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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e31822d301e
Image of the Month

Circumferential Peptic Ulceration From Meckel Diverticulum by Capsule Endoscopy

Montemaggi, Alessandra*; Paci, Monica*; Barp, Jacopo*; Milla, Monica; Lionetti, Paolo*

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*Department of Sciences for Woman and Child's Health, University of Florence, Meyer Children's University Hospital

Gastroenterology Unit, Careggi Hospital, Florence, Italy.

Address correspondence and reprint requests to Prof Paolo Lionetti, Dipartimento di Scienze per la Salute della Donna e del Bambino, Università di Firenze, AOU Meyer, Viale Pieraccini 24, Firenze 50139, Italy (e-mail: paolo.lionetti@unifi.it).

Received 11 April, 2011

Accepted 5 July, 2011

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

The authors report no conflicts of interest.

A 14-year-old girl presented with episodes of vertigo and syncope. Laboratory data were hemoglobin 6.9 g/dL, mean cell volume 67.4 fL, hematocrit 26.5%, undetectable ferritin, and fecal occult blood was positive. She underwent an extensive workup, including upper gastrointestinal endoscopy, ileocolonoscopy, technetium-99m pertechnetate scan, and ultrasound scan, which proved inconclusive in determining a source of occult gastrointestinal bleeding. Wireless capsule endoscopy disclosed an image that seemed to be a shallow circumferential ulcer around the ileal lumen that was initially supposed to be caused by inflammatory bowel disease. Laparoscopy revealed the presence of a Meckel diverticulum with a wide orifice (Fig. 1). Laparoscopic diverticulectomy was then performed. Gastrointestinal bleeding was caused by peptic ulcer secondary to acid from ectopic gastric mucosa, confirmed by histology.

Figure 1
Figure 1
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Obscure small-bowel disorders cannot always be diagnosed accurately by traditional imaging techniques (eg, radiologic, endoscopic) (1–3). False-negative technetium-99m pertechnetate scan may occur if the gastric mucosa mass within the diverticulum is insufficient, or it can result from the rapid dilution of radioactive secondary to fast bleeding from the ectopic mucosa (4,5).

Wireless capsule endoscopy is an endoscopic technique that has been shown to be safe and effective and can provide clinically useful information in the management of obscure conditions of the small bowel in children (3–6). The most common indication in children is small-intestine Crohn disease (45%) and second, gastrointestinal obscure bleeding (23%), which is the most common indication in adult practice (6).

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REFERENCES

1. Ge ZZ, Chen HY, Gao YJ, et al. Clinical application of wireless capsule endoscopy in pediatric patients for suspected small bowel diseases. Eur J Pediatr 2007; 166:825–829.

2. Mata A, Bordas JM, Feu F, et al. Wireless capsule endoscopy in patients with obscure gastrointestinal bleeding: a comparative study with push enteroscopy. Aliment Pharmacol Ther 2004; 20:189–194.

3. Riccioni ME, Urgesi R, Spada C, et al. Unexplained iron deficiency anaemia: is it worthwhile to perform capsule endoscopy? Dig Liver Dis 2010; 42:560–566.

4. Sagar J, Kumar V, Shah DK. Meckel's diverticulum: a systematic review. J R Soc Med 2006; 99:501–505.

5. Malik AA, Shams-ul-Bari, Wani KA, et al. Meckel's diverticulum-revisited. Saudi J Gastroenterol 2010;16:3–7.

6. Fritscher-Ravens A, Scherbakov P, Bufler P, et al. The feasibility of wireless capsule endoscopy in detecting small intestinal pathology in children under the age of 8 years: a multicentre European study. Gut 2009; 58:1467–1472.

Copyright 2012 by ESPGHAN and NASPGHAN

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