Torsed gangrenous Meckel’s diverticulum presenting as acute abdomen

INTRODUCTION

Meckel’s diverticulum is the most common congenital variant of the gastrointestinal tract. It arises from the omphalomesenteric duct/vitelline duct.^[1] Normally, it regresses at the 7–8^th week of gestation.^[2] However, failure of its regression can cause complications. It was first described by John Fredrich Meckel in 1809, hence given the name Meckel’s diverticulum.^[3] The possible common complications associated with it include hemorrhage, obstruction, diverticulitis, hernia, and inflammation.^[4] Rarely, Meckel’s diverticulum can also cause intussusception.

CASE REPORT

A 10-year-old child presented to the emergency with complaints of acute abdominal pain and obstipation for 2 days. Physical examination revealed tenderness in the right upper and lower quadrant of the abdomen. No similar previous history, no known comorbidities, and no history of any past surgery were present. The patient underwent routine laboratory investigations. C-reactive protein of the patient was raised (43 mg/dL). Total leukocyte counts were elevated and were 14,000/uL. The patient underwent an x-ray abdomen which revealed multiple air-fluid levels within the small bowel which was suggestive of intestinal obstruction [Figure 1]. Ultrasound was done thereafter which revealed dilated small bowel loops. CECT was advised in view of abdominal tenderness. Computed tomography (CT) showed features of small bowel obstruction with two transition points in terminal and mid ileal loops. Fat-density lesion was seen within the bowel loops which we initially thought to be a benign bowel wall lipoma. Blind-ending tubular structure was also seen at the mesenteric border adjacent to the site of transition [Figure 2]. Clear-cut intussusception was not evident on imaging to explain the cause of symptoms. Based on the imaging, we made a differential diagnosis of closed-loop obstruction due to thick adhesion/ thick band or a remote possibility of internal hernia as the cause of intestinal obstruction.

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Figure 1:

(a) X-ray abdomen erect view shows dilated small bowel loops with multiple air fluid levels suggestive of intestinal obstruction and (b) supine radiograph of the abdomen shows dilated small bowel loops with absence of rectal gas shadow.

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Figure 2:

(a-c) Axial, coronal, and sagittal reformatted contrast-enhanced computed tomography abdomen images showing dilated small bowel loops with fat density lesion within the bowel lumen (arrow). Blind ending tubular structure (dashed arrow) is seen at the mesenteric border adjacent to the transition point.

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The patient underwent laparoscopic-assisted surgery for the same, 5 h after the CT scan. Intraoperative findings revealed ileo-ileal intussusception with the lead point as Meckel’s diverticulum. Gangrenous changes were also noted in the ileum. Laparoscopy-assisted intussusception reduction and resection anastomosis of gangrenous bowel and Meckel’s diverticulum were done. The biopsy specimens from Meckel’s diverticulum area showed transmural hemorrhagic necrosis. The nodule was entirely necrotic with the suggestion of gastric heterotopia as shown in [Figure 3]. However, no evidence of any viable gastric mucosa was seen.

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Figure 3:

(a and b) Intraoperative images showing broad based Meckel’s diverticulum (arrow) arising from the mesenteric border of ileum (b) shows ileoileal intussusception (arrowhead) in the distal ileum with gangrenous intussusception (asterix). (c) Histopathology image showing haemorrhagic small intestinal wall and gangrenous Meckel’s, H&E stain, 2x.

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The patient made an uneventful post-operative recovery and was discharged after 48 h of admission. Complete recovery and resolution of symptoms were seen at 6-week follow-up.

DISCUSSION

Meckel’s diverticulum is a true diverticulum and arises as an out pouching of all three layers of the gastrointestinal mucosa caused by failure of regression of the omphalomesenteric duct.^[1] Mostly, it remains asymptomatic. Around 2–4% of the patients with Meckel’s diverticulum become symptomatic.^[4] The common symptoms associated with Meckel’s diverticulum are pain abdomen, gastrointestinal hemorrhage, and features of intestinal obstruction, which are secondary to the complications associated with Meckel’s diverticulum, that is, diverticulitis, perforation, hemorrhage in ectopic mucosa, and intussusception leading to obstruction. Intussusception is a rare complication of Meckel’s diverticulum as was seen in our case of a child who presented in emergency with features of acute intestinal obstruction.

Meckel diverticulum may invert or invaginate into the small intestinal lumen, resulting in the pulling of the mesenteric fat into the center of the diverticulum.^[5] Once the diverticulum is inverted into the small intestinal lumen along with its mesentery, it may serve as the site of intestinal obstruction or act as a lead point for an ileoileal or ileocolic intussusception as was seen in our case. Usually, Meckel’s diverticulum lies at the antimesenteric border within 100 cm of the ileocecal valve; however, rarely, it can lie on the mesenteric border.

CONCLUSION

Meckel’s diverticulum is an important differential diagnosis in a pediatric acute abdomen. Rarely, it can lie on the mesenteric border as a blind ending loop.