbilical aberrations of vitelline duct, parasitic infestation of Meckel’s diverticulum and carcinoma of the diverticulum arise infrequently^[2].

Intestinal mucosa coating the walls of ileum usually covers the mucosal surface of Meckel’s diverticulum which is concomitantly constituted by ectopic tissue such as gastric mucosa or less frequently, pancreatic tissue. The anomaly is observed within 4.6% to 7.1% of Meckel’s diverticulum with systemic symptoms. Occurrence of ectopic tissue is occasional in asymptomatic variant of Meckel’s diverticulum and 0% -18.2% instances display an ectopic gastric tissue while 0% -5% depicts the presence of ectopic pancreatic tissue. Altogether, ectopic gastric and pancreatic tissue constitutes almost all (97%) the instances of ectopic tissue emergence. Ectopic duodenal and colonic tissues are exceptional. Systemic symptoms, particularly gastrointestinal haemorrhage is induced within Meckel’s diverticulum on account of the anomalous tissue^[7].

Disease Attributes: Nerve fibre density of the wall of Meckel’s diverticulum is implicated in the genesis of constitutional symptoms. Intestinal mucosal lining and wall of Meckel’s diverticulum generally depict an augmented nerve fibre density, in contrast to ectopic gastric mucosal coating or muscular wall of the ileum. Enhanced nerve fibre density ensures an intense local peristalsis which induces an intussusception of Meckel’s divertculum. Nerve fibre density declines with age thus systemic symptoms of Meckel’s diverticulum frequently emerge with juvenile patients^[7,8]. Ectopic gastric mucosa enhances acid secretion and nerve fibre density tends to decline with older age, thus intestinal obstruction with Meckel’s diverticulum appears in younger children, in contrast to gastro-intestinal haemorrhage secondary to Meckel’s diverticulum.

General characteristics of Meckel’s diverticulum are explained by a two percent rule: prevalence of uncomplicated Meckel’s diverticulum is confined to 2% population, diverticulum is situated at an estimated 2 feet ( approx 61 cm) from the ileocaecal valve, congenital aberration is 2 inches (5 cm) in length, it depicts 2 frequent configurations of ectopic tissue (gastric and pancreatic) and the lesion is commonly detected at 2 years of age.

Clinical Elucidation: Meckel’s diverticulum is considered as a true diverticulum as the diverticular wall is comprised of three coats of intestinal wall. Typical appearance is on the anti-mesenteric border and it’s vascular perfusion arises from vitelline artery.

The congenital disorder frequently presents with lower gastro-intestinal haemorrhage in paediatric patients^[7,8]. A deficient, atrophic vitelline duct configures as a Meckel’s diverticulum while a patent vitelline duct conjoins with small intestine along with umbilicus and generates an umbilical discharge. Umbilical hernia commingled with Meckel’s diverticulum is a congenital condition, frequently detected in neonatal period. Thus a competent history, appropriate physical examination and conscientious imaging studies including a plain X ray abdomen is beneficial^[8.9]. Constitutional symptoms or secondary complications comprise of intestinal obstruction, intestinal perforation, peritonitis, pathological intestinal diverticula, lower gastro-intestinal bleed along with gangrenous bowel. Duodenal, colonic or pancreatic mucosa is demonstrated in the Meckel’s diverticulum besides Brunner’s glands, hepatobiliary tissue or endometrial mucosa situated at the tip of Meckel’s diverticulum^[8,9]. Complications due to Meckel’s diverticulum appear in 4% -16% instances. The anomaly is equally prevalent within genders, though complications are four times frequent in males. Role of Helicobacter pylori in pathogenesis of gastritis and haemorrhage within the ectopic gastric mucosa is debatable.

Palpable thickening of wall of Meckel’s diverticulum is an insufficient indicator of anomalous tissue. Proportion of diverticular height to diverticular diameter impacts the quantification and dispersal of ectopic tissue within Meckel’s diverticulum. Height to diameter ratio of greater than 1.6 centimetres indicates ectopic tissue to be situated at the tip of the diverticulum while a height to diameter ratio beneath 1.6 centimetres enunciates the location of ectopic tissue at the base of the diverticulum. Hypothesized pleuri-potent cells engendering ectopic tissue states that aberrant diverticular tissue originates within pleuri-potent cells of embryonic yolk sac which subsequently conjoins with vitelline duct^[9,10].

Small bowel mechanical obstruction on account of intussusception or painless haemorrhage per rectum or an inflamed Meckel’s diverticulum with peritonitis can appear. Common coexistent symptoms are fever, vomiting, abdominal pain and bloody stools. However, systemic symptoms with underlying pathology of an inflamed or perforated Meckel’s diverticulum can be confused with inflamed appendix^[9,10].

Carcinoma of Meckel’s diverticulum arises from or secondarily incorporates Meckel’s diverticulum at mean age at 60 years.

Figure 1 MD: mucosal prominence with glandular hyperplasia[18].

Figure 2 MD: muscular hyperplasia with vascular congestion[19].

Figure 3 MD: ectopic gastric mucosa and pancreatic glands[20].

Figure 4 MD: Ectopic Gastric Mucosa With Mucosal Perforation[21].

Figure 5 MD: ectopic gastric mucosa[22].

Figure 6 MD: mucosal and glandular prominence[18].

Figure 7 MD: ectopic gastric mucosa[21].

Figure 8 MD: ileal mucosa with hypertrophy[23].

Figure 9 MD: diverticular outline with mucosal pre-eminence[24].

Figure 10 MD: with carcinoid tumour: reactive to synaptophysin[25].

Complications of Meckel’s Divertculum: Classic Meckel’s diverticulum demonstrates complications such as band formation, strangulation of the diverticulum and a malignant transformation. Complications are age- specific and conditions such as intestinal obstruction or gastro-intestinal haemorrhage are frequent with paediatric patients, though intestinal obstruction appears in relatively young individuals. Intestinal inflammation and Littre’s hernia (hernia of bowel segment containing Meckel’s diverticulum) appears in adults. Malignant transformation concurs with elderly population^[10,11]. Nevertheless, symptomatic triad of intestinal obstruction, gastro-intestinal haemorrhage and intestinal inflammation frequents the adult and paediatric instances of Meckel’s divertculum, thus making it crucial to discern constitutional symptoms and complexities of Meckel’s diverticulum.

Individuals displaying non-specific abdominal complaints are detected intra – operatively. Complications such as intestinal perforation or small bowel obstruction necessitate a quick, preliminary identification. The French surgeon Alexis Littre in 1700 A.D. demonstrated an incarcerated femoral hernia comprising of diverticulum of the small intestine. Hernia sac with occupant Meckel’s diverticulum is termed as “Littre’s Hernia”^[9]. Of undetermined prevalence, Littre’s hernia is induced due to projection of Meckel’s diverticulum through a hernial orifice. Littre’s hernia articulates as an inguinal (50%), umbilical (20%), femoral (20%), incisional or adjunctive hernias (10%). Percentage contribution of small bowel loops and Meckel‘s diverticulum constituting inguinal hernia is problematic to assess on clinical grounds^[3,4]. Thus, pre-operative diagnosis is rarely accurate. Silent or incidental Meckel’s diverticulum constituting a Littre’s hernia is clinically discerned during an unrelated abdominal laprotomy or within an inguinal incision. Symptomatic Meckel’s diverticulum is elucidated in an estimated 4%-6% individual.

Painless gastro-intestinal bleeding as a frequent, initial representation is elucidated in children with a rough incidence of 10.9% and 38.9%. Majority of Littre’s hernia are located within umbilical hernia. Painful inflammation or diverticulitis commonly appears in adults along with bowel obstruction.

Conditions such as intussusceptions, intestinal inflammation, omphalo-mesenteric bands, intestinal adhesions or adeno-carcinoma induce bowel obstruction (26.2% to 53.4%).

Meckel’s diverticulum with systemic symptoms is eliminated surgically along with co-existent, asymptomatic pathological intestinal diverticula, incidentally detected on an unrelated abdominal laprotomy. Intestinal obstruction (second frequent complication of Meckel’s diverticulum) is engendered by confinement of intestinal loops with a fibrous meso-diverticular band or volvulus of the diverticulum circumscribing meso- diverticular band. Intussusception as well as an expansive hernia sac (Littre’s hernia) also induces an intestinal obstruction^[11,12].

Malignancy and Meckel’s Diverticulum: Carcinoma arising from Meckel’s diverticulum is infrequent (1%-3%) and is not accountable for instances of resection with incidental diverticula. In contrast to tumours of ileum, Meckel’s diverticulum depicts an augmented possibility of malignant conversion.

Frequent neoplasm defined with Meckel’s diverticulum are carcinoid tumour (33%) and gastro-intestinal stromal tumours such as leiomyosarcoma (18%) followed by gastric adeno-carcinoma (12%) along with exceptional pancreatic adenocarcinoma, intraductal papillary mucinous neoplasm, gastro-intestinal stromal tumours and gastro-intestinal lymphomas.

Carcinoid tumours associated with incidental Meckel’s diverticulum depict elevated complications with enhancing age. Incidence of carcinoma arising within Meckel’s diverticulum amplifies with advancing age and culminates by the seventh decade.

Surgical extermination of an asymptomatic, incidental Meckel’s diverticulum with carcinoma requires re-evaluation^[11,12].

Investigative Profile: Incidental Meckel’s diverticulum is a diagnostic challenge and is detected during investigations for associated disorders. Imaging modalities such as abdominal ultrasound, plain X-ray abdomen, angiography, Computerized Tomography (CT) and magnetic resonance imaging (MRI) permits the discernment of Meckel’s diverticulum^[13,14].

Sensitivity and specificity of radiographic assays is not optimal. Small bowel obstruction and intussusception is detected on surgical intervention and Meckel’s diverticulum is mistaken for a normal appendix. Angiography can adequately discern origin of gastro-intestinal Haemorrhage. Elucidation of vitelline artery conjoining from superior mesenteric artery is considered diagnostic of an originating Meckel’s diverticulum. Angiography as an investigative modality is decisive in instances where rate of gastro-intestinal haemorrhage appears greater than 0.5 millilitres / minute^[4,5]. Plain X ray abdomen lacks distinctive or diagnostic features of Meckel’s diverticulum. Ultra-sound is not a sensitive technique of detection and Meckel’s diverticulum appears as a duplication cyst^[13,14,15].

Abdominal Computerized Tomography (CT) is employed for complex cases such as intussusception secondary to the diverticulum and appropriately distinguishes initial point of intussusception. Ultrasound and computerized tomography (CT) enunciates the diverticulum as simulating a cyst or blind pouch when diverting from ileum. Abutting loops of small intestine require a distinction from Meckel’s diverticulum although a fibrotic band adhering the diverticulum to umbilicus or mesentery ascertains the demarcation. Computerized tomography (CT) scans quantify peritoneal fat interspersed within bowel loops and qualifies the distinction amidst diverticulum and intestinal loops^[15,16].

Vigilant observation is required to as certain Meckel’s diverticulum on Computerized Tomography (CT) scan. A nuclear scan with Technetium 99 m pertechnetate suitably delineates Meckel’s diverticulum. Radio-active tracer accumulates in specific tissues such as ectopic gastric tissue. Assay with particular findings can depict focal uptake of radio-active tracer in conjunction with normal gastric mucosa^[16,17]. Truly positive test signifies functional ectopic gastric mucosa in appropriate quantities situated within Meckel’s diverticulum. Precision of Technetium 99m pertechnetate scan is augmented with several techniques such as employment of H2 receptor blockers, naso-gastric aspiration, saline lavage of bladder and with a repetitive scan. Meckel’s scan discerns Technetium 99m pertechnetate uptake by ectopic gastric mucosa. The particular assay is suitably specific at 95% and paediatric sensitivity of 85% which declines to an estimated 54%-60% in adults.

A Duodenal or jejunal duplication cyst exemplifies false positive outcomes. False negative Technetium 99m pertechnetate scan is elicited with Meckel’s diverticulum which lacks an ectopic gastric mucosa. Gastro-intestinal haemorrhage induces an exudation of radio-active tracer with doubly manifested positive and negative outcomes. Meckel’s diverticulum is superimposed with adjunctive viscera in order to accommodate the tracer such as stomach , kidney or bladder. Pre- emptive medication with certain drugs enhances diagnostic accuracy of the investigation. An H2 antagonistic agent such as cimetidine or ranitidine is employed in order to curtail the secretion of radio-active tracer by gastric epithelium and activates aggregation of tracer. Nuclear scan is repeated with instances of ambiguous results or with clinical findings suggestive of Meckel’s diverticulum. Factors such as anaemia secondary to gastro-intestinal haemorrhage finds the assay applicable with augmented sensitivity and specificit^[4,5].

Direct visualization of Meckel’s diverticulum via surgical or laproscopic techniques, open laprotomy or endoscopic evaluation of small intestine corroborates the diagnosis. Double balloon endoscope is inserted in the ileum until Meckel’s diverticulum is located. Capsule endoscopy with an ingested camera records the bowel movements with forward propulsion. However, the camera lacks appropriate mobilization and extends beyond the orifice of Meckel’s diverticulum or camera can be misdirected^[16,17].

Therapeutic indications Meckel ‘s diverticulum with constitutional symptoms detected in adults is surgically removed, however operative therapies applicable for asymptomatic or incidental Meckel’s diverticulum remain controversial.

Incidental or asymptomatic Meckel’s diverticulum mandates a surgical eradication. Indications of surgical elimination comprises of male patients, age of implicated individual beneath 50 years, diverticulum greater than 2 centimetres in magnitude and appearance of atypical histology^[11,12]. Meckel’s diverticulum is surgically removed within first two years of life. Complications arising from the congenital anomaly are inversely proportional to age of the patient. Incidental Meckel’s diverticulum in paediatric patients are surgically removed when silent or asymptomatic. In elderly patients an asymptomatic Meckel’s diverticulum is permitted to remain in situ. Surgical techniques employed and ensuing complications necessitate an appropriate evaluation prior to embarking upon a procedure to remove an asymptomatic Meckel’s diverticulum as it does not constitute as a surgical emergency. Clinical attributes in which surgical resection is beneficial are: narrow base of diverticulum, lengthy, elongated Meckel’s diverticulum and degree and quantification of palpable mucosal heterotopias. Diverticulectomy is twice as frequent a procedure with male paediatric patients, in contrast to females. Intestinal diverticula with a broad base or accompanied with gastro-intestinal haemorrhage are managed with an adequate bowel resection.

Therapeutic Modalities: Emergence of tissue ectopia within Meckel’s diverticulum proves to be a categorical indication for surgical intervention.

Techniques of surgical resection consist of simple diverticulectomy or primary end-end intestinal anastomosis with concomitant ileo-caecal bowel resection^[9,10].

Suitable treatment of the congenital disorder is laproscopic surgical resection or open surgery. Tissue wedge or segment of abutting intestine may or may not be interposed within excised edges. Numerous laproscopic techniques are employed for resection of Meckel’s diverticulum. Trocar 1 or trocar 3 is inserted with an abdominal incision or intra-peritoneal resection or through bowel exteriorization or with an intestinal segment containing Meckel’s diverticulum. Laproscopy or laproscopic assisted surgical techniques applicable for Meckel’s diverticulum are considered safe and efficacious^[6,7]. Complications ensuing the surgical procedure can appear. Post operative morbidity is at an estimated 5.3%. Estimated two-thirds (66%) of post operative complications are conformed to wound infection or post operative ileus. Morbidity is enhanced in instances of surgical extermination of the diverticulum, in contrast to Meckel’s divertculum remaining in situ.

Prophylactic surgical resection of Meckel’s diverticulum is undertaken during abdominal surgical procedures for associated lesions.

Perforated and gangrenous appendix is considered as a contraindication for prophylactic resection of Meckel’s diverticulum. An estimated 5.3% possibility of post-operative complications following prophylactic surgical resection are elucidated, in contrast to a 1.3% probability of delineating symptoms in Meckel’s diverticulum in situ. However, silent Meckel’s diverticulum in situ is devoid of extensive or extended complications. Possible emergences of systemic symptoms with Meckel’s diverticulum do not decline with enhancing age. Constitutional symptoms appear with Meckel’s diverticulum presenting in the male sex (17%), age below 50 years (25%), diverticular magnitude greater than 2 centimetres (42%) and appearance of ectopic tissue (70%).

Diverticulectomy or segmental resection of the ileum is the preferred procedure with broad based Meckel’s diverticulum, in order to curtail intestinal luminal restriction as well as gastro-intestinal haemorrhage. Surgical resection is comprehensive in order to limit ectopic gastric mucosa and prevent configuration of an intestinal ulcer. Peptic ulcer arising on account of acid secretion from ectopic gastric mucosa is frequently situated in the ileum, contrary to Meckel’s diverticulum, on account of peristaltic activity within the congenital anomaly and recalcitrant ectopic gastric mucosa with acid secretion. Long and thin Meckel’s diverticulum without haemorrhage is managed with simple surgical resection as ectopic gastric or pancreatic tissue is confined to the tip^[2,3].

Conclusion

Meckel’s diverticulum appears on the anti-mesenteric border and is a true diverticulum as the diverticular wall is composed of three coats of intestinal wall. Duodenal, colonic or pancreatic mucosa, Brunner’s glands, hepatobiliary tissue or endometrial mucosa are demonstrated in Meckel’s diverticulum. Small bowel mechanical obstruction on account of intussusception , painless haemorrhage per rectum or inflamed Meckel’s diverticulum with peritonitis arise as complications. Neoplasm associated with Meckel’s diverticulum are carcinoid tumour (33%) and gastro-intestinal stromal tumours such as leiomyosarcoma (18%), gastric adeno-carcinoma (12%) and exceptionally pancreatic adenocarcinoma, intraductal papillary mucinous neoplasm, gastro-intestinal stromal tumours and gastro-intestinal lymphomas. Diverticulectomy or segmental surgical resection of the ileum is preferred in order to curtail luminal restriction and gastro-intestinal haemorrhage. Comprehensive surgical extermination restricts the ectopic gastric mucosa and prevents an intestinal ulcer.

Table: Complications of Meckel’s diverticulum[2,3].

References

1. Meckel, J.F. Uber die Divertikel am Darmkanal. (1809) Arch Physiol 9: 421-453.

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2. Hansen, C.C., Soreide, K. Systematic review of epidemiology, presentation and management of Meckel’s diverticulum in the 21^st (2018) Medicine 97(35): 12154.

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3. Jadlowiec, C.C., Bayron, J., William, T. M. Is incidental Meckel’s divrticulum truly benign? (2015) Case reports surgery: 4.

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4. Sagar, J., Kumar, V., Shah, D.K. Meckel’s diverticulum: a systematic review. (2006) J R Soc Med 99(10): 501-505.

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5. Parihar, D., Raikwar, P., Arvinder, P., et al. Meckel’s diverticulum and patent vitello-intestinal duct in children: A review of 5 years of experience with 16 cases. (2018) J Dental Med Sci 17(2): 5-7.

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6. Reddy, S., Reddy, P., Victor, V. B. Strangulated Meckel’s diverticulum in Inguinal Hernia. (2018) Scholarly J Surgery 1(1): 12-13.

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7. Sancar, S., Demirci, H., Sayan, A., Arıkan, A., Meckel’s diverticulum : 10 years experience. (2015) Ulus Cerrahi Derg 31(2): 65-67.

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8. Alemayehu, H., Hall, M., Desai, A.A., et al. Demographic disparities of children presenting with symptomatic Meckel’s diverticulum in children’s hospitals. (2014) Paediatr Surg Int 30(6): 649-653.

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9. Chen, J.J., Lee, H.C., Chun-Yan, Y., et al. Meckel’s diverticulum factors associated with clinical manifestations. (2014) ISRN Gastroenterol: 5.

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10. Huang, C.C., Lai, M.W., Hwang, F.M. et al. Diverse presentation in paediatric Meckel’s diverticulum: a review of 100 cases. (2014) Paediatr Neonatol : 55(5): 369-375.

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11. Francis, A., Kantarovich, D., Khoshnam, N., et al” Paediatr Meckel Diverticulum: report of 208 cases and a review of literature. (2016) Fetal Paediatr Pathol 35(3): 199-206.

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12. Gezer, H.O., Temiz, A., Ä°nce,, et al. Meckel’s diverticulum in children : evaluation of macroscopic appearance for guidance in subsequent surgery. (2016) J Pediatr Surg 51(7): 1177-1180.

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13. Duan, X., Ye, G., Hongqiang, B., et al. Laproscopic versus laproscopically assisted management of Meckel’s diverticulum in children. (2015) Int J Clin  Exp Med 8(1): 94-100.

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14. Rattan, K.N., Singh, J., Dalal, P., et al. Meckel’s diverticulum in children: our 12 year experience. (2016) Afr J Pediatr Surg 13(4): 170-174.    

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15. Bandi, A., Tan, Y.W., Tsang, T. Correlation of gastric heteropia and Meckel’s diverticular bleeding in children- a unique association. (2014) Pediatr Surg Int 30(3): 313-316.

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16. Kawamoto, S., Raman, S.P., Blackford, A., et al. CT detection of symptomatic and asymptomatic Meckel’s diverticulum. (2015) AJR Am J Roentgenol 205(2): 281-291.

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17. Suh, M., Lee, H.Y., Jung, K., et al. Diagnostic accuracy of Meckel ‘s scan with initial haemoglobin level to detect symptomatic Meckel’s diverticulum. (2015) Eur J Pediatr Surg 25(5): 449-453.

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18. Image 1  &  6Courtesy:  

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19. Image 2 Courtesy : Research gate.

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20. Image 3 Courtesy:

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21. Image 4 & 7 Courtesy : Wikimedia commons.

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22. Image 5 Courtesy: View image.

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23. Image 8 Courtesy: African J of Paediatric Surgery.

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24. Image 9 Courtesy: Histology of birds.

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25. Image10 Courtesy : Hindawi.org.

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