A multimodal approach to uncovering Meckel's diverticulum‐related chronic abdominal pain in adults

A 49-year-old female presented with chronic intermittent middle abdominal pain. She has an underlying history of an appendectomy performed 10 years ago and mild chronic superficial gastritis, under medication control with regular esophagogastroduodenoscopy follow-up. Lab data upon arrival showed no obvious sign of inflammation or anemia. We arranged a series of examinations including plain abdominal X-ray, computed tomography, esophagogastroduodenoscopy, and colonoscopy, but none of the exams demonstrated remarkable findings. Due to intractable pain, tests were conducted for porphyrin and heavy metals (considering a possible history of contact), both of which showed negative results. For the chronic abdominal pain, capsule endoscopy was arranged and revealed an ileal diverticular orifice, with the double-lumen sign at 55% of total small bowel transit time (Figure 1A). Tc99m pertechnetate Meckel's scan showed faint occult functional Meckel's diverticulum (MD) in the proximal right lower quadrant (Figure 1B). The patient underwent exploratory laparoscopy and MD, with a size of 1.4 × 1.1 × 0.5 cm, was identified at 90 cm from the ileocecal valve at the anti-mesentery border (Figure 1C). The diverticulum was excised, and a histopathological examination of the specimen confirmed the diagnosis of Meckel's diverticulum with chronic inflammation. The patient's abdominal pain was relieved after surgery and did not recur at subsequent regular outpatient department follow-up visits. MD, a congenital malformation, poses diagnostic challenges, which in adults can range from asymptomatic to severe, including risks of obstruction, hemorrhage, and malignancy.1, 2 Meckel's scan (MS) is the preferred initial diagnostic method for children, but a 2021 Taiwan study, indicates its diagnostic rate drops to 34.5% in adults due to lower ectopic mucosa levels.3 In contrast, small-bowel capsule endoscopy (SBCE) provides a 45.5% diagnostic yield, though less than balloon-assisted endoscopy (BAE), which achieves 100%.3 The European I-CARE study now recommends SBCE as the standard for adults with gastrointestinal bleeding after inconclusive endoscopies, reserving MS and BAE for unclear SBCE results, due to MS's lower sensitivity and BAE's invasiveness.4 Currently, there is limited evidence supporting the diagnosis of non-hemorrhagic MD, indicating a gap in the current diagnostic approaches.3-5 The combined use of SBCE and MS particularly for adults with small, non-hemorrhaging MD, highlights the importance of tailored diagnostic strategies and high suspicion in adults with unexplained gastrointestinal symptoms. Conception of the case report: Y.-H. Chen. Analysis and interpretation: L.X. Koo, M.-C. Wu, Y.-C. Chen, Y.-W. Chen, and Y.-H. Chen. Writing of the manuscript: L.X. Koo and Y.-H. Chen. Major revision: Y.-H. Chen. All authors read and approved the final manuscript. All authors declare no conflicts of interest. Verbal informed consent was obtained for this case report. Ethics committee approval is not necessary because this is a case image report. Nonetheless, the authors followed the principles of the Declaration of Helsinki throughout the writing process.