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Meckel's Diverticulitis Causing Small Bowel Obstruction by a Novel Clinics and Practice 2011; volume 1:e51 Meckel’s diverticulitis causing 92.8% neutrophils), raised serum amylase (468 U/L) and raised urinary amylase (769 Correspondence: Vishalkumar Shelat, small bowel obstruction by a U/L). Serum lipase, electrolytes, creatinine Department of General Surgery, Tan Tock Seng novel mechanism and liver function tests were unremarkable. Hospital, 11 Jalan Tan Tock Seng, Singapore Chest and abdominal films were unremark - 308433, Singapore. E-mail: [email protected] Vishalkumar G. Shelat, Kaiwen Kelvin Li, able. The patient underwent computed tomog - Anil Rao, Tay Sze Guan raphy (CT) scan of her abdomen/pelvis on the Key words: Meckel’s diverticulum; Meckel’s diver - first day of admission which showed mild Department of General Surgery, Tan Tock ticulitis; small bowel obstruction. dilatation of the small bowels, particularly in Seng Hospital, Singapore, Singapore the distal jejunum and proximal ileum with Received for publication: 4 May 2011. thickening of the bowel wall and submucosal Accepted for publication: 21 June 2011. oedema. No transition point was seen on the CT scan (Figure 1). This work is licensed under a Creative Commons Abstract Attribution NonCommercial 3.0 License (CC BY- She received symptomatic treatment. NC 3.0). However, her abdomen became increasingly Meckel’s diverticulum occurs in 2% of the distended and she developed vomiting over ©Copyright V.G. Shelat et al., 2011 general population and majority of patients next three days. A repeat CT scan of the Licensee PAGEPress, Italy remain asymptomatic. Gastrointestinal bleed - abdomen/pelvis was performed on the fourth Clinics and Practice 2011; 1:e51 ing is the most common presentation in the day of admission and this showed interval doi:10.4081/cp.2011.e51 paediatric population. While asymptomatic and worsening of small bowel dilatation along with incidentally found Meckel’s diverticulum may a transition point in the distal ileum (Figure be left alone, surgery is essential for treating a 2). She underwent emergency exploratory ing all layers of the intestinal wall and is usu - symptomatic patient. Despite advances in laparotomy. Intra-operatively, gangrenous 6 cm ally situated 60-100 cm from the ileocecal valve imaging and technology, pre-operative diagno - long Meckel’s diverticulum was found with on the anti-mesenteric border of the terminal sis is often difficult. We present a first report of omentum adherent at its tip (Figure 3). The ileum. The apex of the diverticulum may be an unusual mechanism of small bowel obstruc - small bowel loop was obstructed secondary to free or attached by a fibrous band to the tion due to Meckel’s diverticulitis in a paedi - the omental band. The terminal ileum distal to umbilicus or to the mesentery, in which case it atric patient. The diagnosis was only apparent the band was collapsed. The small bowel was can cause intestinal obstruction. As the cells at laparotomy. otherwise viable. A short segment of the termi - lining the vitelline duct are pluripotent, it is nal ileum containing the Meckel’s diverticu - not uncommon to find heterotopic tissue with - lum and adhesion band was resected and sta - in a Meckel’s diverticulum. In one study, het - pled anastamosis with linear staples was per - erotopic gastric mucosa was found in 62% of Introduction formed. The histology showed an infracted cases, pancreatic tissue was found in 6% while Meckel’s diverticulum lined by small intestine- pancreatic tissue and gastric mucosa were Meckel’s diverticulum is the most common type mucosa. No gastric-type mucosa or pan - found in 5%. 7 The raised serum amylase levels 1 congenital abnormality of the small intestine. creatic tissue was identified. Her recovery was in our patient were reflective of intestinal It arises due to an incomplete obliteration of prolonged due to ileus. She was discharged on ischaemia rather than ectopic pancreatic tis - the omphalomesenteric duct. The majority of post-operative day 8 and was well at her clinic sue. Most people with Meckel’s diverticulum patients remain asymptomatic; with only 4- follow-up visit. remain asymptomatic with only 4-16% develop - 16% of patients experiencing symptoms. 2 ing symptoms arising from complications such Gastrointestinal bleeding is the most common as intestinal obstruction, gastrointestinal presentation in the paediatric population bleeding, and diverticulitis. 2,8 In a large series while intestinal obstruction is the most com - Discussion of 1476 cases of Meckel’s diverticulum found mon complication in adults. We present a first intra-operatively in a single institution over a report of an unusual mechanism of small Meckel’s diverticulum was first described by span of 52 years, it was found that 16% were bowel obstruction due to Meckel’s diverticulitis Fabricus Heldanus in 1650, 3 then reported by symptomatic with a mean age of 31 years and in a paediatric patient. Levator in 1671 4 and by Ruysch in 1730. 5 a male:female ratio of 3:1. 8 In the paediatric However, its embryonic origin was established patient population, the commonest complica - by Johann Friedrich Meckel much later in 1809 tion is gastrointestinal bleeding arising from and since then bears his name. 6 peptic ulceration due to acid secreted by het - Case Report During the first few weeks of gestation, the erotopic gastric mucosa. 9 On the other hand, midgut loop remains in open connection with intestinal obstruction is the most frequent A 15-year-old girl presented with one day the yolk sac by way of the vitelline duct. complication in the adult patient population. history of colicky central abdominal pain asso - Normally, the vitelline duct obliterates. Our case is an infrequent case where intestin - ciated with loss of appetite and nausea. There Meckel’s diverticulum represents a common al obstruction occurred in a paediatric patient. was no other history to note. She was afebrile vestigial remnant of the omphalomesenteric Intestinal obstruction occurs by various mech - with normal hemodynamic parameters. She duct (also known as the vitelline duct). anisms: omphalomesenteric band, internal was mildly dehydrated and abdominal exami - Persistence of the duct may also rarely lead to hernia through vitelline duct remnants, volvu - nation revealed tenderness over the periumbil - (i) fistula between umbilicus and ileum when lus around vitelline duct remnant, intussus - ical and suprapubic regions. Bowel sounds the entire duct remains patent; (ii) umbilical ceptions, incarceration within a hernia sac were active and the abdomen was not distend - sinus when the umbilical end of the duct is not (Littre’s hernia) or chronic Meckel’s divertic - ed. Digital rectal examination was unremark - obliterated and (iii) fibrous cord between the ulitis. 2 Enteroliths formed in the diverticulum able. Laboratory tests showed leukocytosis umbilicus and the ileum representing an oblit - causing intestinal obstruction have also been with left shift (16,600 white blood cells/mm3, erated duct. It is a true diverticulum contain - reported. 10,11 The small bowel obstruction in [page 102 ] [Clinics and Practice 2011; 1:e51] Case Report our patient was not explained by any of the ing with symptoms other than per-rectal bleed - omphalomesenteric remnant without any pal - above mechanisms. This is the first report of ing. In a study of 776 patients, 88% of patients pable mass in the lumen may be treated with a an omental band adherent to Meckel’s divertic - with Meckel’s diverticulum presenting with simple wedge resection of the diverticulum ulum causing intestinal obstruction. per-rectal bleeding had a correct preoperative and closure of the ileal defect. 28 In cases where Charles Mayo once remarked Meckel’s diagnosis while only 11% of patients who pre - the diverticulum has a wide base or palpable diverticulum is frequently suspected, often sented with other symptoms were rightly diag - ectopic tissue or where there is inflammatory looked for and seldom found. 12 Preoperative nosed preoperatively. 13 Plain X-ray, CT scans or ischemia changes in adjacent ileum, it is diagnosis of symptomatic Meckel’s diverticu - and barium studies are rarely useful in pre- preferable to resect the involved bowel with lum is difficult, especially in patients present - operative diagnosis of Meckel’s. In our patient, end-to-end bowel anatamosis. 24,29 Segmental CT scan was done twice and it failed to recog - ileal resection is also required for treatment of nize the presence of inflamed Meckel’s diver - patients with gastrointestinal bleeding as the ticulum on two occasions. Hence pre-operative site of bleeding is usually in the adjacent diagnosis is many times not possible and a ileum. Involvement of the diverticulum by high index of suspicion is essential in dealing benign tumors can be dealt with a simple with an undiagnosed abdominal pain. When diverticulectomy, depending on the site and the patient presents with gastrointestinal size of the lesion. Where malignant tumors are bleeding, technetium-99m pertechnate scan is involved, wide intestinal and mesenteric a useful non-invasive investigation. In chil - resection would be required. 30,31 dren, it has a sensitivity of 80-90%, specificity In conclusion, Meckel’s diverticulum is not of 95% and accuracy of 90% 14 but in the adults, uncommon and hence should be considered as it is less reliable with a sensitivity of 62.5%, a differential diagnosis in a patient with an specificity of 9% and accuracy of 46%. 15 As the unestablished cause of intestinal obstruction. Figure 1. Computed tomography scan technetium-99 m pertechnate scan is specific showing dilated small bowel loops and to ectopic gastric mucosa and not specifically mucosal oedema. The bowel wall is well to Meckel’s diverticulum, it may be positive in enhancing. gut duplication cysts with ectopic gastric References mucosa. 16 Management of incidentally detected 1. Anderson DJ. Carcinoid tumour in Meckel’s diverticulum is controversial. Meckel’s diverticulum: laparoscopic treat - Resection of incidentally found Meckel’s diver - ment and review of literature.
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