Report of Meckel’s Diverticulum Mimicking Stricturing Crohn’s Disease in an Adolescent Male

Report of Meckel’s Diverticulum Mimicking Stricturing Crohn’s Disease in an Adolescent Male | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Report of Meckel’s Diverticulum Mimicking Stricturing Crohn’s Disease in an Adolescent Male Merissa Maccani, Courtney Bartel, Oscar Lopez-Nunez, Aaron Garrison, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6572158/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Crohn’s Disease, a form of inflammatory bowel disease (IBD), can present with hematochezia, iron deficiency anemia, intestinal obstruction, and elevated fecal calprotectin. Although less common in an adolescent male, Meckel’s Diverticulum is an alternative diagnosis to consider. We present a case wherein a 16-year-old patient with presumed stricturing Crohn’s Disease with absence of clinical improvement on standard therapies. Case Presentation: We present a case of a 16-year-old patient with presumed stricturing Crohn’s Disease with absence of clinical improvement on anti-TNF therapy. Lab work was notable for iron deficiency anemia, elevated fecal calprotectin, and normal inflammatory markers. On further review of his imaging, there were concerns for possible Meckel’s Diverticulum. Following diagnostic laparoscopy, his diagnosis was confirmed and his anemia resolved. Through discussion of this case, we illustrate how providers can differentiate between two similar conditions. Conclusions: Although less common in an adolescent, Meckel’s Diverticulum is an alternative diagnosis to consider in the setting of failure to improve on traditional therapies for IBD. Hematochezia Meckel’s Diverticulum anemia case report Figures Figure 1 Figure 2 Figure 3 Background Crohn’s Disease, a form of inflammatory bowel disease (IBD), is a chronic relapsing and remitting inflammatory condition affecting any part of the gastrointestinal tract that can present as a constellation of symptoms including hematochezia, iron deficiency anemia, abdominal pain, and weight loss ( 1 ). Typically, 87% of children present with the inflammatory phenotype at diagnosis, however, some patients may present with more severe phenotype, with stricturing or penetrating disease ( 2 ). While iron deficiency anemia, elevated fecal calprotectin, and intestinal strictures warrant a high level of concern for Crohn’s Disease, Meckel’s Diverticulum can present with a similar constellation of findings ( 3 , 4 ). Meckel’s Diverticulum, a congenital anomaly of the gastrointestinal tract, is a result of an incomplete obliteration of the vitelline (omphalomesenteric) duct during fetal development ( 4 , 5 ). Typically, it presents within the first two years of life, with painless rectal bleeding ( 4 ). Approximately half of patients present between 0 to 4 years of age ( 4 ). Complications of Meckel’s include bleeding, intussusception, diverticulitis, volvulus, and perforation ( 4 ). Although less common in adolescent males, Meckel’s Diverticulum should be considered as an alternative diagnosis when there is a lack of response to traditional therapies for IBD ( 4 ). Normal inflammatory markers and normal albumin can help further differentiate patients, favoring Meckel’s Diverticulum over IBD ( 22 – 24 ). We report a case of Meckel’s Diverticulum presenting as an intestinal stricture in an adolescent, initially misdiagnosed as refractory stricturing Crohn’s disease. Case Presentation A 16-year-old male presented with hematochezia. He had a four-year history of iron deficiency anemia, often requiring both blood and iron transfusions. At age 12, he underwent an initial endoscopic evaluation that was macroscopically normal. Pathology confirmed the presence of numerous Helicobacter -like organisms. After completing therapy for Helicobacter pylori gastritis, he demonstrated clearance of the infection with a normal stool antigen. Anthropometrics remained within normal limits during this time. Despite clearing his Helicobacter pylori , hematochezia continued. At the age of 14, he underwent two more repeat endoscopies, both of which did not demonstrate any macroscopic evidence of bleeding. Notably, microscopically there was no evidence of acute or chronic inflammation. Magnetic resonance enterography (MRE), confirmed normal small bowel. He underwent a capsule endoscopy that showed evidence of ulcers at the distal terminal ileum. He was started on 5-aminosalicylic acid (5-ASA) therapy for presumed diagnosis of Crohn’s Disease. Symptoms persisted despite one year of therapy, and thus endoscopic evaluation was repeated. The colonic mucosa was found to be macroscopically normal. The terminal ileum was erythematous but without the presence of ulcers. Pathology again demonstrated no diagnostic abnormalities. Ongoing hematochezia was not concordant with the repeat colonoscopy. During episodes of bleeding, hemoglobin dropped as low as 6.6 gm/dL. Serum albumin, inflammatory markers [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR)], and platelets were within normal range throughout. However, fecal calprotectin was elevated and ranged between 212 µg/g and 551 µg/g during this time (Table 1) [normal <50 ug/g]. He presented four months later to a quaternary care facility with epigastric pain, nausea, vomiting, and lightheadedness. Hemoglobin was found to be 5.8 gm/dL and inflammatory markers were elevated (CRP: 2.2 mg/dL, ESR: 25 mm/hour). A MRE showed focal mural thickening and luminal narrowing involving the ileum. Double balloon retrograde enteroscopy (DBE) was performed, which was notable for a distal ileal stricture. A few scattered shallow erosions in the mid and distal ileum were noted, and again histopathology demonstrated no acute or chronic changes. Due to the stricture, the patient’s therapy was escalated to include intravenous corticosteroids followed by infliximab for presumed stricturing Crohn’s Disease. One month later in clinic, he presented with diarrhea and nocturnal stooling. Repeat imaging confirmed a persistent small bowel stricture. After re-reviewing with a fellowship-trained pediatric abdominal radiologist, the medical team broadened the differential to include etiologies like Meckel’s Diverticulum (Figure 1). Following shared decision making with the family, a diagnostic laparoscopy was performed. A very large Meckel’s Diverticulum with a feeding vessel was identified just proximally to the terminal ileum (Figure 2A). The remaining bowel otherwise appeared normal on evaluation. Histology from the resected sample confirmed a diverticulum containing all layers of the small bowel wall (true diverticulum) with focal areas containing ectopic gastric-type mucosa, consistent with a Meckel’s Diverticulum (Figure 2C, 2D). Following resection, the patient had resolution of his clinical symptoms and infliximab was discontinued. His repeat endoscopy and colonoscopy three months post-operatively was macroscopically and microscopically normal. Hemoglobin normalized and other labs including inflammatory markers, albumin, and platelets remained normal (Table 1). Repeat fecal calprotectin two years following surgery was normal (53 µg/g) (Figure 3). He remained asymptomatic throughout this two-year follow-up period. Discussion and Conclusions We present the case of an adolescent male with persistent iron deficiency anemia, hematochezia, and an intestinal stricture identified on endoscopic evaluation, who was initially treated for Crohn’s Disease. However, following a lack of response to standard therapies, exploratory laparoscopy ultimately revealed Meckel’s Diverticulum. The stricture most likely developed secondary to chronic mucosal inflammation, ulceration and fibrosis, caused by longstanding acid secretion from the ectopic gastric mucosa. Although the stricture had similar features to that of a Crohn’s Disease, the heterotopic ulcerated gastric mucosa on top is rather characteristic of Meckel’s Diverticulum (Figure 2E) while the remaining samples of the terminal ileum and colon showed no evidence of mucosal chronicity. Meckel’s Diverticulum can present with a wide range of clinical symptoms. In pediatric patients, the most common presentation is obstruction, followed by gastrointestinal bleeding, both of which our patient had (17). In contrast, adults more commonly present with bleeding over obstruction (17). While most individuals with Meckel’s Diverticulum (90–96%) remain asymptomatic, complications such as bowel perforation, volvulus, and intussusception can occur (4, 10, 17). The delayed diagnosis of Meckel’s Diverticulum, initially mistaken as Crohn’s Disease, has been previously documented in the literature (6-16), although these cases are less common in pediatric cases. To date, only three case reports describe pre-adolescent patients, initially suspected of having Crohn’s Disease who were later found to have Meckel’s Diverticulum (Table 2). Our case is unique due to the chronicity of the patient’s symptoms and the utility of DBE as part of the initial work up. After evidence of a presumed stricture on DBE, his therapy for IBD was escalated to infliximab despite unremarkable microscopic findings reported on numerous endoscopies. If his IBD therapy was suboptimal prior to this point, we would have seen more evidence of disease clinically or on histopathology. This suggests that broadening the differential was warranted prior to escalating his therapy to infliximab. In our case, the patient had persistently elevated fecal calprotectin levels prior to surgical resection. Fecal calprotectin is a cytosolic protein primarily found in neutrophils but also present in macrophages and monocytes. It is mainly used to differentiate IBD from functional gastrointestinal disorders (18-20). Mucosal inflammation or infection leads to chemotaxis of granulocytes and monocytes with ultimate release of calprotectin (20). Thus, the presence of calprotectin in the feces is a non-specific marker of gastrointestinal inflammation (19,20). A meta-analysis of 10 pediatric IBD studies, including 867 children, reported a pooled sensitivity of 99% (95% CI 92%-100%) and specificity of 65% (54%–74%), for fecal calprotectin, supporting its utility as a screening tool (21). However, an elevated fecal calprotectin can be secondary to many conditions including gastroenteritis, H. pylori -related peptic ulcer disease, polyps, IBD, neoplasms and in our case, Meckel’s Diverticulum (22, 23, 24). The elevated fecal calprotectin in our case was likely secondary to mucosal inflammation from acid producing heterotopic gastric mucosa leading to mucosal ulceration. Serum inflammatory markers, like C-reactive protein (CRP), are also commonly used to evaluate acute inflammation and have clinical utility in monitoring clinical disease activity (22). Additionally, hypoalbuminemia is an important marker of enteropathy and intestinal inflammation and is present in about one fifth of patients the year preceding (25). Our patient had persistently normal albumin levels and near normal inflammatory markers which are useful when considering a diagnosis of IBD (26). Despite a persistently elevated fecal calprotectin, these other serum markers help support an alternative diagnosis other than refractory IBD. This case highlights the importance of considering Meckel’s Diverticulum in the differential diagnosis of new-onset Crohn’s disease, particularly when clinical, endoscopic, and histologic findings are incongruent, and when patients do not respond to conventional IBD therapies. Given the implications of initiating systemic immunosuppressive medication such as infliximab, consideration of Meckel’s Diverticulum is warranted in patients with an uncertain diagnosis of Crohn’s Disease prior to treatment initiation. Abbreviations IBD inflammatory bowel disease MRE magnetic resonance enterography 5-ASA 5-aminosalicylic acid CTE computed tomography enterography Hgb Hemoglobin HCT hematocrit CRP C-reactive protein ESR Erythrocyte sedimentation rate FCP fecal calprotectin CTA Computed Tomography Angiography DBE Double balloon retrograde enteroscopy Declarations Ethics approval and consent to participate Not applicable as this was a case report. Consent for publication Written Informed consent was obtained from legal guardians of the patient involved in the study. Availability of data and materials All data generated or analysed during this study are included in this published article [and its supplementary information files. Competing Interests Not applicable. No competing interests. Funding Not applicable. There was no funding for this project. Authors' contributions Drs. Merissa Maccani, Courtney Bartel, and Nicole Zeky conceptualized and drafted the initial manuscript, and critically reviewed and revised the manuscript. Drs. Oscar F. Lopez-Nunez, Aaron Garrison, Jonathan R. Dillman provided clinical expertise and critically reviewed and revised the manuscript. Dr. Jasbir Dhaliwal conceptualized, assisted in drafting the manuscript, and provided oversight for the crafting of this case report manuscript. She critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Acknowledgements Not applicable. No Acknowledgments. References Day AS, Ledder O, Leach ST, Lemberg DA. Crohn's and colitis in children and adolescents. World J Gastroenterol. 2012;18(41):5862–9. 10.3748/wjg.v18.i41.5862 . Dhaliwal J, Walters TD, Mack DR, et al. Phenotypic variation in paediatric inflammatory bowel disease by age: A multicentre prospective inception cohort study of the Canadian Children IBD Network. J Crohns Colitis. 2020;14(4):445–54. 10.1093/ecco-jcc/jjz106 . Rosen MJ, Dhawan A, Saeed SA. Inflammatory bowel disease in children and adolescents. JAMA Pediatr. 2015;169(11):1053–60. 10.1001/jamapediatrics.2015.1982 . Lin XK, Huang XZ, Bao XZ, Zheng N, Xia QZ, Chen CD. Clinical characteristics of Meckel diverticulum in children: A retrospective review of a 15-year single-center experience. Med (Baltim). 2017;96(32):e7760. 10.1097/MD.0000000000007760 . Chen Q, Gao Z, Zhang L, et al. Multifaceted behavior of Meckel's diverticulum in children. J Pediatr Surg. 2018;53(4):676–81. 10.1016/j.jpedsurg.2017.11.059 . Eng NL, Kulaylat A, Jeganathan NA, Scow JS, Deutsch M. Meckel's Diverticulum Charading as Crohn's Disease: A Single-Institution Case Series. Cureus. 2023;15(4):e38191. 10.7759/cureus.38191 . Published 2023 Apr 27. 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Meckel's Diverticulum Diagnosed in a Child with Suspected Small Bowel Crohn's Disease. Pediatr Gastroenterol Hepatol Nutr. 2019;22(1):98–104. 10.5223/pghn.2019.22.1.98 . Levesque BG, Chua HK, Kane SV. Meckel's ileitis: not all regional enteritis is Crohn's disease. Inflamm Bowel Dis. 2011;17(6):E45. 10.1002/ibd.21686 . Enç F, Yorulmaz E, Melıkoğlu L, et al. A case of Meckel's diverticulitis treated on the assumption of Crohn's disease. Turk J Gastroenterol. 2010;21(2):175–8. 10.4318/tjg.2010.0079 . Harinck F, van Putten PG, Kreijne JE, Bruno MJ, van der Woude CJ, de Vries AC. An unexpected cause of terminal ileitis. Gastrointest Endosc. 2017;85(2):453. 10.1016/j.gie.2016.10.001 . Hegde S, Dillman JR, Gadepalli S, Rabah R, Ladino-Torres MF. MR enterography of perforated acute Meckel diverticulitis. Pediatr Radiol. 2012;42(2):257–62. 10.1007/s00247-011-2116-1 . Mendoza Alvarez L, Rajderkar D, Beasley GL. An Unusual Case of a Perforated Meckel's Diverticulum. Case Rep Pediatr. 2023;2023:2289520. 10.1155/2023/2289520 . Published 2023 Apr 21. Hansen CC, Søreide K. Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century. Med (Baltim). 2018;97(35):e12154. 10.1097/MD.0000000000012154 . Ricciuto A, Griffiths AM. Clinical value of fecal calprotectin. Crit Rev Clin Lab Sci. 2019;56(5):307–20. 10.1080/10408363.2019.1619159 . Henderson P, Anderson NH, Wilson DC. The diagnostic accuracy of fecal calprotectin during the investigation of suspected pediatric inflammatory bowel disease: a systematic review and meta-analysis. Am J Gastroenterol. 2014;109(5):637–45. 10.1038/ajg.2013.131 . Pathirana WGW, Chubb SP, Gillett MJ, Vasikaran SD. Faecal Calprotectin. Clin Biochem Rev. 2018;39(3):77–90. Holtman GA, Lisman-van Leeuwen Y, Reitsma JB, Berger MY. Noninvasive Tests for Inflammatory Bowel Disease: A Meta-analysis. Pediatrics. 2016;137(1). 10.1542/peds.2015–2126 . Bressler B, Panaccione R, Fedorak RN, Seidman EG. Clinicians' guide to the use of fecal calprotectin to identify and monitor disease activity in inflammatory bowel disease. Can J Gastroenterol Hepatol. 2015;29(7):369–72. 10.1155/2015/852723 . Mari A, Baker FA, Mahamid M, Yacoob A, Sbeit W, Khoury T. Clinical utility of fecal calprotectin: potential applications beyond inflammatory bowel disease for the primary care physician. Ann Gastroenterol. 2019;32(5):425–30. 10.20524/aog.2019.0394 . Ramraj R, Garcia A, Mosen D, Waiwaiole L, Smith N. Utility of Fecal Calprotectin in Evaluation of Chronic Gastrointestinal Symptoms in Primary Care. Clin Pediatr (Phila). 2018;57(9):1058–63. 10.1177/0009922817744607 . Irwin JR, Ferguson E, Simms LA, et al. Detectable Laboratory Abnormality Is Present up to 12 Months Prior to Diagnosis in Patients with Crohn's Disease. Dig Dis Sci. 2019;64(2):503–17. 10.1007/s10620-018-5357-0 . Vermeire S, Van Assche G, Rutgeerts P. Laboratory markers in IBD: useful, magic, or unnecessary toys? Gut. 2006;55(3):426–31. 10.1136/gut.2005.069476 . Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files CaseReportTables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6572158","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":467571902,"identity":"30808dae-c6ac-4d74-a211-284284a88df7","order_by":0,"name":"Merissa Maccani","email":"","orcid":"","institution":"Cincinnati Children's Hospital Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Merissa","middleName":"","lastName":"Maccani","suffix":""},{"id":467571903,"identity":"89b5f409-d691-4ebc-b252-308142dc7226","order_by":1,"name":"Courtney Bartel","email":"","orcid":"","institution":"Cincinnati Children's Hospital Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Courtney","middleName":"","lastName":"Bartel","suffix":""},{"id":467571905,"identity":"7add85a6-8543-4701-bf04-28dc3b93bcfe","order_by":2,"name":"Oscar Lopez-Nunez","email":"","orcid":"","institution":"Cincinnati Children's Hospital Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Oscar","middleName":"","lastName":"Lopez-Nunez","suffix":""},{"id":467571908,"identity":"fb88f901-086f-47c3-9787-e033276a9abb","order_by":3,"name":"Aaron Garrison","email":"","orcid":"","institution":"Cincinnati Children's Hospital Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Aaron","middleName":"","lastName":"Garrison","suffix":""},{"id":467571910,"identity":"679d4dfa-7590-494b-b2d7-21938062abbe","order_by":4,"name":"Jonathan Dillman","email":"","orcid":"","institution":"Cincinnati Children's Hospital Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Dillman","suffix":""},{"id":467571912,"identity":"60cbf86f-7c5e-4caa-a17c-df07a79a60df","order_by":5,"name":"Nicole Zeky","email":"","orcid":"","institution":"Cincinnati Children's Hospital Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Nicole","middleName":"","lastName":"Zeky","suffix":""},{"id":467571913,"identity":"8b57217f-9de6-48cf-bc1d-8b12d3fca13a","order_by":6,"name":"Jasbir Dhaliwal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIie2PsUrEQBCGJxzEJmA7zZlX2BCICil8lA1C0iTaWlisjWmCafMYayWCxUpQm8i1OWxMExsbG0lz4sQTC3GJpeB+zSyzfPz/ABgMfxBLgA2cpoSZUAA7WwDOrxVrVNCfVAj7Qx0VmhiJKWWW3/WP3RXMLzauT2rnGJMyv7+RA4SH7p6mWJFuM96Df1lEonZuMauag3hZQLx7rnS3pDZyBZFUpNA7k+gEDwA184RGKZ/6tbLoSHnDhE0qFQ/WSksp2SnyL8XVnG9Vz3SLQl+2lLI6Q69q0mBZsJgxjeKVSd8NKpzLxX79Ur2G7mbeBO1wFDJXU+yzMH7fUwRTPyu6wuOXJsVgMBj+He9egGMvG+ZyngAAAABJRU5ErkJggg==","orcid":"","institution":"Cincinnati Children's Hospital Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Jasbir","middleName":"","lastName":"Dhaliwal","suffix":""}],"badges":[],"createdAt":"2025-05-01 13:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6572158/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6572158/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84366890,"identity":"086f9caa-f506-490f-af51-b714e6586768","added_by":"auto","created_at":"2025-06-11 06:13:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":124826,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Axial contrast-enhanced CT image through the pelvis shows a short segment of bowel wall thickening and luminal narrowing (arrows). An adjacent bowel loop is dilated (*). Findings were interpreted as suspicious for stricturing Crohn’s Disease. (B) and (C) Similar findings were present on follow-up MR enterography, including focal luminal narrowing and postcontrast hyperenhancement (arrows). The dilated bowel loop appeared “fecalized” containing stool-like material.\u003c/p\u003e","description":"","filename":"Figure1Imaging.png","url":"https://assets-eu.researchsquare.com/files/rs-6572158/v1/047a8138d2817f392647ab2a.png"},{"id":84367806,"identity":"ec0c40f7-412a-4b2d-9402-a7765ae80b22","added_by":"auto","created_at":"2025-06-11 06:29:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":12147519,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Gross photograph of a resected small intestine segment containing a 10.5 cm diverticulum (arrows) terminating in a blind pouch. The opened section reveals a 1.5 cm circumferential linear ulceration (white arrow) corresponding to a stricture. Proximal and distal resection margins are marked by black and white asterisks, respectively. (B) Representative mucosal biopsy from two months before surgery, showing preserved villous and crypt architecture of the ileal mucosa without inflammatory epithelial lesions (H\u0026amp;E, 4X). (C) Photomicrograph of a polypoid area within the resected Meckel diverticulum, demonstrating the transition from small intestinal mucosa to gastric heterotopic mucosa (black asterisk) with areas of mucosal erosion (H\u0026amp;E, 4X). (D) High-power view of the gastric heterotopic mucosa (black asterisk), highlighting its detailed morphology (H\u0026amp;E, 40X). (E) Low-power view of the intestinal wall, showing extensive ulceration (black asterisk), congestion, ectopic gastric mucosa, a fibrotic submucosa, and thickened muscularis propria, consistent with stricture. (H\u0026amp;E, 4X).\u003c/p\u003e","description":"","filename":"Figure2Pathology.png","url":"https://assets-eu.researchsquare.com/files/rs-6572158/v1/c066367df1f34a02bfdb44c7.png"},{"id":84365871,"identity":"707cb221-523b-4638-857b-702e08c3550d","added_by":"auto","created_at":"2025-06-11 06:05:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1022999,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline of events of the patient’s clinical course\u003c/p\u003e\n\u003cp\u003eAbbreviations: EGD: esophagogastroduodenoscopy; H. pylori\u003cem\u003e: Helicobacter pylori\u003c/em\u003e; MRE: magnetic resonance enterography.\u003c/p\u003e","description":"","filename":"Figure3CaseTimeline.png","url":"https://assets-eu.researchsquare.com/files/rs-6572158/v1/e323a6d0f36561f0ee7c366e.png"},{"id":106397819,"identity":"29e4483a-07e9-475f-9771-20f5e0b95fc2","added_by":"auto","created_at":"2026-04-08 08:15:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":16825203,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6572158/v1/2e551e40-7ed3-4d76-a1cb-e453b4637aff.pdf"},{"id":84365869,"identity":"f3acb55c-327e-4f62-bf63-72b8c11462a9","added_by":"auto","created_at":"2025-06-11 06:05:35","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18080,"visible":true,"origin":"","legend":"","description":"","filename":"CaseReportTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6572158/v1/99ae4c504a498cb50b4df0ee.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Report of Meckel’s Diverticulum Mimicking Stricturing Crohn’s Disease in an Adolescent Male","fulltext":[{"header":"Background","content":"\u003cp\u003eCrohn\u0026rsquo;s Disease, a form of inflammatory bowel disease (IBD), is a chronic relapsing and remitting inflammatory condition affecting any part of the gastrointestinal tract that can present as a constellation of symptoms including hematochezia, iron deficiency anemia, abdominal pain, and weight loss (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Typically, 87% of children present with the inflammatory phenotype at diagnosis, however, some patients may present with more severe phenotype, with stricturing or penetrating disease (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile iron deficiency anemia, elevated fecal calprotectin, and intestinal strictures warrant a high level of concern for Crohn\u0026rsquo;s Disease, Meckel\u0026rsquo;s Diverticulum can present with a similar constellation of findings (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Meckel\u0026rsquo;s Diverticulum, a congenital anomaly of the gastrointestinal tract, is a result of an incomplete obliteration of the vitelline (omphalomesenteric) duct during fetal development (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Typically, it presents within the first two years of life, with painless rectal bleeding (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Approximately half of patients present between 0 to 4 years of age (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Complications of Meckel\u0026rsquo;s include bleeding, intussusception, diverticulitis, volvulus, and perforation (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although less common in adolescent males, Meckel\u0026rsquo;s Diverticulum should be considered as an alternative diagnosis when there is a lack of response to traditional therapies for IBD (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Normal inflammatory markers and normal albumin can help further differentiate patients, favoring Meckel\u0026rsquo;s Diverticulum over IBD (\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). We report a case of Meckel\u0026rsquo;s Diverticulum presenting as an intestinal stricture in an adolescent, initially misdiagnosed as refractory stricturing Crohn\u0026rsquo;s disease.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 16-year-old male presented with hematochezia. He had a four-year history of iron deficiency anemia, often requiring both blood and iron transfusions. \u0026nbsp;At age 12, he underwent an initial endoscopic evaluation that was macroscopically normal. Pathology confirmed the presence of numerous \u003cem\u003eHelicobacter\u003c/em\u003e-like organisms. After completing therapy for \u003cem\u003eHelicobacter\u003c/em\u003e \u003cem\u003epylori\u003c/em\u003e gastritis, he demonstrated clearance of the infection with a normal stool antigen. Anthropometrics remained within normal limits during this time.\u003c/p\u003e\n\u003cp\u003eDespite clearing his \u003cem\u003eHelicobacter pylori\u003c/em\u003e, hematochezia continued. At the age of 14, he underwent two more repeat endoscopies, both of which did not demonstrate any macroscopic evidence of bleeding. Notably, microscopically there was no evidence of acute or chronic inflammation. Magnetic resonance enterography (MRE), confirmed normal small bowel. \u0026nbsp;He underwent a capsule endoscopy that showed evidence of ulcers at the distal terminal ileum. He was started on 5-aminosalicylic acid (5-ASA) therapy for presumed diagnosis of Crohn\u0026rsquo;s Disease. Symptoms persisted despite one year of therapy, and thus endoscopic evaluation was repeated. The colonic mucosa was found to be macroscopically normal. The terminal ileum was erythematous but without the presence of ulcers. Pathology again demonstrated no diagnostic abnormalities. \u0026nbsp; Ongoing hematochezia was not concordant with the repeat colonoscopy. During episodes of bleeding, hemoglobin dropped as low as 6.6 gm/dL. Serum albumin, inflammatory markers [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR)], and platelets were within normal range throughout. However, fecal calprotectin was elevated and ranged between 212 \u0026micro;g/g and 551 \u0026micro;g/g during this time (Table 1) [normal \u0026lt;50 ug/g].\u003c/p\u003e\n\u003cp\u003eHe presented four months later to a quaternary care facility with epigastric pain, nausea, vomiting, and lightheadedness. Hemoglobin was found to be 5.8 gm/dL and inflammatory markers were elevated (CRP: 2.2 mg/dL, ESR: 25 mm/hour). A MRE showed focal mural thickening and luminal narrowing involving the ileum. Double balloon retrograde enteroscopy (DBE) was performed, which was notable for a distal ileal stricture. A few scattered shallow erosions in the mid and distal ileum were noted, and again histopathology demonstrated no acute or chronic changes. \u0026nbsp;Due to the stricture, the patient\u0026rsquo;s therapy was escalated to include intravenous corticosteroids followed by infliximab for presumed stricturing Crohn\u0026rsquo;s Disease.\u003c/p\u003e\n\u003cp\u003eOne month later in clinic, he presented with diarrhea and nocturnal stooling. Repeat imaging confirmed a persistent small bowel stricture. After re-reviewing with a fellowship-trained pediatric abdominal radiologist, the medical team broadened the differential to include etiologies like Meckel\u0026rsquo;s Diverticulum (Figure 1). Following shared decision making with the family, a diagnostic laparoscopy was performed. A very large Meckel\u0026rsquo;s Diverticulum with a feeding vessel was identified just proximally to the terminal ileum (Figure 2A). The remaining bowel otherwise appeared normal on evaluation. Histology from the resected sample confirmed a diverticulum containing all layers of the small bowel wall (true diverticulum) with focal areas containing ectopic gastric-type mucosa, consistent with a Meckel\u0026rsquo;s Diverticulum (Figure 2C, 2D).\u003c/p\u003e\n\u003cp\u003eFollowing resection, the patient had resolution of his clinical symptoms and infliximab was discontinued. His repeat endoscopy and colonoscopy three months post-operatively was macroscopically and microscopically normal. Hemoglobin normalized and other labs including inflammatory markers, albumin, and platelets remained normal (Table 1). Repeat fecal calprotectin two years following surgery was normal (53 \u0026micro;g/g) (Figure 3). He remained asymptomatic throughout this two-year follow-up period.\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eWe present the case of an adolescent male with persistent iron deficiency anemia, hematochezia, and an intestinal stricture identified on endoscopic evaluation, who was initially treated for Crohn\u0026rsquo;s Disease. However, following a lack of response to standard therapies, exploratory laparoscopy ultimately revealed Meckel\u0026rsquo;s Diverticulum. The stricture most likely developed secondary to chronic mucosal inflammation, ulceration and fibrosis, caused by longstanding acid secretion from the ectopic gastric mucosa. \u0026nbsp; Although the stricture had similar features to that of a Crohn\u0026rsquo;s Disease, the heterotopic ulcerated gastric mucosa on top is rather characteristic of Meckel\u0026rsquo;s Diverticulum (Figure 2E) while the remaining samples of the terminal ileum and colon showed no evidence of mucosal chronicity.\u003c/p\u003e\n\u003cp\u003eMeckel\u0026rsquo;s Diverticulum can present with a wide range of clinical symptoms. In pediatric patients, the most common presentation is obstruction, followed by gastrointestinal bleeding, both of which our patient had (17). In contrast, adults more commonly present with bleeding over obstruction (17). While most individuals with Meckel\u0026rsquo;s Diverticulum (90\u0026ndash;96%) remain asymptomatic, complications such as bowel perforation, volvulus, and intussusception can occur (4, 10, 17).\u003c/p\u003e\n\u003cp\u003eThe delayed diagnosis of Meckel\u0026rsquo;s Diverticulum, initially mistaken as Crohn\u0026rsquo;s Disease, has been previously documented in the literature (6-16), although these cases are less common in pediatric cases. To date, only three case reports describe pre-adolescent patients, initially suspected of having Crohn\u0026rsquo;s Disease who were later found to have Meckel\u0026rsquo;s Diverticulum (Table 2). Our case is unique due to the chronicity of the patient\u0026rsquo;s symptoms and the utility of DBE as part of the initial work up. After evidence of a presumed stricture on DBE, his therapy for IBD was escalated to infliximab despite unremarkable microscopic findings reported on numerous endoscopies. If his IBD therapy was suboptimal prior to this point, we would have seen more evidence of disease clinically or on histopathology. This suggests that broadening the differential was warranted prior to escalating his therapy to infliximab. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our case, the patient had persistently elevated fecal calprotectin levels prior to surgical resection. Fecal calprotectin is a cytosolic protein primarily found in neutrophils but also present in macrophages and monocytes. It is mainly used to differentiate IBD from functional gastrointestinal disorders (18-20). Mucosal inflammation or infection leads to chemotaxis of granulocytes and monocytes with ultimate release of calprotectin (20). Thus, the presence of calprotectin in the feces is a non-specific marker of gastrointestinal inflammation (19,20). A meta-analysis of 10 pediatric IBD studies, including 867 children, reported a pooled sensitivity of 99% (95% CI 92%-100%) and specificity of 65% (54%\u0026ndash;74%), for fecal calprotectin, supporting its utility as a screening tool (21). However, an elevated fecal calprotectin can be secondary to many conditions including gastroenteritis, \u003cem\u003eH. pylori\u003c/em\u003e-related peptic ulcer disease, polyps, IBD, neoplasms and in our case, Meckel\u0026rsquo;s Diverticulum (22, 23, 24). The elevated fecal calprotectin in our case was likely secondary to mucosal inflammation from acid producing heterotopic gastric mucosa leading to mucosal ulceration.\u003c/p\u003e\n\u003cp\u003eSerum inflammatory markers, like C-reactive protein (CRP), are also commonly used to evaluate acute inflammation and have clinical utility in monitoring clinical disease activity (22). Additionally, hypoalbuminemia is an important marker of enteropathy and intestinal inflammation and is present in about one fifth of patients the year preceding (25). Our patient had persistently normal albumin levels and near normal inflammatory markers which are useful when considering a diagnosis of IBD (26). Despite a persistently elevated fecal calprotectin, these other serum markers help support an alternative diagnosis other than refractory IBD.\u003c/p\u003e\n\u003cp\u003eThis case highlights the importance of considering Meckel\u0026rsquo;s Diverticulum in the differential diagnosis of new-onset Crohn\u0026rsquo;s disease, particularly when clinical, endoscopic, and histologic findings are incongruent, and when patients do not respond to conventional IBD therapies. Given the implications of initiating systemic immunosuppressive medication such as infliximab, consideration of Meckel\u0026rsquo;s Diverticulum is warranted in patients with an uncertain diagnosis of Crohn\u0026rsquo;s Disease prior to treatment initiation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIBD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einflammatory bowel disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance enterography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e5-ASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e5-aminosalicylic acid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecomputed tomography enterography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHgb\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHemoglobin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehematocrit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eErythrocyte sedimentation rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efecal calprotectin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed Tomography Angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDBE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDouble balloon retrograde enteroscopy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eNot applicable as this was a case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003cbr\u003e\u003c/strong\u003eWritten Informed consent was obtained from legal guardians of the patient involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003cbr\u003e\u003c/strong\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003cbr\u003e\u003c/strong\u003eNot applicable. No competing interests. \u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003eNot applicable. There was no funding for this project. \u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDrs. Merissa Maccani, Courtney Bartel, and Nicole Zeky conceptualized and drafted the initial manuscript, and critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eDrs. Oscar F. Lopez-Nunez, Aaron Garrison, Jonathan R. Dillman provided clinical expertise and critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eDr. Jasbir Dhaliwal conceptualized, assisted in drafting the manuscript, and provided oversight for the crafting of this case report manuscript. She critically reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. No Acknowledgments. \u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDay AS, Ledder O, Leach ST, Lemberg DA. Crohn's and colitis in children and adolescents. World J Gastroenterol. 2012;18(41):5862\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3748/wjg.v18.i41.5862\u003c/span\u003e\u003cspan address=\"10.3748/wjg.v18.i41.5862\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhaliwal J, Walters TD, Mack DR, et al. 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Laboratory markers in IBD: useful, magic, or unnecessary toys? Gut. 2006;55(3):426\u0026ndash;31. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/gut.2005.069476\u003c/span\u003e\u003cspan address=\"10.1136/gut.2005.069476\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hematochezia, Meckel’s Diverticulum, anemia, case report","lastPublishedDoi":"10.21203/rs.3.rs-6572158/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6572158/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground:\u003c/p\u003e\n\u003cp\u003eCrohn’s Disease, a form of inflammatory bowel disease (IBD), can present with hematochezia, iron deficiency anemia, intestinal obstruction, and elevated fecal calprotectin. Although less common in an adolescent male, Meckel’s Diverticulum is an alternative diagnosis to consider. We present a case wherein a 16-year-old patient with presumed stricturing Crohn’s Disease with absence of clinical improvement on standard therapies.\u003c/p\u003e\n\u003cp\u003eCase Presentation:\u003c/p\u003e\n\u003cp\u003eWe present a case of a 16-year-old patient with presumed stricturing Crohn’s Disease with absence of clinical improvement on anti-TNF therapy. Lab work was notable for iron deficiency anemia, elevated fecal calprotectin, and normal inflammatory markers. On further review of his imaging, there were concerns for possible Meckel’s Diverticulum. Following diagnostic laparoscopy, his diagnosis was confirmed and his anemia resolved. Through discussion of this case, we illustrate how providers can differentiate between two similar conditions.\u003c/p\u003e\n\u003cp\u003eConclusions:\u003c/p\u003e\n\u003cp\u003eAlthough less common in an adolescent, Meckel’s Diverticulum is an alternative diagnosis to consider in the setting of failure to improve on traditional therapies for IBD.\u003c/p\u003e","manuscriptTitle":"Report of Meckel’s Diverticulum Mimicking Stricturing Crohn’s Disease in an Adolescent Male","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-11 06:05:30","doi":"10.21203/rs.3.rs-6572158/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1e8bc8e-a6d2-4e50-a3ad-0c6c5a343726","owner":[],"postedDate":"June 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-08T08:12:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-11 06:05:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6572158","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6572158","identity":"rs-6572158","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}