Clinical Radiology (2009) 64, 109e118

REVIEW

Radiological features of Meckels diverticulum and its complications

P.D. Thurleya,*, K.E. Hallidaya, J.M. Somersa, W.I. Al-Darajib, M. Ilyasb, N.J. Brodericka
Departments of aRadiology and bHistopathology, Queens Medical Centre, Nottingham University Hospitals, Nottingham, UK
Received 20 March 2008; received in revised form 16 July 2008; accepted 22 July 2008

Meckels diverticulum is the most common congenital abnormality of the small bowel. The majority of patients with this anomaly will remain asymptomatic; however, several complications may occur, including obstruction, intussusception, perforation, diverticulitis, and gastrointestinal haemorrhage. These complications may produce a variety of different clinical features and radiological appearances. The purpose of this article is to review the potential imaging manifestations of Meckels diverticulum and its complications and discuss the advantages and disadvantages of the imaging techniques available. 2008 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction
Wilhelm Fabricius Hildanus, a German surgeon, was the rst to record his observations on what is now known universally as Meckels diverticulum in 1598 when he described an unusual diverticulum. Alexis Littre also reported the presence of an ileal diverticulum within a hernia in 1700. Despite this, it was Johann Friedrich Meckel the Younger who eventually gave his name to Meckels diverticulum after describing the anomaly in 1809 whilst working as professor of anatomy at the University of Halle.1e3 Meckels diverticulum is usually found within 100 cm of the ileo-caecal valve4 and is the most common congenital abnormality of the small bowel with an incidence of between 1 and 4%. It represents a true diverticulum as it is composed of all the layers of the intestinal wall.5,6 It occurs due to a failure of the omphalomesenteric duct to involute completely, with brous obliteration of the umbilical end and patency of the ileal end

of the duct.7 Clinically the diagnosis of Meckels diverticulum is important as the lifetime risk for developing a complication has been calculated to be 4.2e6.4%,8 with the risks decreasing with increasing age.9 Many possible complications of Meckels diverticulum have been described. In a series of 776 patients with Meckels diverticulum recorded complications were gastrointestinal bleeding (28%), intussusception (13%), obstruction (11%), perforation (11%), strangulation due to a mesodiverticular band (8%), diverticulitis (6%), volvulus (5%), (Littres) hernia (2%), and neoplasm (1%). Sixteen percent of the patients in this series either had their diverticulum diagnosed as an incidental nding or the complications were not clearly recorded.10 Several different imaging methods may be used to investigate complications of a Meckels diverticulum, the aim of this review is to discuss the merits and limitations of these techniques.

* Guarantor and correspondent: P.D. Thurley, Department of Radiology, Queens Medical Centre, Nottingham University Hospitals, Nottingham NG7 2UH, UK. Tel.: 44 115 9691169; fax: 44 115 9627776. E-mail address: pthurley@doctors.org.uk (P.D. Thurley). 0009-9260/$ - see front matter 2008 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.crad.2008.07.012

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Plain radiography
Plain radiographs are not usually helpful in making the diagnosis of a Meckels diverticulum.11,12 They may be normal or show non-specic signs, such as small bowel obstruction13,14 or perforation. Rarely enteroliths may be identied on plain lm (Fig. 1); these are typically triangular and at, with a radiolucent centre. However, these ndings are not completely specic, and similar appearances can be seen with enteroliths in other diverticula or stones within the urinary tract.15 They can even mimic teeth within an ovarian dermoid cyst.16 Other possible plain lm ndings include a polypoid lling defect representing an inverted diverticulum,17 layering of radio-opaque material within a diverticulum (giving the appearance of milk of calcium)18 and segmental dilatation of the ileum.19 Overall the ndings on plain lm are not usually common or specic enough to be of practical use to conrm or exclude a Meckels diverticulum, but this diagnosis should be considered in a patient with distal small bowel obstruction or perforation without a history of previous surgery.

Contrast studies
Findings on upper gastrointestinal contrast studies are variable. The classic appearance (Fig. 1) is a single diverticulum arising from the antimesenteric border of the distal ileum,4 although it will appear as a lling defect if it is inverted.13 Other

useful features are a characteristic fold pattern adjacent to the diverticulum, which is triradiate when the bowel is collapsed and produces a mucosal triangular plateau appearance when the bowel is distended. In addition, lling defects or mucosal irregularity may be seen, representing ectopic gastric mucosa14 or blood clots in cases where the patient has presented with haemorrhage.20 These features may help distinguish a Meckels diverticulum from a duplication cyst or acquired diverticulum, both of which arise from the mesenteric border of the ileum.4 Small bowel enema (enteroclysis; Figs. 2 and 3) is advocated by some authors as a more sensitive investigation than barium follow-through for the detection of a Meckels diverticulum.21e23 A study reviewing 415 enteroclyses in a single institution over a 2.5-year period included 13 patients who had a conrmed histological diagnosis of Meckels diverticulum; 11 of these were correctly identied radiologically, with one false-positive result.24 However, there are disadvantages to enteroclysis when compared to barium follow-through studies4 due to the need to intubate the duodenum, which may cause discomfort to the patient and increase the radiation dose. The overall sensitivity for small bowel contrast studies in detecting a Meckels diverticulum varies within the published literature. The largest study of 776 patients included 118 patients who had undergone barium studies, with 55 (47%) of these correctly diagnosed as having a Meckels diverticulum.10 Unfortunately, the types of barium study used in this series were not specied. A review of

Figure 1 (a) Abdominal radiograph of an elderly man presenting with small bowel obstruction. Dilated loops of small bowel are present in the epigastrium. Enteroliths within a Meckels diverticulum (arrows) are visible within the pelvis. (b) Image from a barium follow-through study of the same patient. The Meckels diverticulum is visible as a blind-ending sac arising from the distal ileum (arrow).

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Figure 3 Small bowel enema shows a blind-ending sac arising from the antimesenteric border of the distal ileum (arrow) in keeping with a Meckels diverticulum.

Figure 2 A 23-year-old male patient who presented with gastrointestinal haemorrhage. Small bowel enema demonstrated a Meckels diverticulum with a triradiate mucosal pattern (a) when collapsed and mucosal triangular plateau pattern when distended (b). Diagrams to show a collapsed (c) and distended (d) Meckels diverticulum. Illustrations courtesy of Dr A Luck (Consultant Breast Radiologist, Birmingham University Hospitals).

119 cases of surgical resection of a Meckels diverticulum in adults included nine patients who had been investigated with small bowel enema; the correct diagnosis was made in four patients.12 A series evaluating imaging of inverted Meckels diverticulum included 15 subjects who had undergone barium examination; 10 of these had their diverticulum identied directly, whereas the other ve had an intussusception diagnosed on the basis of the barium study, but the diverticulum itself could not be visualized.13 From a group of 49 patients who underwent operations to resect a Meckels diverticulum, eight small bowel enema studies were performed. Of these, seven showed an abnormality, and in six the diverticulum could be identied directly.21 However, a case series of 164 patients, all aged 18 years or less, did not include any patients in whom contrast studies were diagnostic, although the number of patients who had undergone a barium study was not specied.25 This correlates with other observations that barium studies are

more useful in adults than the paediatric population.10 The identication of a Meckels diverticulum during enemas performed for intussusception reduction has also been described. However, to condently identify a Meckels diverticulum on an enema and also differentiate it from another pathological lead point is difcult. A bulbous or triangular mass arising from the intussusceptum (Fig. 4) has been suggested as a sign that is more suggestive of an inverted Meckels diverticulum than other pathological lead points.26 The practical use of this knowledge is not clear, and ultrasound has been proposed as a more sensitive mode when assessing an intussusception for a lead point.27

Ultrasound
The sonographic appearances of Meckels diverticulum vary depending on the development of complications. If the patient develops Meckels diverticulitis (Fig. 5) the appearances mimic those of appendicitis. In a series of 10 patients with Meckels diverticulitis who underwent preoperative ultrasound, six had an inamed diverticulum identied within the right iliac fossa and were wrongly diagnosed with appendicitis.28 An inamed Meckels diverticulum may also appear sonographically similar to a duplication cyst, which is commonly found in the region of the terminal ileum. The two conditions can be distinguished by the more irregular mucosa seen in Meckels

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Figure 4 An 11-day-old infant who presented with a distended abdomen and poor feeding. Abdominal radiograph (not shown) demonstrated multiple, distended, gas-lled loops of bowel. A contrast enema was performed, which revealed an intussusception. Following reduction of the intussusception a lling defect in keeping with a lead point (arrow) was visible. This was proven to be an inverted Meckels diverticulum with ectopic gastric mucosa.

a non-compressible, cystic mass with a thick, irregular wall, which may be a teardrop shape, an elongated tubular shape or may resemble a blindending sac.30 Occasionally this can be demonstrated to be connected to the umbilicus.31 Ultrasound is commonly used to investigate cases of suspected intussusception (Fig. 6). In cases where the intussusception is secondary to an inverted Meckels diverticulum the appearances are of a target-like mass with a central area of hyperechogenicity,13 also described as a double target sign.32 As described above, there are also certain features visible on a subsequently performed enema which may alert a radiologist to the possible underlying lesion. Ultrasound is not the most sensitive technique in the diagnosis of a Meckels diverticulum, but the clinical signs and symptoms of this condition can be varied and non-specic and ultrasound may be performed for other reasons, especially in children. As a result it is helpful to be able to recognize the sonographic features of Meckels diverticulum to prevent misdiagnosis when an ultrasound is requested without this particular diagnosis in mind.30

Computed tomography (CT) and magnetic resonance imaging (MRI)

Although CT is being used more frequently to image the abdomen, it is not clear whether identifying a Meckels diverticulum as an

diverticulum14 and the characteristic double-layered wall seen in duplication cysts.29 Several sonographic features suggestive of Meckels diverticulitis have been described. These include

Figure 5 (a) Ultrasound image from a child with longstanding, subacute, abdominal pain and chronic anaemia. There is a complex mass and surrounding uid within the right iliac fossa. (b) CT image of the same patient shows a thick-walled loop of bowel (arrow) with associated free uid. Laparotomy demonstrated an inamed Meckels diverticulum containing ectopic pancreatic tissue.

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Figure 6 Ultrasound images (a and b) of intussusception secondary to a Meckels diverticulum. A central area of hyperechogenicity has been described in such patients and termed the double target sign.

incidental nding will increase, as the appearances on conventional CT usually resemble a normal loop of bowel.33 CT can prove useful in the presence of enteroliths, as it may detect less heavily calcied stones and allow more accurate localisation of the enteroliths than possible with plain lm by demonstrating the relationship of the stone containing diverticulum to the ileum.34 CT enteroclysis is an alternative to conventional CT if a small bowel lesion is suspected. This has been developed as a useful technique that combines the advantages of small bowel enema in assessing the mucosa and lumen with those of cross-sectional imaging in assessing extraluminal pathology.35 MR enteroclysis is an alternative to CT enteroclysis with the added advantages of reducing the dose of ionizing radiation and the ability to evaluate small bowel function through MR uoroscopy.36 Both of these techniques have been used to successfully identify a Meckels diverticulum.37e39 The appearances of a Meckels diverticulum on conventional CT will vary according to the complication that precipitated the patients presentation. If the patient has developed Meckels diverticulitis (Fig. 5), the appearances are of a thick-walled loop of bowel in the region of the terminal ileum with associated inammatory change in the surrounding mesentry, separate from the appendix.31 Of 11 patients with Meckels diverticulitis who had undergone CT imaging for acute abdominal pain the correct diagnosis was suggested preoperatively in seven of the patients. In this study the size of the diverticulum varied widely, in short axis from 1.5e6 cm and in long axis from 2e7 cm, the exact location of the diverticulum also varied between patients.40 Bleeding from a Meckels diverticulum is a common presenting complication. It is possible to identify haemorrhage from a Meckels

diverticulum using CT, and a case has been reported where CT angiography was diagnostic of a bleeding Meckels diverticulum whilst the lesion was occult on conventional angiography.41

Mesenteric angiography
Mesenteric angiography can be used to investigate gastrointestinal haemorrhage associated with a Meckels diverticulum, although active extravasation of contrast medium into the bowel can only reliably be seen when blood loss exceeds 0.5 ml/ min. In comparison, imaging using technetium99m labelled red blood cells can identify haemorrhage at rates as low as 0.1 ml/min.42 Despite this, angiography has been used successfully to identify Meckels diverticula that have been occult on nuclear medicine imaging and can be used to complement scintigraphy to localize and identify a possible cause of bleeding.10 A Meckels diverticulum can be recognized angiographically in the absence of haemorrhage by demonstrating a persistent vitellointestinal artery (Fig. 7). In a series of 16 patients with bleeding from a Meckels diverticulum the feeding vitellointestinal artery was identied in 11 of the patients.43 This vessel usually arises from the superior mesenteric artery and appears as a long, nonbranching artery extending into the right iliac fossa, terminating in a cluster of small tortuous vessels.44 Less commonly a Meckels diverticulum can be supplied by branches originating from the ileocolic artery, in which case bleeding can mimic haemorrhage from the caecum or ascending colon on angiography.4 Angiodysplasia involving the caecum and ascending colon has also been described in association with Meckels diverticulum. A series of ve patients, all male and under the age of 21 years,

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Figure 7 Angiography of the superior mesenteric artery in a patient with obscure gastrointestinal bleeding who had previously had a normal technetium-99m pertechnetate Meckels scan. There is a persistent vitellointestinal artery (a) with a vascular blush (b) (arrows) representing a Meckels diverticulum, which was subsequently resected surgically. Images courtesy of Dr P Bungay (Consultant Vascular and Interventional Radiologist, Derby Hospitals).

who subsequently underwent resection of a Meckels diverticulum had angiographic appearances of angiodysplasia present preoperatively.45 Other authors have also reported this association and suggest that angiodysplasia in these patients is a congenital rather than acquired lesion.46 This possible association is important as angiodysplasia may cause further gastrointestinal bleeding following resection of a Meckels diverticulum47 or potentially lead to an incorrect assumption that angiodysplasia is the cause of haemorrhage in a patient with an unrecognized Meckels diverticulum.

Nuclear medicine
Ectopic gastric mucosa within a Meckels diverticulum is seen with scintigraphy (Figs. 8 and 9) due to the uptake of technetium-99m pertechnetate by mucus secretory cells.48 In a patient with haemorrhage from a Meckels diverticulum, the sensitivity of a Meckels scan is 85% amongst children,49 decreasing to 54% in adults.5 The sensitivity of scintigraphy can be improved by the use of H2 antagonists, pentagastrin or glucagon.50 In addition, the improved resolution of single photon emission computed tomography (SPECT) has been successful in identifying cases that are not visible using conventional imaging.7 The commonest ectopic tissue found within Meckels diverticula is gastric mucosa (Fig. 10), less

commonly ectopic pancreatic or duodenal mucosa is present.5 The reported incidence of ectopic mucosa in Meckels diverticulum varies from 15e50%, the frequency depending on the number of nonsymptomatic incidental cases included in each series.25,51 A higher incidence is reported in patients who present with gastrointestinal haemorrhage (55e100%)52 and in paediatric patients (61%).44 Other scintigraphic techniques can be useful in the diagnosis of Meckels diverticula. Although a technetium-99 m labelled red blood cell scan is a more sensitive test than mesenteric angiography in detecting haemorrhage, it is not specic and will be positive irrespective of the cause of haemorrhage. The use of radiolabelled monoclonal antibodies to granulocytes in the detection of Meckels diverticulitis associated with intussusception has been reported, although this was identied on an examination performed to evaluate a patient with suspected appendicitis.53 Meckels diverticulum may also be identied as an incidental nding on PET/CT.54 Although a Meckels scan is highly specic (95%),49 there are a few other conditions that can mimic this condition. Ten to 30% of duodenal and jejunal duplication cysts contain gastric mucosa and can have similar appearances to a Meckels diverticulum on scintigraphy.55 Other false-positive results have been reported in the absence of ectopic gastric mucosa, in cases of intussusception, volvulus, inammatory bowel disease,56 and in postoperative patients.57

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radiological investigations can attenuate gamma radiation, and for this reason scintigraphy should not be performed if there is residual contrast medium within the abdomen.58 It is also recognized that pertechnetate is only taken up by specic cells within the gastric mucosa; therefore, it is possible to have abundant gastric mucosa within a Meckels diverticulum but no appreciable uptake on scintigraphy.59 Despite these limitations, scintigraphy is helpful in evaluating patients with a suspected Meckels diverticulum and is accurate in certain patient groups, especially children with evidence of gastrointestinal haemorrhage.

Capsule endoscopy
Gastrointestinal bleeding is one of the more common presentations of Meckels diverticulum,10 and in such patients standard endoscopy will not identify the source of the haemorrhage. Wireless capsule endoscopy (WCE) is an alternative to angiography or scintigraphy in the investigation of obscure gastrointestinal bleeding with some authors claiming a sensitivity and specicity of 89% and 95% in this patient group.60 Although not all studies have produced such impressive results, WCE has been shown to consistently produce a higher diagnostic yield than radiological studies in the investigation of gastrointestinal bleeding in which conventional endoscopy has not identied the cause of haemorrhage.61 Further advantages of WCE include the fact that it is safe and well tolerated by patients.62 Despite this, WCE does have some important limitations. The system for identifying the location of the capsule, and therefore, the pathology, is

Figure 8 Technetium-99m pertechnetate Meckels scan in a young patient who had presented with gastrointestinal haemorrhage. There is abnormal uptake just to the right of the midline (arrows) due to a Meckels diverticulum. Physiological activity noted in the urinary bladder and stomach.

Although the commonest cause of a negative Meckels scan is the absence of gastric mucosa, other causes of a false-negative Meckels scan have been identied. Barium from previous

Figure 9 Meckels scan showing less obvious uptake by a Meckels diverticulum (arrows). Histopathological examination of the diverticulum revealed ectopic gastric mucosa with an associated benign peptic ulcer.

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Figure 10 Histological specimen from a Meckels diverticulum. Low power image (a) shows heterotopic gastric and pancreatic tissue. High power of the same image showing foci of gastric mucosa (right) and pancreatic tissue (left).

prone to inaccuracy and, unlike standard endoscopy, WCE does not facilitate biopsy or intervention.63 The main complication described following WCE is capsule retention, which can cause bowel obstruction64 and may require surgical or endoscopic intervention.65,66 However, the overall rate of capsule retention in WCE is 1% in most series,67 and even if this complication does occur, the retention of the capsule at the site of a stricture may be helpful in localizing pathology at laparotomy.61 Although the sensitivity of WCE in detecting a Meckels diverticulum is not well established there have been several reports of WCE successfully identifying a Meckels diverticulum as a source of gastrointestinal haemorrhage.68,69 This investigation may be used more frequently as the technology evolves and is likely to have a role in the diagnosis of gastrointestinal bleeding where

conventional endoscopy has not been of help, with some authors already advocating WCE as the investigation of choice in this patient group.65

Discussion
The statement that Meckels diverticulum is frequently suspected, often looked for, and seldom found70 is still true today. However, with an increase in the use of more sensitive radiological tests, it may be that this diagnosis is made more frequently in asymptomatic patients. This raises the question of management of a Meckels diverticulum arising as an incidental nding. Although it is generally accepted that any patient with symptoms relating to a Meckels diverticulum should undergo surgical resection, operating on asymptomatic individuals is more controversial.

Table 1

Sensitivity of radiological investigations in identication of Meckels diverticulum Maglinte et al. Dixon & Nolan St-Vil et al. (1987)21 (1991)25 (1980)24 (n 13) (n 19) (n 164) Kusumoto et al. Groebli et al. (1992)10 (2001)12 (n 776) (n 119) e 55/118 (47%) e e e 0/47 (0%) e 4/9 (44%) 1/14 (7%) e Menezes et al. (2008)72 (n 71) e e e e 6 showed intussusception (total no. examined not specied) 18/27 (67%) e 2 dayse14 years

Plain lm Unspecied barium examination Enteroclysis Computed tomography Ultrasound

e e 11/13b(85%) e e

e e 6/8 (75%) e e

e 0a e e e

Technetium99m Angiography Age of patients included in the study

a b

2/5 (40%) 1/3 (33%) 6e38 years

1/6 (17%) 2/3 (67%) 3e53 years; mean 26.1 years

32/37 (86%) 174/210 (83%) e 23/39 (59%) 0e18 years; Not specied mean 5.2 years

3/4 (75%) 1/3 (33%) 16e87 years; mean 43 years; median 38 years

No barium investigations were diagnostic in this series, the number of patients undergoing investigation was not specied. Correct diagnosis/total number of patients imaged.

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Various factors that increase the likelihood of developing complications in asymptomatic patients have been proposed, including the age of the patient and the presence of ectopic mucosa.5 However, there is no clear consensus on which asymptomatic patients, if any, should undergo surgery. Resection of a Meckels diverticulum is not without risk to the patient. A review of 1476 patients showed a 20% morbidity and 3% mortality for resection of an asymptomatic Meckels diverticulum and a 13% morbidity and 0% mortality in symptomatic patients. The authors of the study observed that patient age <50 years, male sex, diverticula longer than 2 cm, and ectopic mucosa or abnormal features within a diverticulum were all characteristics seen more commonly in symptomatic patients.3 A smaller series (n 47) including all patients who had undergone removal of a Meckels diverticulum over a 10-year period in a single institution also concluded that male patients were more likely to develop symptoms.71 The authors recorded a surgical complication rate of 8.5% and recommended that if asymptomatic diverticula are encountered they should not be routinely resected, especially in female patients. Preoperative radiological diagnosis of a Meckels diverticulum remains challenging, the reported sensitivities of the different imaging methods available are summarized in Table 1.10,12,21,24,25,72 Plain lm, ultrasound, and CT appearances can be normal or show non-specic changes. Contrast studies of the small bowel can demonstrate the diverticulum; however, the sensitivity of this test is not well established. Technetium-99m pertechnetate scintigraphy is useful, especially in cases of paediatric gastrointestinal haemorrhage, although a negative examination does not completely exclude the diagnosis. Mesenteric angiography performed for bleeding can also demonstrate suspicious features even if the rate of haemorrhage is not brisk enough to show active extravasation of contrast. WCE is also emerging as a useful tool in selected patients. Overall, in view of the relatively high frequency of this anomaly and the varied clinical presentation, it is important that radiologists should be familiar with the possible imaging appearances of this condition.

References
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4. Rossini P, Gourtsoyiannis N, Bezzi M, et al. Meckels diverticulum: imaging diagnosis. AJR Am J Roentgenol 1996; 166:567e73. 5. Park JJ, Wolff BG, Tollefson MK, et al. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950e2002). Ann Surg 2005;241:529e33. 6. Matsagas MI, Fatouros M, Koulouras B, et al. Incidence, complications, and management of Meckels diverticulum. Arch Surg 1995;130:143e6. 7. Levy AD, Hobbs CM. From the archives of the AFIP. Meckel diverticulum: radiologic features with pathologic correlation. RadioGraphics 2004;24:565e87. 8. Bani-Hani KE, Shatnawi NJ. Meckels diverticulum: comparison of incidental and symptomatic cases. World J Surg 2004;28:917e20. 9. Leijonmarck CE, Bonman-Sandelin K, Frisell J, et al. Meckels diverticulum in the adult. Br J Surg 1986;73:146e9. 10. Kusumoto H, Yoshida M, Takahashi I, et al. Complications and diagnosis of Meckels diverticulum in 776 patients. Am J Surg 1992;164:382e3. 11. Elsayes KM, Menias CO, Harvin HJ, et al. Imaging manifestations of Meckels diverticulum. AJR Am J Roentgenol 2007; 189:81e8. 12. Groebli Y, Morel P. Meckels diverticulum in adults: retrospective analysis of 119 cases and historical review. Eur J Surg 2001;167:518e24. 13. Pantongrag-Brown L, Levine MS, Elsayed AM, et al. Inverted Meckels diverticulum: clinical, radiologic and pathologic ndings. Radiology 1996;199:693e6. 14. Jain TP, Sharma R, Chava SP, et al. Pre-operative diagnosis of Meckels diverticulum: report of a case and review of literature. Trop Gastroenterol 2005;26:99e101. 15. Wouter van Es H, Sybrandy R. Case 19: enteroliths in a Meckel diverticulum. Radiology 2000;214:524e6. 16. Ewing HP, Gear MWL. Enteroliths in Meckels diverticulum misinterpreted as teeth. Br J Surg 1984;13:965e7. 17. Johnson JF, Lorenzetti RJ, Ballard ET. Plain lm identication of inverted Meckel diverticulum. Pediatr Radiol 1993; 23:551e2. 18. Sanchez Alegre ML. Milk of calcium in Meckels diverticu lum. AJR Am J Roentgenol 2000;174:1466e7. 19. Ojha S, Menon P, Rao KLN. Meckels diverticulum with segmental dilatation of the ileum:radiographic diagnosis in a neonate. Pediatr Radiol 2004;34:649e51. 20. Craig O, Mertt J. Radiological demonstration of Meckels diverticulum. Br J Surg 1980;67:881e3. 21. Dixon PM, Nolan DJ. The diagnosis of Meckels diverticulum: a continuing challenge. Clin Radiol 1987;38:615e9. 22. Nolan DJ. The true yield of the small-intestinal barium study. Endoscopy 1997;29:447e53. 23. Nolan DJ. Where barium scores and other imaging modalities fail. Imaging 1999;11:133e8. 24. Maglinte DDT, Elmore MF, Isenberg M, et al. Meckel diverticulum: radiologic demonstration by enteroclysis. AJR Am J Roentgenol 1980;134:925e32. 25. St-Vil D, Brandt ML, Panic S, et al. Meckels diverticulum in children: a 20-year review. J Pediatr Surg 1991;26:1289e92. 26. Kim G, Daneman A, Alton DJ, et al. The appearance of inverted Meckel diverticulum with intusssusception on air enema. Pediatr Radiol 1997;27:647e50. 27. Navarro OM, Daneman A, Chae A. Intussusception: the use of delayed, repeated reduction attempts and the management of intussusceptions due to pathological lead points in pediatric patients. AJR Am J Roentgenol 2004;182:1169e76. 28. Baldisserotto M, Maffazzoni DR, Dora MD. Sonographic ndings of Meckels diverticulitis in children. AJR Am J Roentgenol 2003;180:425e8.

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