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The frequency of administering intravenous contrast in CT examinations decreases as the serum creatinine level increases.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.D. Ferrer Puchol, P. Montesinos García, M. Forment Navarro, E. Sanz Rodrigo, E. Blanco Pérez, E. Taberner López" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M.D." "apellidos" => "Ferrer Puchol" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Montesinos García" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Forment Navarro" ] 3 => array:2 [ "nombre" => "E." "apellidos" => "Sanz Rodrigo" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Blanco Pérez" ] 5 => array:2 [ "nombre" => "E." 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Multidetector computed tomography of the abdomen with intravenous contrast, transverse plane (a) and sagittal reconstruction (b). Surgical staples identified in the rectum (white arrows) as well as a small presacral fluid collection (asterisk).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Rivera Domínguez, D. de Araujo Martins-Romeo, T. Ruiz García, A. García de la Oliva, L. Cueto Álvarez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Rivera Domínguez" ] 1 => array:2 [ "nombre" => "D." "apellidos" => "de Araujo Martins-Romeo" ] 2 => array:2 [ "nombre" => "T." "apellidos" => "Ruiz García" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "García de la Oliva" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Cueto Álvarez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833819300335" "doi" => "10.1016/j.rx.2019.02.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833819300335?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510719300539?idApp=UINPBA00004N" "url" => "/21735107/0000006100000004/v2_201907190802/S2173510719300539/v2_201907190802/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Radiology through images</span>" "titulo" => "Computed tomography of complicated Meckel's diverticulum in adults" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "297" "paginaFinal" => "305" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Parra-Fariñas, S. Quiroga-Gomez, S. Castro-Boix, F. Vallribera-Valls, E. Castellà-Fierro" "autores" => array:5 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Parra-Fariñas" "email" => array:1 [ 0 => "carmenparrafarinas@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Quiroga-Gomez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Castro-Boix" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Vallribera-Valls" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "E." "apellidos" => "Castellà-Fierro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Radiología, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía General y Digestiva, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tomografía computarizada del divertículo de Meckel complicado en adultos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2460 "Ancho" => 905 "Tamanyo" => 304039 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">48-Year-old male who attended the emergency department due to gastrointestinal bleeding. (A and B) Computed tomography which reveals a blind-ending tubular structure in the lower right quadrant of the abdomen (arrows) with intravenous contrast extravasation (arrowhead). (C) The multiplanar coronal reconstruction showed the diverticulum in the right ileal region (arrow) and the vitellointestinal artery (arrowhead).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Meckel's diverticulum (MD), first described by Fabricus Heldanos in 1650, is named after Johann Friedrich Meckel, who established its embryonic origin in 1809.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> MD occurs when there is no involution of the omphalomesenteric duct. It is the most common congenital malformation of the gastrointestinal tract and is present in 1–2% of the population. Most MDs are asymptomatic and are detected by chance during surgery or at autopsy.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2,3</span></a> However, symptomatic forms can exhibit a wide range of clinical manifestations, from painless and benign to acute and potentially fatal cases, which are often seen in the emergency department.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> Radiographic techniques play a key role in detecting and differentiating them from other common entities with a similar clinical picture, aiding the therapeutic approach.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3,5–9</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Embryology, anatomy and clinical manifestations of Meckel's diverticulum</span><p id="par0010" class="elsevierStylePara elsevierViewall">Meckel's diverticulum is a true diverticulum consisting of all three layers of the bowel wall as a result of incomplete occlusion of the bowel end of the omphalomesenteric (or vitelline) duct, which connects the primitive midgut to the yolk sac during embryonic development. Incomplete atrophy can lead to serious congenital anomalies: umbilicoileal fistula, a fibrous cord connecting the ileum to the umbilicus, omphalomesenteric duct sinus, enterocyst and MD, which is the most common anomaly of the vitelline duct, present in 98% of cases.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,10,11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">MDs typically emerge from the antimesenteric border of the distal small bowel (30–100<span class="elsevierStyleHsp" style=""></span>cm from the ileocaecal valve), are up to 5<span class="elsevierStyleHsp" style=""></span>cm long and 2<span class="elsevierStyleHsp" style=""></span>cm in diameter.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,6,8,12</span></a> Approximately 50% are lined by heterotopic mucosa, mainly the gastric mucosa (62%) and pancreatic mucosa (6%).<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8,13</span></a> Many cases of bleeding, bowel obstruction and intussusception are linked to the presence of this pancreatic mucosa or ectopic gastric mucosa.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> In general, they are supplied by the omphalomesenteric (or vitellointestinal) artery, a remnant of the primitive vitelline artery, which originates from the medial or distal branches of the superior mesenteric artery.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Kawamoto et al.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> showed in a retrospective study that MDs are most commonly found in the right abdomen (67% of the case series analysed). The majority are located at the level of the umbilicus (37.5%), followed by the upper and lower right quadrants (17% and 12.5%, respectively).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Soltero and Bill<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> estimated that MD has a 4.2% chance of causing disease at some point in life. Over 50% of these complications manifest in childhood or in the first 20 years of life, and are rare in patients aged over 40 years.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,7,9,15</span></a> Numerous studies have also shown that symptomatic MD is seen more commonly in males than in females.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4,6,9</span></a> Complications associated with MD include gastrointestinal bleeding (38%), obstruction (34%) and diverticulitis (28%) in adult patients, and obstruction (40%), bleeding (31%) and diverticulitis (39%) in paediatric patients.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> Gastrointestinal bleeding has traditionally been reported as more common in children, and obstruction and diverticulitis as more common in adults.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">6,7,9</span></a> Other less common associated complications include the formation of enteroliths, inverted MD and tumours.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">9,16</span></a><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Computed tomography in the diagnosis of Meckel's diverticulum</span><p id="par0035" class="elsevierStylePara elsevierViewall">Traditionally, computed tomography (CT) has played a limited role in the preoperative assessment of uncomplicated MD,<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> given how difficult it is to differentiate, with normal adjacent bowel loops.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> However, this is now changing thanks to the development of multidetector computed tomography (MDCT). A greater spatial resolution and the potential to perform multiplanar reconstructions with MDCT has led to an increase in the detection of MD.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> Various articles have shown the usefulness of MDCT in the detection of both symptomatic and asymptomatic MD.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4,9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In MDCT images, MD can be seen as a gas- or liquid-filled structure with a blind end communicating with the distal ileum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), which is generally found by detecting the caecum and terminal ileum, and following the ileum in a retrograde fashion proximally.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8,9,11</span></a> CT enterography and/or magnetic resonance (MR) enterography can aid diagnosis,<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">18,19</span></a> as can the observation of the omphalomesenteric artery, which is considered pathognomonic of MD,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> through CT angiography.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Enteroliths in MD are uncommon findings (3–12%),<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> but their identification is a useful sign<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). They are believed to form due to stasis. Lithiasis usually occurs in the absence of ectopic gastric mucosa, since an acid environment develops which prevents the precipitation of calcium salts.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4,12</span></a> Approximately 50% of enteroliths can be observed with a conventional simple abdominal X-ray. Simple CT, on the other hand, is more useful for diagnosis, as they usually appear faceted, laminated or present peripheral calcification.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a><elsevierMultimedia ident="tb0010"></elsevierMultimedia></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Below we will describe the signs observed with MDCT which help to diagnose MD associated with complications such as bowel obstruction, inflammation and active gastrointestinal bleeding.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Bowel obstruction</span><p id="par0060" class="elsevierStylePara elsevierViewall">Obstruction following MD is a common complication (12–23%),<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> particularly in adults (40%).<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> It can occur due to a volvulus or an internal hernia related to the persistence of a fibrotic band connecting the diverticulum to the umbilicus, an intussusception, or due to incarceration of the bowel loop containing the MD in a inguinal, umbilical or femoral hernia, leading to symptoms of bowel obstruction, which requires emergency surgical treatment.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">MDCT is a sensitive technique for the diagnosis of a small bowel obstruction. MD is seen as a blind-ending tubular structure that communicates with the small bowel, generally in the location of the transition zone of the obstructed bowel (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Sometimes, the MD may be inverted, which serves as a starting point for intussusception. In CT, inverted MD is seen as an intraluminal fatty mass in the distal small bowel, due to mesenteric fat trapped in the inverted diverticular sac.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">9,11,20</span></a> The underlying physiopathology of this phenomenon is not fully understood. Inverted MD is thought to occur because of abnormal peristaltic movements due to an ulcer or ectopic tissue in the base of the MD.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> A polypoid lesion in the ileum, consisting of a fatty core and a thick non-fatty outer lining with contrast enhancement, which corresponds to the diverticular wall formed by complete bowel wall layers, should point to the diagnosis of an inverted MD. However, obstruction associated with intussusception is rare in adults<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> and other causes should therefore be considered,<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12,20</span></a> including intussusception caused by benign (lipoma) or malignant tumours (metastases, lymphoma).<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Different complications could also coexist. Inflammation of the MD can also lead to a small bowel obstruction. In this case, a contrast-enhanced CT scan shows signs associated with mesenteric and diverticular inflammatory changes at the point of transition of the dilated small bowel loops which could even escalate and give rise to pneumatosis intestinalis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="tb0015"></elsevierMultimedia></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Inflammation</span><p id="par0085" class="elsevierStylePara elsevierViewall">Inflamed MDs, which cause diverticulitis, appear to be more common in adults (5–19%) than in children.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12,17</span></a> These patients have abdominal pain which mimics other complications such as appendicitis, a tubo-ovarian abscess or pyosalpingitis in women<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">21,22</span></a> when acute lower right quadrant pain presents with fever, nausea and vomiting. Inflammation of the MD may occur following a peptic ulcer, as a result of acid secretion related to heterotopic gastric mucosa or due to obstruction of the diverticular neck by enteroliths or foreign bodies, with consecutive stasis and a subsequent bacterial infection (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>). Diverticulitis may also result from a diverticular torsion causing ischaemia and inflammatory changes.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> Inflammation of the MD may escalate due to perforation and peritonitis or could lead to inflammatory adhesions and a bowel obstruction, as mentioned previously. A normal-looking caecum and vermiform appendix are useful signs that point to Meckel's diverticulitis.<elsevierMultimedia ident="tb0020"></elsevierMultimedia></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Gastrointestinal bleeding</span><p id="par0095" class="elsevierStylePara elsevierViewall">Bleeding is the most common initial symptom and has been reported most frequently in children under 2 years of age and in young adults (15–28%).<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> Generally, it occurs due to ulcers caused by acid secretions from the heterotopic gastric mucosa located in the diverticulum.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4,5</span></a> Bleeding may present most frequently as anaemia due to painless intermittent blood loss or as acute massive blood loss. Patients’ stools may be melenic or have the typical bright reddish colour with a “currant jelly-like aspect”.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,6,13</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In non-contrast-enhanced CT images, an MD can be seen as a blind-ending tubular structure stemming from the ileum loops with a thick wall and hyperdense contents, which corresponds to blood (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). MDCT angiography may identify contrast extravasation in cases of active bleeding, when the bleeding exceeds 0.3–0.5<span class="elsevierStyleHsp" style=""></span>ml/min (a rate that is slightly lower than the limit assigned to catheter angiography).<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> When active contrast extravasation is observed in the distal ileal loops with no underlying anomalies in the CT scan, the diagnosis of bleeding from an MD should be taken into account (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> MDCT angiography may also identify a persistent omphalomesenteric artery which emerges as a terminal branch from medial or distal branches of the superior mesenteric artery (<a class="elsevierStyleCrossRefs" href="#fig0025">Figs. 5–7</a>).<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3,6,23</span></a> The differential diagnosis of active bleeding in the terminal ileum should include bleeding due to angiodysplasia or vasculitis, bleeding due to a ruptured ileocolic artery aneurysm and bleeding associated with an underlying small bowel tumour.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Inverted MDs can also lead to gastrointestinal bleeding (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>) caused by the presence of ulcers, even in the absence of heterotopic gastric mucosa, due to repeated mechanical trauma to the mucosa by intermittent intussusceptions or by affected blood supply to the MD, which causes ischaemia.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">MDCT enterography, which combines the improved temporal and spatial resolution of MDCT with large volumes of ingested neutral enteric contrast material to permit visualisation of the small bowel wall and lumen, is a good diagnostic tool in patients with gastrointestinal bleeding of unknown origin and may help to differentiate MD from normal small bowel loops (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>).<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">MDCT can also indicate the presence of heterotopic mucosa (gastric or pancreatic) when there is nodular wall enhancement within the MD (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>),<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">8,11,23</span></a> which corresponds to dense staining of the vitelline artery described above with conventional angiography studies. Identification using images of the ectopic mucosa in an MD is important, since it is the main risk factor for serious complications such as bleeding, inversion of the MD, small bowel obstruction and inflammation.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,8</span></a> The differential diagnosis should include neoplasms arising within the MD, which are very rare (reported incidence of 0.5–3.2%).<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> The most common forms are carcinoid tumours, although gastrointestinal stromal tumours (GISTs), leiomyosarcomas, carcinosarcomas and adenosarcomas.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> Carcinoid tumours are generally small, isolated and asymptomatic,<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5,6</span></a> and on rare occasions cause a characteristic carcinoid syndrome. However, they often behave like malignant tumours with a high risk of metastasis. With MDCT, neuroendocrine tumours and GISTs within an MD can look very much like heterotopic mucosa. When a nodular mass is seen in an MD, the diverticulum must be surgically excised, given that it may be a tumour or heterotopic mucosa which could result in complications.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a><elsevierMultimedia ident="tb0025"></elsevierMultimedia></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Authorship</span><p id="par0125" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0130" class="elsevierStylePara elsevierViewall">Responsible for the integrity of the study:</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0135" class="elsevierStylePara elsevierViewall">Study conception:</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0140" class="elsevierStylePara elsevierViewall">Study design:</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4.</span><p id="par0145" class="elsevierStylePara elsevierViewall">Data collection:</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5.</span><p id="par0150" class="elsevierStylePara elsevierViewall">Data analysis and interpretation:</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6.</span><p id="par0155" class="elsevierStylePara elsevierViewall">Statistical processing:</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7.</span><p id="par0160" class="elsevierStylePara elsevierViewall">Literature search:</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8.</span><p id="par0165" class="elsevierStylePara elsevierViewall">Drafting of the article:</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9.</span><p id="par0170" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant contributions:</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10.</span><p id="par0175" class="elsevierStylePara elsevierViewall">Approval of the final version:</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1220913" "titulo" => "Abstract" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1135466" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1220912" "titulo" => "Resumen" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1135465" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Embryology, anatomy and clinical manifestations of Meckel's diverticulum" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Computed tomography in the diagnosis of Meckel's diverticulum" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Bowel obstruction" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Inflammation" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Gastrointestinal bleeding" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Authorship" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-04" "fechaAceptado" => "2018-10-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1135466" "palabras" => array:4 [ 0 => "Meckel diverticulum" 1 => "Embryology" 2 => "Diverticular diseases" 3 => "Computed tomography multidetector" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1135465" "palabras" => array:4 [ 0 => "Divertículo de Meckel" 1 => "Embriología" 2 => "Enfermedades diverticulares" 3 => "Tomografía computarizada multidetector" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To review the embryology, the clinical findings and the appearance in multidetector computed tomography (MDCT) of complicated Meckel's diverticulum (DM) in adults.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The presence of an MD in a MDCT should be suspected when a blind tubular structure connected to the terminal ileum by a neck of variable size is observed. Multiplanar 2D reconstructions images and CT enterography can help in the diagnosis. In patients with symptoms of obstruction or intestinal inflammation, the possibility of a complication secondary to a MD should be considered, especially when the terminal ileum and the vermiform appendix are normal. MDCT angiography, in cases of acute gastrointestinal bleeding, can identify contrast extravasation and accumulation of blood in the MD, and could demonstrate the persistent omphalomesenteric artery, which is diagnostic of MD. Other MDCT findings such as the presence of enteroliths or associated inflammatory changes around the MD can facilitate the preoperative diagnosis of MD complications.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Objetivo</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Revisar la embriología, los hallazgos clínicos y la apariencia en la tomografía computarizada multidetector (TCMD) del divertículo de Meckel (DM) complicado en adultos.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusión</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La presencia de un DM en una TCMD debe sospecharse cuando se observa una estructura tubular ciega conectada al íleon terminal por un cuello de tamaño variable. Las reconstrucciones multiplanares y la enterografía por TC pueden ayudar al diagnóstico. En pacientes con síntomas de obstrucción o inflamación intestinal, se debe considerar la posibilidad de un DM complicado; especialmente cuando el íleon terminal y el apéndice vermiforme son normales. La angiografía por TCMD, en casos de hemorragia digestiva aguda, puede identificar extravasación de contraste y acumulación de sangre en el DM. La observación de la arteria onfalomesentérica es diagnóstica de DM. Otros hallazgos en la TCMD, como la presencia de enterolitos o cambios inflamatorios en torno al DM, pueden facilitar el diagnóstico.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Parra-Fariñas C, Quiroga-Gomez S, Castro-Boix S, Vallribera-Valls F, Castellà-Fierro E. Tomografía computarizada del divertículo de Meckel complicado en adultos. Radiología. 2019;61:297–305.</p>" ] ] "multimedia" => array:13 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2422 "Ancho" => 905 "Tamanyo" => 328427 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Healthy 37-year-old male, who attended the emergency department reporting dark red rectal bleeding. (A and B) Contrast-enhanced computed tomography (CT) images show a blind-ending tubular structure emerging from the ileal loops (thick arrow) connected to the terminal ileum by a thick neck (thin arrows). This presented hyperdense contents, corresponding to blood (arrowhead). C) The coronal reconstruction showed the Meckel's diverticulum (thick arrow) and a long, thin, branchless artery emerging from the superior mesenteric artery, which corresponds to a persistent omphalomesenteric artery (arrowheads). The CT image showed no active bleeding. The histopathological findings confirmed the presence of ulcers and heterotopic gastric mucosa.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1259 "Ancho" => 1255 "Tamanyo" => 273814 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">(A–D) 69-Year-old male with an endoscopic diagnosis of colorectal cancer. (A) Intravenous contrast-enhanced computed tomography (CT) for preoperative staging revealed a blind-ending tubular structure (thick arrows) and enteroliths inside the lumen (arrowheads), which corresponded to an asymptomatic Meckel's diverticulum.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1925 "Ancho" => 905 "Tamanyo" => 213019 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">32-Year-old male admitted to our hospital with a small bowel obstruction and no history of previous surgery. (A) Simple abdominal X-ray showing multiple dilated small bowel loops (arrows) and gas in the bowel wall, which corresponds to pneumatosis intestinalis in the hypogastric region (arrowheads). (B–E) Intravenous contrast-enhanced computed tomography showing a giant Meckel's diverticulum with a narrow neck (thin white arrows) in the location of the transition zone of the obstructed bowel and pneumatosis intestinalis (black arrow) due to diverticular ischaemia. The surgical findings confirmed a Meckel's diverticulum which was causing a mechanical obstruction of the small intestine.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1225 "Ancho" => 1255 "Tamanyo" => 217181 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">(A–D) 52-Year-old male with a history of pain in the right iliac fossa, loss of appetite, nausea, vomiting and raised leukocytes and C-reactive protein, with suspected appendicitis. Computed tomography showed a diverticular structure connected to the small bowel, with a laminated enterolith inside the lumen (arrowheads) associated with inflammatory signs in the adjacent mesenteric fat (thick arrows) and localised perforation, with the presence of extraluminal aerial images (thin arrows).</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 2460 "Ancho" => 905 "Tamanyo" => 304039 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">48-Year-old male who attended the emergency department due to gastrointestinal bleeding. (A and B) Computed tomography which reveals a blind-ending tubular structure in the lower right quadrant of the abdomen (arrows) with intravenous contrast extravasation (arrowhead). (C) The multiplanar coronal reconstruction showed the diverticulum in the right ileal region (arrow) and the vitellointestinal artery (arrowhead).</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 2105 "Ancho" => 701 "Tamanyo" => 276230 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">19-Year-old male who presented with intermittent rectal bleeding. (A) Computed tomography showing a diverticular structure in the pelvis (arrow) with a thick enhanced wall in the distal section (arrowhead), corresponding to the gastric and pancreatic tissue confirmed histologically. (B) A maximum intensity projection image in the coronal plane showed a vitellointestinal artery (arrow) emerging from the ileocolic artery with branches in the diverticular neck. It also revealed a thick enhanced nodular wall in the blind end (arrowhead), corresponding to heterotopic mucosa. (C) The images obtained during laparoscopic surgery showed the entire Meckel's diverticulum from the neck (thick arrow) to the distal end (thin arrow).</p>" ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1542 "Ancho" => 905 "Tamanyo" => 222663 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">19-Year-old female who presented with intermittent lower gastrointestinal bleeding. (A) Computed tomography (CT) enteroclysis revealed a diverticular structure in the supravesical fossa (arrow). (B) CT angiography showed extravasation of the intravenous contrast (arrowhead) inside the diverticulum (arrows), corresponding to active gastrointestinal bleeding. (C) The image in the oblique coronal plane showed the Meckel's diverticulum (thick arrow), its neck (thin arrows), the ileal loop where it emerges (arrowheads) and hyperdense contents, corresponding to blood (asterisk). (D) The maximum intensity projection reconstruction in the frontal plane showed the omphalomesenteric artery, which was supplying the Meckel's diverticulum (arrows). (E) Image obtained during surgery showing the diverticulum.</p>" ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 2105 "Ancho" => 677 "Tamanyo" => 142411 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">64-Year-old male who presented with acute lower gastrointestinal bleeding. (A) Computed tomography (CT) angiography showed active extravasation of the intravenous contrast inside the ileal lumen (arrow). (B) The multiplanar coronal reconstruction of the CT image clearly showed an inverted Meckel's diverticulum in the ileum with a thick wall (thick arrow) and an ulcerated area (thin arrow). (C) The sagittal reconstruction showed the inverted Meckel's diverticulum (arrow) and extravasation of the intravenous contrast, corresponding to active bleeding.</p>" ] ] 8 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">It should be noted that</span>: The finding of heterotopic gastric mucosa in MD is common and in many cases it is what causes the symptoms. Most MDs are located in the right abdomen at the level of the umbilicus. Most MDs remain asymptomatic and, if complications do arise, they are usually observed in the first years of life; complicated MD is rarely observed in patients over 40 years of age.</p></span>" ] ] 9 => array:5 [ "identificador" => "tb0010" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">It should be noted that</span>: Observing the omphalomesenteric artery through CT angiography and enteroliths are useful for diagnosing MD.</p></span>" ] ] 10 => array:5 [ "identificador" => "tb0015" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">It should be noted that</span>: Obstruction is the most common complication in adults. When an inverted diverticulum is the cause, a lipomatous intraluminal mass is observed in the distal ileum, lined by the MD wall which contains all three layers of the bowel wall.</p></span>" ] ] 11 => array:5 [ "identificador" => "tb0020" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">It should be noted that</span>: Meckel's diverticulitis should be considered in the differential diagnosis of patients with suspected appendicitis and women with a suspected tubo-ovarian abscess or pyosalpingitis.</p></span>" ] ] 12 => array:5 [ "identificador" => "tb0025" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">It should be noted that</span>: MDCT angiography may identify contrast extravasation in cases of active bleeding and point to the presence of heterotopic mucosa.</p></span>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ueber die divertikel am darmkanal" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.F. 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