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Unlike other carcinomas, hepatocellular carcinoma (HCC) metastasizes to distant organs relatively rarely. In contrast, it routinely metastasizes to liver vasculature/liver, affecting portal veins 3-10 times more often than hepatic veins. This portal metastatic predominance is traditionally rationalized within the model of a reverse portal flow, due to accompanying liver cirrhosis. However, this intuitive model is not coherent with facts: 1) reverse portal flow occurs in fewer than 10% of cirrhotic patients, while portal metastasis occurs in 30-100% of HCC cases, and 2) portal vein prevalence of HCC metastasis is also characteristic of HCC in non-cirrhotic livers. Therefore, we must assume that the route for HCC metastatic dissemination is the same as for other carcinomas: systemic dissemination via the draining vessel, i.e., via the hepatic vein. In this light, portal prevalence versus hepatic vein of HCC metastasis appears as a puzzling pattern, particularly in cases when portal HCC metastases have appeared as the sole manifestation of HCC. Considering that other GI carcinomas (colorectal, pancreatic, gastric and small bowel) invariably disseminate via portal vein, but very rarely form portal metastasis, portal prevalence of HCC metastasis appears as a paradox. However, nature does not contradict itself; it is rather our wrong assumptions that create paradoxes. The 'portal paradox' becomes a logical event within the hypothesis that the formation of the unique portal venous system preceded the appearance of liver in evolution of chordates. The analysis suggests that the appearance of the portal venous system, supplying hormones and growth factors of pancreatic family, which includes insulin, glucagon, somatostatin, and pancreatic polypeptide (HGFPF) to midgut diverticulum in the early evolution of chordates (in an Amphioxus-like ancestral animal), promoted differentiation of enterocytes into hepatocytes and their further evolution to the liver of vertebrates. These promotional-dependent interactions are conserved in the vertebrate lineage. I hypothesize that selective homing and proliferation of malignant hepatocytes (i.e., HCC cells) in the portal vein environment are due to a uniquely high concentration of HGFPF in portal blood. HGFPF are also necessary for liver function and renewal and are significantly extracted by hepatocytes from passing blood, creating a concentration gradient of HGFPF between the portal blood and hepatic vein outflow, making post-liver vasculature and remote organs less favorable spaces for HCC growth. It also suggested that the portal vein environment (i.e., HGFPF) promotes the differentiation of more aggressive HCC clones from already-seeded portal metastases, explaining the worse outcome of HCC with the portal metastatic pattern. The analysis also offers new hypothesis on the phylogenetic origin of the hepatic diverticulum of cephalochordates, with certain implications for the modeling of the chordate phylogeny.

Internal organs exhibit left-right asymmetric sizes, shapes and anatomical positions, but how these different lateralities develop is poorly understood. Here we use the experimentally tractable Xenopus model to uncover the morphogenetic events that drive the left-right asymmetrical lobation of the liver. On the right side of the early hepatic diverticulum, endoderm cells become columnar and apically constricted, forming an expanded epithelial surface and, ultimately, an enlarged right liver lobe. In contrast, the cells on the left side become rounder, and rearrange into a compact, stratified architecture that produces a smaller left lobe. Side-specific gain- and loss-of-function studies reveal that asymmetric expression of the left-right determinant Pitx2c elicits distinct epithelial morphogenesis events in the left side of the diverticulum. Surprisingly, the cellular events induced by Pitx2c during liver development are opposite those induced in other digestive organs, suggesting divergent cellular mechanisms underlie the formation of different lateralities.

A 3-month-old female patient is presented, with ileo-ileal intussusception secondary to Meckel's diverticulum. The patient underwent emergency surgery due to a diagnosis of intestinal obstruction secondary to intussusception. Resumen: Se reporta caso de paciente femenino de 3 meses de edad, con una intususcepción intestinal íleo-ileal secundario a divertículo de Meckel, intervenida quirúrgicamente de urgencia por diagnóstico de obstrucción intestinal secundario a una invaginación intestinal. Keywords: Intussusception, Meckel's diverticulum, Palabras clave: Intususcepción intestinal, Divertículo Meckel

Introduction Meckel’s diverticulum (MD) commonly presents as gastrointestinal bleeding in the pediatric population and intestinal obstruction in adults. There is no consensus for surgical excision of an incidentally diagnosed MD. We present a hitherto unreported vascular cause of intestinal gangrene due to MD. Case presentation A 16 year old boy was referred as an acute abdomen for tertiary hospital management. Clinical examination and CT suggested small bowel obstruction and emergency laparotomy was performed. A giant MD compressing the root of mesentery, causing critical occlusion of the ileal vessels and extensive ileal gangrene was found. The gangrenous bowel was resected and a jejuno-ascending colon anastamosis was done. Postoperative recovery was uneventful. Discussion This case report highlights an unrecognized complication of a giant Meckel’s diverticulum. There are no clear guidelines on the management of an incidentally discovered MD though certain studies recommend resection of an incidental MD in males and individuals less than 50 years of age or when the MD is larger than 2 cm or contains histologically abnormal tissue. Other meta-analyses do not recommend routine resection. MD has been identified as a high risk region for ileal malignancy and its resection usually has minimal morbidity. A valid consent for opportunistic resection of a Meckel’s diverticulum in any laparotomy would be discerning. Conclusion Appropriate opportunistic resection of an incidental Meckel’s diverticulum may prevent extensive surgical morbidity later. This case highlights the need to revisit guidelines for management of incidentally identified MD.

Highlights • Complicated Meckel’s diverticulum can have different clinical presentations and can cause bowel obstruction especially if a phytobezoar gets impacted in it. • Surgical management is needed and laparoscopic approach could be an option with a better outcome for treatment of this condition., Introduction Meckel’s diverticulum is the most common anomaly of the gastrointestinal tract, occurring in 1–3% of the general population. The most common complication of Meckel’s diverticulum is intestinal obstruction. In this report, we describe a rare cause of intestinal obstruction due to Meckel’s; the phytobezoar. After thorough literature review, the authors found about ten individual reports of the same topic. In all these cases, diagnosis was established intra-operatively. Case presentation A forty-seven-year old male presented to the emergency department with a one-day history of abdominal pain associated with vomiting and constipation. Physical examination diagnostic tests revealed features of intestinal obstruction. Discussion The lifetime risk of complications in patients with a Meckel’sdiverticulum is usually small and occurs only in up to 4%. In adults’ intestinal obstruction is the most common complication (40%). Conclusion Complicated Meckel’s diverticulum can have different clinical presentations and can cause bowel obstruction. An association with bezoars impaction is possible and it should be suspected in adult patients presenting with bowel obstruction of unknown causes especially those with high vegetarian diet.

Highlights • Meckel' diverticulum is the most common congenital anomaly of the small intestine. • It is a relatively not rare disease in the clinical field. • But the presentation as a retroperitoneal abscess as complications of Meckel's diverticulum is a very rare clinical entity. In this report,. • We present a 31-year-old man with perforated Meckel's divertculum with retroperitoneal abscess. • I also reviewed other disease of retroperitoneal abscess. (As I known as, This case report is the first report including review of retroperitoneal abscess)., Introduction The frequent complications of Meckel’s diverticulum are hemorrhage, intestinal obstruction, and inflammation, and perforation. The presentation as a retroperitoneal abscess as complications of Meckel’s diverticulum is a very rare clinical entity. Presentation of case We report a rare case of perforated Meckel's diverticulum with retroperitoneal abscess. A 31-year-old presented with a half-hour history of severe epigastric pain and diffuse periumbilical pain. Abdominal computed tomography (CT) revealed pneumoperitoneum and retroperitoneal abscesses which air, with diffuse infiltration of the small bowel mesentery and a tubular structure that originated in the ileum at the umbilicus level. Preoperative diagnosis was perforation of Meckel's diverticulum or small bowel perforation. We performed an approximate 10-cm segmental resection of the ileum that contained the Meckel’s diverticulum. Discussion Retroperitoneal abscesses are rare complications of Meckel’s diverticulum and are associated with its perforation. Conclusion The complications of Meckel’s diverticulum should be kept in mind in the differential diagnosis of retroperitoneal abscesses.

Highlights • The most commom complications of Meckel’s diverticulum are inflammation, haemorrhage, and intestinal obstruction. • The perforation of a Meckel’s diverticulum by a foreign body is a very rare complication, with few cases reported in the literature. • Definitive treatment is surgical intervention, and should not be delayed by supplementary radiographic imaging in patients with peritonitis., Introduction Meckel’s diverticulum is the most common congenital abnormality of the gastrointestinal tract. The perforation of a Meckel’s diverticulum by a foreign body is a very rare complication. Case presentation A 61-year-old male presented to the Emergency Department with complaints with abdominal pain and fever, and abdominal rebound tenderness on physical examination. An intestinal perforation by a foreign body was diagnosed by CT scan. The patient was submitted to a diagnostic laparoscopy and a perforation of a Meckel’s diverticulum by a foreign body was identified. The foreign body was removed and a stapled diverticulectomy was performed. Discussion Meckel’s diverticulum is asymptomatic in most of the affected individuals, with a 4.2–16.9% probability of symptomatic presentations. The clinical presentation ranges from intestinal obstruction, to bleeding, inflammation and perforation. While children with Meckel’s diverticulum present more often with gastrointestinal bleeding, intestinal obstruction is the most common presentation in adults. Foreign body perforation of a Meckel’s diverticulum is an extremely rare event. There is general agreement that a symptomatic Meckel’s diverticulum should be resected. Laparoscopy is a safe diagnostic and therapeutic tool that can decrease diagnostic time and theoretically avoids the morbidity and mortality of a delayed diagnosis. Conclusion The perforation of a Meckel diverticulum by a foreign body is an extremely rare event and may have a bad prognosis in case of a delayed diagnosis.

Highlights • Rare complication of meckel disease. • The urinary symptoms are the main revealing table. • Despite the various investigations done, the diagnosis was carried out, in all the reported cases, in per-operatory. • The treatment of the vescoentericfistula is surgical in all cases. A diverticulectomy and a suture of the bladder fistula were carried out in all the reported cases., Introduction Enterovesical fistulas usually result from diverticulitis, Crohn's disease, or colorectal cancer. A perforated Meckel's diverticulum can exceptionally result in an vesico-diverticulum fistula, as noted in only seven previously reported cases. Case report A 35-year old Arabic male, quadriplegic,who presented epigastralgia evolving for a week, associated with abdominal distension and cloudy urine. On examination he was feverish (38.5 °C), dehydrated with tenderness in the entire distended abdomen; rectal examination revealed a hypotonic sphincter with no other abnormality. After investigations, acute peritonitis diagnosis was retained. Exploratory laparotomy revealed a vesico-diverticular fistula resulting from a performed Meckel’s diverticulum. Diverticulectomy, ileostomy and bladder sutures were performed after peritoneal cleansing. The postoperative course was uneventful. The anatomo-pathological examination confirmed the diagnosis of a perforated Meckel’s diverticulum that did not contain ectopic gastric or pancreatic tissue. Conclusion Vesico-diverticular fistula resulting from a perforated Meckel's diverticulum is a rare complication. To our knowledge, this is only the fourth reported case which is not associated to inflammatory bowel disease.

Highlights • Mesenteric Meckel’s diverticulum and intestinal duplication cyst both are congenital anomaly of the gastrointestinal tract. • Preoperative diagnosis is very hard to establish even after Surgery. • Ectopic gastric or pancreatic mucosa can be found in both these pathologies. • Surgical treatment is gold standard of both because of their complictions., Introduction A Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract. They arise from the middle-to-distal ileum. Contrary to MD, intestinal duplication cyst (IDC) is uncommon congenital anomaly of GI, but can occur anywhere from the tongue to the anus. Presentation of case Here we report an 18-year-old male who presented to the department of abdominal surgery with chronic abdominal pain, frequent vomiting and mild abdominal distension. Following radiological investigation, a laparotomy was performed with the preoperative diagnosis of a mesenteric cyst. Intraoperativelly it became apparent that the cystic mass was on the mesenteric aspect of the small bowel without intestinal communication. Resection of the cyst was performed. Histological examination of the specimen revealed the presence of gastric tissue, which resembles MD. Although, the exact diagnosis of this cystic mass is ambiguous between MD and IDC, because of similar clinical signs, their complications and presence of gastric mucosa, however surgical treatment is gold standard of both. Conclusion This case report underlines the necessity of how to differentiate between MD and IDC, although, surgical management is recommended for both.

Background Meckel’s diverticulum is the most common developmental anomaly of the gastrointestinal tract, affecting 1–3% of the general population. This anomaly is caused by incomplete obliteration of the omphalomesenteric duct during the 7th week of gestation and is located in the last meter of the ileum in 90% of patients. Meckel’s diverticulum is often an incidental finding during a laparotomy for other causes, such as acute appendicitis, and occasional complications are bleeding, obstruction, diverticulitis, and perforation. Objective Primary aim of this study was to present and share an extremely rare case of double Meckel's diverticulum. Methods A 20-year-old woman who was admitted due to symptoms of right lower quadrant pain, nausea, and vomiting. A laparotomy with a McBurney’s incision was performed because of a presumed diagnosis of acute appendicitis. The surgical exploration revealed a double Meckel’s diverticulum localized 50 cm proximal to the ileocecal valve, but no acute appendicitis. The operation was finished after a diverticulectomy and appendectomy. No complications occurred during the postoperative follow-up. Conclusions We conducted a literature review of studies published in the English language on double Meckel’s diverticulum, accessed via PubMed, Medline, and the Google Scholar databases. We found only five case reports of such a Meckel’s diverticulum variant.

The distribution of ghrelin-like immunoreactive cells in amphioxus ( Branchiostoma belcheri ) was investigated by using immunohistochemical staining with rabbit antiserum against synthetical mammalian ghrelin. The results showed that ghrelin-like immunoreactive cells were distributed widely in the nervous system, Hatschek’s pit, wheel organ, digestive tract and gonads (ovary and testis). In nervous system, ghrelin-like immunoreactive neurons and their protrusions were distributed specifically on the dorsal side, ventral side and funnel part of brain vesicle, with a few dispersive immunoreactive nerve cells and their fibers in nerve tube. Ghrelin-like immunoreactivities were also detected in Hatschek’s pit epithelial cells and wheel organ cells, with positive substance located along cell membrane. In digestive tract, ghrelin-like immunoreactive cells existed in hepatic diverticulum, anterior and posterior region of midgut, and could be classified into two types, closed- and opened-type endocrine cells. The number of positive cells was most in hepatic diverticulum, secondary in posterior region of midgut and least in anterior region of midgut. In gonads, ghrelin-like immunoreactive substance was detected in oogonia, oocytes and follicle cells in ovary at the small and large growth stages and in early spermatogenic cells and Sertoli cells in testis. The extensive distribution of ghrelin-like cells in amphioxus suggested that these kinds of cells are conservative in evolution and diversified in function. At the same time, we found for the first time that ghrelin-like immunoreactive cells existed in brain vesicle and Hatschek’s pit, which provided new morphological evidence for the existence of an activation pathway between brain vesicle and Hatschek’s pit for the regulation of growth hormone excretion.

Summary Surgery for Killian–Jamieson diverticulum of the esophagus is scarcely reported in the literature owing to the rarity of this entity. This is a case report of such a diverticulum and a description of the transcervical diverticulectomy that we performed on a 49-year-old lady. The patient was investigated for symptoms of gastroesophageal reflux disease and was diagnosed with a left-sided Killian–Jamieson diverticulum.

Background/Purpose: The process of tracheoesophageal separation during early development of the foregut has been disputed and has led to difficulties explaining how congenital abnormalities of the trachea and esophagus might occur. This study clarifies the embryogenesis of tracheoesophageal separation by using sequential 3-dimensional imaging at crucial stages of foregut development. Methods: Timed pregnant Sprague Dawley rats were killed at days 11, 11.5, 12, 12.5, and 13. The embryos were harvested, histologically sectioned, and stained with H&E. Digitized photographs were taken of sequential serial transverse sections and their tracings layered in a 3-dimensional rendering program before being "skinned" to produce a 3-dimensional object. Results: The first respiratory structures to develop are the bronchi on day 11.5. They are evident first as bulges on the ventrolateral wall of the foregut approximately two thirds of the way between the lowest pharyngeal pouch and the level of the hepatic diverticulum and pancreatic buds. Lateral grooves dorsal to the respiratory bud on the lateral walls extend cranially. On day 12 the lateral bulges have developed into the 2 main bronchi, although the trachea is yet to separate from the foregut. On days 12.5 to 13 the trachea progressively elongates, and by day 13 tracheoesophageal separation is complete. Conclusions: After the main bronchi have developed, the trachea forms when the ventral component of the foregut is "cut" away from the dorsal component. There is an area of apoptosis at the point of tracheoesophageal separation, and, as the embryo grows, this causes the separation point to stay at a constant distance from the pharynx. Meanwhile, the trachea and esophagus distal to it increase dramatically in length. The area immediately caudal to the initial point of tracheoesophageal separation ultimately forms the stomach. J Pediatr Surg 38:173-177. Copyright 2003, Elsevier Science (USA). All rights reserved.

INTRODUCTION Primer small intestine bezoar is seen rarely. It frequently arises from underlying small intestine pathologies (diverticle, tumor, stricture etc.). We report a very rare case of disopyrobezoar in the duodenal diverticulum, a kind of phytobezoar caused by persimmons, which was treated laparoscopically. PRESENTATION OF CASE The 47-year-old patient applied to polyclinic with complaints of epigastric tenderness, occasional distension, and acid regurgitation. In endoscopical examination, impacted bezoar was determined in the diverticulum in the duodenum. Because it is too hard, it was unable to remove endoscopically. On the abdominal tomography, a smooth-bounded non-homogeneous mass including gas and soft tissue areas in the 2nd portion of the duodenum was detected. A barium meal confirmed the presence of a 5 cm diameter diverticulum on the lateral wall of the second portion of the duodenum. It also showed an intraluminalfilling defect as well as the mottled appearance of the bezoar. Learned from history of the patient, that the patient consumed over persimmon in childhood. DISCUSSION Generally, duodenal diverticles are asymptomatic. Surgical treatment is rarely necessary because of complications such as bleeding, perforation, abdominal pain, bezoar formation. As well as using methods such as gastric lavage, enzymatic dissolution, endoscopical fragmentation in the treatment of phytobezoar, their chances of success are low because its structure is rigid. Usually, surgical intervention is required. CONCLUSION For the treatments of bezoar cases located in the small intestine, laparoscopic surgical method is a safe and feasible method in selected cases.

Twenty five cases of Meckel's diverticulum were studied between 1985-1995. Eight of these were symptomatic and in the remaining 17 it was an incidental finding. The symptomatic patients presented with intestinal obstruction (5 cases), perforated peritonitis (2 cases) and intussusception (1 case). All cases of acute appendicitis were also subjected to a search for Meckel's diverticulum. Of the 25 Meckel's diverticuli encountered, 22 were resected and in 3 patients it was left in situ. Both the patients with perforated Meckel's diverticulum showed ectopic gastric mucosa. Complications occurred only after surgery for symptomatic Meckel's diverticulum. All patients undergoing incidental diverticulectomy had a smooth and uncomplicated recovery.

Tumors and perforation of Meckel's diverticulum are rare manifestations. A gastrointestinal stromal tumor in a Meckel's diverticulum causing perforation and subsequent peritonitis in a 75-year-old man is presented. The literature on tumors in Meckel's diverticulum is extensively reviewed and discussed.

Background Diverticulum of the vermiform appendix is rarely encountered. Previous reports in the literature indicate that appendiceal diverticulum without inflammations are asymptomatic. Methods During the past 10 years, 217 patients have been evaluated in our office for chronic lower abdominal pain. Six patients in this group were unusual in that no diagnosis could be made after a complete history, physical examination, and multiple imaging and laboratory studies. Each patient had a normal computed tomography scan of the abdomen, upper endoscopy, colonoscopy, barium enema, and small bowel enteroclysis. Each of the 6 patients underwent an exploratory laparoscopy and appendectomy. Results All 6 patients in this series had acquired diverticulum of the appendix with inspissated intraluminal secretions without histological evidence of inflammation. The age range was 37 to 57 years. Most patients were male, and most had a single diverticulum projecting into the mesoappendix. All 6 patients had complete resolution of their chronic abdominal pain after the laparoscopic appendectomy. Conclusions An unusual cause of mild chronic abdominal pain can be the presence of appendiceal diverticulum with inspissated intraluminal secretions. The evaluation of these patients is usually normal. Exploratory laparoscopy with appendectomy should be the final evaluation for patients with mild chronic abdominal pain.

Duodenal diverticula are noted in 5% to 22% of patients studied by upper gastrointestinal contrast radiography and by autopsy.1 At ERCP, duodenal diverticula occur in up to 23% of patients.2 With regard to the diverticulum itself, most of these patients will be without symptoms; however, a small fraction develop complications including choledocholithiasis, pancreatitis, perforation, and hemorrhage.3,4 With the advent of therapeutic endoscopy, the diagnosis and treatment of duodenal diverticula– associated bleeding has changed dramatically since its first description. We present a patient in whom both the diagnosis and primary treatment of a bleeding duodenal diverticulum were by endoscopy alone. We then review previous endoscopic attempts at management of this rare but important condition.

Esophageal diverticula are rare pathologies and are commonly classified according to their location as pharyngo-esophageal, midthoracic or epiphrenic diverticula [1]. Epiphrenic diverticulum, or diverticulum of distal esophagus, usually occurs in the distal 10 cm of the esophagus. The patients with epiphrenic diverticulum present with clinical symptoms and signs mimicking those associated with other distal esophageal motility disorders, including hiatal hernia, achalasia and reflux esophagitis [2]. We report a case of epiphrenic diverticulum of esophagus in a 70 year old male.

During a cholecystectomy for stones, an unusual lesion mimicking a neoplasm was found in a 40-year-old man. The lesion was resected using an endoscopic stapler, and the histologic diagnosis was Meckel's diverticulum with chronic inflammation and calcification of the diverticular wall. It is possible that the diverticulum had been responsible for abdominal pain in this patient, in whom it had an atypical appearance.

Foreign body perforation of Meckel's diverticulum is a very rare event. We report two cases of fish bone perforation of Meckel's diverticulum that presented within 5 days of each other. Both patients presented with acute abdomen and were initially suspected to have acute appendicitis. The diagnosis was only made at surgery when the appendix was found to be normal and Meckel's diverticulum was found to be inflamed and perforated by a fish bone. Both cases were treated successfully with Meckel's diverticulectomy.

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract involving the small bowel and terminal ileum. Gastro intestinal bleed is the commonest complication in the paediatric age group. Radiological studies like barium meal follow through examination rarely reveal reflux of contrast into the diverticulum and are limited in their ability to diagnose the disorder. Surgical exploration was the only means of confirming the diagnosis in the past. We wish to highlight the role of nuclear imaging using 99m technetium pertechnetate as a simple, non invasive investigation in the diagnosis of Meckel's diverticulum.

Perforation of Meckel's diverticulum in children is a rare and serious complication. The authors report a case of a 3-year-old boy with perforation and hemoperitoneum caused by Meckel's diverticulum. Difficulty of preoperative diagnosis is discussed, indication for incidental diverticulotomy is established, and the literature is reviewed.

A case of incomplete intestinal obstruction caused by a giant Meckel's diverticulum in a 13-year-old girl is reported. Short resection of the ileum with the diverticulum and end-to-end anastomosis was carried out. The possibilities of diagnosis and treatment as well as the controversial classification of this rare congenital anomaly are discussed.

A 3-week-old boy presented with repeated episodes of vomiting and constipation. At laparotomy a jejunal diverticulum arising from its antimesenteric border and extending retroperitoneally was found. The narrow neck of diverticulum caused a situation similar to a Richter's hernia. The fundus of diverticulum was attached to the upper pole of left kidney. A retroperitoneal jejunal diverticulum is a new addition to the cause of neonatal intestinal obstruction.

Meckel's diverticulum is the most common congenital abnormality of the small intestine, occurring in about 2 per cent of the population. Complications of a Meckel's diverticulum, including hemorrhage, inflammation, bowel obstruction, and neoplasms, occur in 15 to 33 per cent of cases and invariably demand operative treatment. When signs or symptoms arise from a Meckel's diverticulum, morbidity and mortality are high. Incidental Meckel's diverticulectomy should be performed at any age when the morbidity and mortality of the primary procedure will not be increased substantially.

A review of the literature of bleeding duodenal diverticula is presented. Two adequately documented cases of bleeding from duodenal diverticula have been found. A third case is described of massive gastrointestinal hemorrhage from such a lesion, which was adequately controlled by surgery, although death followed, caused by overwhelming postoperative pneumonia. The uncontrollable or recurrent gastrointestinal bleeding in a patient with a radiographically demonstrable duodenal diverticulum and no other significant lesion should be considered an indication for exploration.

Summary A case of Meckel's diverticulum which was suspected clinically and roentgenologically is presented. The significant features were two episodes of abdominal pain and vomiting three years apart, persistent occult blood in the stools and a slowly progressive anemia. At surgery within an intussusception of the ileum was found an inverted Meckel's diverticulum. At the apex of the diverticulum was an ulcerating tumor of pancreatic tissue wh ich apparently acted as a traction polyp and was the si te of bleeding. Microscopic examination showed ectopic gastric mucosa within the lining of the diverticulum. Due to overstaining the tumor composed of heterotopic pancreatie tissue was initially thought to be a carcinoid in a Meckel's diverticulum. That heterotopie tissue within a Meckel's diverticulum may be mistaken for carcinoid is recorded in the literature. The case illustrates the value of abdominal exploration whenever indeterminate intestinal bleeding is encountered and presents some of the variable pathologie and complicating features which may be encountered m the study of a Meckel's diverticulum.

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The subject of intestinal obstruction following Meckel's diverticulum is generally discussed. The details of a case of volvulus secondary to Meckel's diverticulum with operation and recovery are also presented.

The management of the patient with massive gastrointestinal hemorrhage due to a Meckel's diverticulum is discussed. The fluorescein string test is helpful in localizing the source of hemorrhage to the region of the distal ileum.

1. 1. A brief review is given of the history, embryology and incidence of Meckel's diverticulum. 2. 2. The complications which may result from the presence of such a diverticulum are noted. 3. 3. A case of bowel obstruction associated with torsion and gangrene of a Meckel's diverticulum is presented. 4. 4. A case of bleeding Meckel's diverticulum in an eleven months old infant is presented.

Summary A patient with an intraluminal duodenal diverticulum causing the onset of symptoms at age 76 is reported. The features of roentgen diagnosis are illustrated. The embryological, clinical, and pathological characteristics of this rare anomaly are described.

Summary A case of recurrent pancreatitis associated with an intraluminal diverticulum of the duodenum is reported for the first time. The significance of the association of these two lesions is discussed. The pancreatitis has not recurred since the excision of the diverticulum. It is suggested that the pancreatitis in this patient was due to reflux of duodenal contents into the pancreatic duct because of the partial duodenal obstruction and the deformity of the ampulla of Vater produced by the intraluminal diverticulum.

A total of 600 cases, comprising 4 of our cases and 596 others in Japan, was analyzed, and the diagnosis of Meckel's diverticulum was made in only 34 of them. The rate of diagnosis was 5.7 per cent, which is very low. The most common complication of this disease was intestinal obstruction, the second most common was intussusception, the third was inflammation, and the fourth was rectal bleeding. Ectopic tissue, present in ninety-three patients, consisted of ectopic gastric mucosa in fifty-eight. 99mTc-P scanning was performed on fifteen patients. In twelve of them ectopic gastric mucosa was observed. However, it was not found in three, all of whom had false-positive scans.