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Bleeding Meckel diverticulum responds to intravenous pantoprazole.

To the Editor: Meckel diverticulum (MD) is the most common developmental anomaly of the gastrointestinal tract, affecting 2% of the general population. Although it is often noted as an incidental finding during laparotomy, in 5% of cases it may present with serious complications such as massive bleeding, intussusception, obstruction and acute diverticulitis with risk of perforation. Painless rectal bleeding and melena are the most common complications. Half of Meckel diverticular cases may contain ectopic gastric or pancreatic mucosa. Although it has been reported in all age groups, it typically presents within the first two years and occurs twice as often in boys than girls.

A 9-year-old Native American boy presented initially with hematemesis followed by significant melena and drop of hemoglobin from 13 g/dL to 8 g/dL. Intravenous pantoprazole (Protonix) was given at 40 mg per day. No source of bleeding was identified on upper GI endoscopy or a subsequent red blood cell-tagged isotope bleeding scan. While awaiting technetium pertechnetate radionuclide scan and Meckel scan, the patient's melena resolved and his hemoglobin stabilized on day two. On day four, Meckel diverticulum was diagnosed by the isotope scan and treated with laparoscopic resection. Histologic evaluation revealed ulcerated mucosa with features of recent hemorrhage.

To our knowledge, this is the first reported use of a proton pump inhibitor, pantoprazole, in a case of a bleeding Meckel diverticulum, as well as a unique presentation involving hematemesis. The use of H2-receptor antagonists for Meckel diverticulum was reported to enhance the sensitivity of the isotope scan. However, as early as 1978, Kirkpatrick reported successful treatment of bleeding Meckel diverticulum with cimetidine. (1) Collins reported that the interim use of cimetidine facilitated the performance of elective diverticulectomy for life-threatening hemorrhage from a Meckel diverticulum. (2) Volpato et al also reported successful control of bleeding Meckel diverticulum with ranitidine infusion for 5 days. (3) Control of bleeding by a proton pump inhibitor in this case may reflect the superior efficacy of this agent in reducing acid production by ectopic gastric mucosa. Therapy with H2 receptor antagonists has not been consistently successful, as Manning reported failure of this approach to control a bleeding Meckel diverticulum. (4) The response observed in our patient was prompt and sustained for over two days. Minchom et al reported sustained control of a bleeding Meckel diverticulum for over three months on oral cimetidine in a 12-year-old boy with Duchenne muscular dystrophy. However, perforation of the ulcerated diverticulum and peritonitis followed, confirming that surgery remains the treatment of choice. (5)

Possible reasons for the initial hematemesis in our patient include Mallory-Weiss tears, swallowed nasopharyngeal blood, and red dye-ingested beverages or foods. It is less likely that bleeding from Meckel diverticulum would result in overt upper GI bleeding. However, there was no evidence of these other entities at the time of his endoscopic evaluation. Obscure GI bleeding responding to empiric pantoprazole may still represent a Meckel diverticulum, as highlighted by this patient.

Ahmed Dahshan, MD, FAAP

Division of Pediatric Gastroenterology

Oklahoma University Health Sciences

Center-Tulsa

Tulsa, OK

References

1. Kirkpatrick RA. Cimetidine and Meckel's diverticulum. Ann Intern Med 1978;88:846-847.

2. Collins JC Jr. Hemorrhage from a Meckel's diverticulum: one case with heterotopic gastric mucosa treated with cimetidine. Arch Surg 1980;115:83-84.

3. Volpato M, Marchetto R, Tacchetti G, et al. [Selective therapy with ranitidine in a case of bleeding Meckel's diverticulum] Minerva Dietol Gastroenterol 1989;35:61-63.

4. Manning RJ. Failure of H2 blocker therapy in a case of hemorrhage from a Meckel's diverticulum. J Clin Gastroenterol 1987;9:242.

5. Minchom PE, Wheeler MH, Sibert JR. Cimetidine and peptic ulceration in a Meckel's diverticulum. Arch Dis Child 1980;55:321.
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Title Annotation:Letters to the Editor
Author:Dahshan, Ahmed
Publication:Southern Medical Journal
Date:Mar 1, 2007
Words:611
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