Wandering Meckel's diverticulum on 99m technetium-pertechnetate scintigraphy: A diagnostic dilemma?
A 2-year-old male child admitted to the emergency room with 2 days history of 3 episodes of painless per rectal fresh bleeding. On examination, child was irritable, grossly anemic, afebrile with mild abdomen distention, but audible gut sounds. Per-rectal examination revealed only traces of fresh blood. His hemoglobin was 4.9 g/dl (normal 11-14 g/dl) while other biochemical and bleeding parameters were within the normal limits. Ultrasound abdomen was unremarkable and child had blood transfusions with and started on oral ranitidine (2 mg/kg 12 hourly). On the 3rd admission day, MD scintigraphy was performed with 3 mCi of 99m technetium-pertechnetate injected intravenously with 3 h fasting. Dynamic study for 60 min with a frame rate of 20s/frame was acquired in anterior projection under a dual head digital gamma camera (Ecam, Siemens, Germany) fitted with low energy high resolution collimators. Early images showed the appearance of focus of abnormal tracer deposition in hypogastric region concomitant with the appearance of gastric activity in left hypochondrium and better delineation in subsequent frames same as native gastric activity. Sequential images revealed gross shifting of abnormal focus to left iliac region, hypogastrium, right lumbar, umbilical and finally in epigastric region []. As this abnormal focus remained compact during its tortuous path with no sign of change in its morphology during its whole path, an intraluminal source of radiotracer like bleed (which keeps on changing its shape in lumen of small or large bowel) was ruled out and provisional diagnosis of a wandering MD with heterotopic gastric mucosa was made. The child underwent an exploratory laparotomy and MD was resected and histopathology revealed MD with heterotopic gastric and pancreatic mucosa.