Meckel's diverticulum with small bowel obstruction presenting as appendicitis in a pediatric patient

Background:

Meckel''s diverticulum is a congenital anomaly resulting from incomplete obliteration of the omphalomesenteric duct. The incidence ranges from 0.3% to 2.5% with most patients being asymptomatic. In some cases, complications involving a Meckel''s diverticulum may mimic other disease processes and obscure the clinical picture.

Methods:

This case presents an 8-year-old male with abdominal pain, nausea, and vomiting and an examination resembling appendicitis.

Results:

A CT scan revealed findings consistent with appendicitis with dilated loops of small bowel. During laparoscopic appendectomy, the appendix appeared unimpressive, and an inflamed Meckel''s diverticulum was found with an adhesive band creating an internal hernia with small bowel obstruction. The diverticulum was resected after the appendix was removed.

Conclusion:

The incidence of an internal hernia with a Meckel''s diverticulum is rare. A diseased Meckel''s diverticulum can be overlooked in many cases, especially in those resembling appendicitis. It is recommended that the small bowel be assessed in all appendectomy cases for a pathological Meckel''s diverticulum.     

Laparoscopy for treating a small bowel obstruction due to a Meckel's diverticulum.

A Meckel's diverticulum is one cause of small bowel obstruction in the virgin abdomen. A 17-year-old female presented with a 24-hour history of lower abdominal pain and emesis. Radiological imaging studies revealed a high-grade partial small bowel obstruction. A diagnostic laparoscopy was performed revealing a bowel obstruction secondary to a Meckel's diverticulum. The diverticulum was resected using an endovascular GIA stapler. The patient was discharged on postoperative day 3, tolerating a regular diet. Laparoscopy is a useful diagnostic and therapeutic tool for a patient with a small bowel obstruction with an unclear etiology.     

Laparoscopic treatment of bowel obstruction due to a bezoar in a Meckel's diverticulum

Background and Objectives:

Meckel''s diverticulum is a common anomaly of the gastrointestinal tract that may result in gastrointestinal bleeding, diverticulitis, and small bowel obstruction. This report describes the use of laparoscopy to treat a rare complication of Meckel''s diverticulum–small bowel obstruction due to phytobezoar impaction. More generally, it provides an example of the feasibility and utility of a laparoscopic approach to small bowel obstructions of unknown causes.

Methods:

A 34-year-old male presented to the emergency department complaining of episodic abdominal pain and vomiting. He had no history of abdominal surgery. His vital signs were stable, and his abdomen was distended, but only mildly tender. He had no abdominal wall hernias on examination. Imaging was consistent with small bowel obstruction. He was brought to the operating room where laparoscopy revealed a Meckel''s diverticulum with an impacted phytobezoar as the source of obstruction. The diverticulum was resected and the phytobezoar removed laparoscopically.

Results:

The patient recovered well and was discharged home on the third postoperative day, tolerating a regular diet.

Conclusions:

Phytobezoar impaction in a Meckel''s diverticulum causing small bowel obstruction is a rare event. It can be effectively treated laparoscopically. This case provides an example of the potential utility of laparoscopy in treating small bowel obstructions of unclear etiology.     

Laparoscopic reduction of incarcerated Meckel's diverticulum following abdominal hysterectomy.

BACKGROUND: Laparoscopic techniques are increasingly being utilized to diagnose and successfully manage intestinal obstruction. CASE REPORT: We describe a patient who presented with intestinal obstruction following a recent abdominal hysterectomy. The obstruction was caused by entrapment of a segment of small bowel containing a Meckel's diverticulum within a pouch formed by the peritoneal layer following mass closure of the abdominal wound. DISCUSSION: We discuss the literature on the abdominal wound closure technique. The role of laparoscopy in dealing with intestinal obstruction is reviewed briefly. We have also summarized the management of an incidental Meckel's diverticulum found at laparoscopy.     

A case report: Cecal volvulus caused by Meckel's diverticulum

INTRODUCTION

Meckel''s diverticulum is the most common congenital anomaly of the small intestine. Common complications related to Meckel''s diverticulum include hemorrhage, intestinal obstruction and inflammation. Acute large bowel obstruction is a rare complication of Meckel''s diverticulum and in the presented case it is caused by volvulus.

PRESENTATION OF CASE

We report a 39 year old female who presented with the diagnosis of a large bowel obstruction occurring as a result of cecal volvulus caused by adhesions of a perforated diverticulum.

DISCUSSION

The reported case presents one of the rare complications of MD, which is volvulus. The case described above presented with signs and symptoms suggestive of acute intestinal obstruction and radiological findings suggestive of cecal volvulus. The patient was taken to the operation room for exploration and we discovered the presence of a perforated MD. The main treatment of such case is to perform diverticulectomy in all symptomatic patients.

CONCLUSION

MD is mostly identified intraoperatively. Knowledge of the pathophysiologies by which MD can cause complications such as volvulus is important in order to plan management.     

Giant Meckel’s diverticulum: An exceptional cause of intestinal obstruction

Meckel's diverticulum(MD) results from incomplete involution of the proximal portion of the vitelline(also known as the omphalomesenteric) duct during weeks 5-7 of foetal development. Although MD is the most commonly diagnosed congenital gastrointestinal anom-aly, it is estimated to affect only 2% of the population worldwide. Most cases are asymptomatic, and diagno-sis is often made following investigation of unexplained gastrointestinal bleeding, perforation, inflammation or obstruction that prompt clinic presentation. While MD range in size from 1-10 cm, cases of giant MD(≥ 5 cm) are relatively rare and associated with more severe forms of the complications, especially for obstruction. Herein, we report a case of giant MD with secondary small bowel obstruction in an adult male that was suc-cessfully managed by surgical resection and anasto-mosis created with endoscopic stapler device(80 mm, endo-GIA stapler). Patient was discharged on post-operative day 6 without any complications. Histopatho-logic examination indicated Meckel's diverticulitis with-out gastric or pancreatic metaplasia.     

A large incarcerated Meckel's diverticulum in an inguinal hernia

INTRODUCTION

Littre''s hernia is a rare finding consisting of a Meckel''s diverticulum inside of a hernia sac. Clinically, it is indistinguishable from a hernia involving small bowel and therefore may be difficult to diagnose pre-operatively.

PRESENTATION OF CASE

We report a case of an inguinal hernia involving an unusually large Meckel''s diverticulum measuring 15 cm in length. The diverticulum was resected using a linear GI stapler and the hernia was repaired without complication.

DISCUSSION

Meckel''s diverticulum is an embryologic remnant of the vitelline duct occurring in 1–3% of the adult population with an estimated 4% becoming complicated and presenting with intestinal obstruction, infection, bleeding or herniation. Surgical resection is the recommended treatment for any Meckel''s diverticulum causing symptoms. In the case of a Littre''s hernia, resection of the diverticulum should be followed by repair of the fascial defect in a standard fashion.

CONCLUSION

Littre''s hernia, although rare, should be a consideration at the time of repair for any abdominal hernia involving small bowel as resection of the Meckel''s diverticulum is critical in avoiding recurrent complications.     

Laparoscopic-assisted resection of Meckel's diverticulum in children.

BACKGROUND AND OBJECTIVES: Meckel's diverticulum (MD) presents unique challenges for a pediatric surgeon, as it is prone to varied complications. This case series highlights the diverse presentations and laparoscopic management of MD in children. METHODS: We performed a retrospective analysis of consecutive cases of laparoscopic-assisted transumbilical Meckel's diverticulectomy (LATUM) performed by the same surgeon for incidental as well as diverse Meckel's diverticular complications over 20 months. RESULTS: Eight patients (5 males and 3 females) aged 3 years to 13 years (median, 12) underwent LATUM. Three patients had painless per-rectal bleeding and 1 presented with intestinal obstruction due to a mesodiverticular band and intestinal ischemia. Two patients had features masquerading as appendicitis; one had perforated MD with secondary inflammation of the appendix, and the other had a torsed, gangrenous MD. In 2 patients, incidental MD with a narrow base was noted at appendicectomy for appendicitis. All patients underwent successful LATUM along with appendicectomy in 4 patients. The operative duration was 72 minutes to 165 minutes (mean, 112.1+/-30.6). There were no operative complications, and no conversion to open surgery was required. The hospital stay was 4 days to 7 days (mean, 4.7+/-1.2). The patient with mesodiverticular band intestinal obstruction presented with adhesive intestinal obstruction 2 weeks after the surgery. Laparoscopic-assisted minilaparotomy was done to release the pelvic adhesions. There were no other complications during the follow-up (median, 11 months). CONCLUSIONS: LATUM is a simple, safe, and effective procedure with a better cosmetic outcome that can be performed for diverse manifestations of MD. The technique also allows palpation of the MD and avoids use of expensive staplers.     

Laparoscopic management of acute small bowel obstruction

Background As minimally invasive surgery gains ground, it is entering realms previously considered to be relative contraindications for laparoscopy. We reviewed our experience with the laparoscopic approach to the management of small bowel obstruction (SBO).Methods From December 1997 to November 2002, 65 patients underwent laparoscopic treatment for SBO. The operating surgeon attempted to identify a transitional point between distended and collapsed bowel and then address the obstruction at that point.Results Postoperative adhesions were the cause of the obstruction in 44 patients. Tumor was identified in five cases, hernia in four, bezoar in three, intussusception in three, acute appendicitis and pseudoobstruction in two cases each, and terminal ileitis in one case. The diagnostic accuracy of laparoscopy was 96.9%. Thirty-four patients (52%) were treated by laparoscopy alone. Thirteen patients (20%) required a small target incision for segmental resection. Eighteen operations were converted to formal laparotomy. The mean laparoscopy time was 40 min (range, 25-160). Patients resumed oral intake in 1-3 days. The complication rate was 6.4%. There were two deaths, but none related to laparoscopy. The mean hospital stay was 4.2 days.Conclusions Laparoscopy is a useful minimally invasive technique for the management of acute SBO. It is an excellent diagnostic tool and, in most cases, a therapeutic surgical approach in patients with SBO. However, a significant number of patients will require conversion.Presented in part at the 10th annual congress of the European Association for Endoscopic Surgery (EAES), Lisbon, Portugal, 2-5 June, 2002     

Torsion of Meckel's diverticulum as a cause of small bowel obstruction: A case report

Axial torsion and necrosis of Meckel's diverticulum causing simultaneous mechanical small bowel obstruc-tion are the rarest complications of this congenital anomaly. This kind of pathology has been reported only eleven times. Our case report presents this very unusual case of Meckel's diverticulum. A 41-year-old man presented at the emergency department with complaints of crampy abdominal pain, nausea and re-tention of stool and gases. Clinical diagnosis was small bowel obstruction. Because the origin of obstruction was unknown, computer tomography was indicated. Computed tomography(CT)-scan revealed dilated small bowel loops with multiple air-fluid levels; the oral con-trast medium had reached the jejunum and proximal parts of the ileum but not the distal small bowel loops or the large bowel; in the right mid-abdomen there was a 11 cm × 6.4 cm × 7.8 cm fluid containing cavity with thickened wall, which was considered a dilated bowel-loop or cyst or diverticulum. Initially the patient was treated conservatively. Because of persistent abdominal pain emergency laparotomy was indicated. Abdominal exploration revealed distended small bowel loops proxi-mal to the obstruction, and a large(12 cm × 14 cm) Meckel's diverticulum at the site of obstruction. Meckel's diverticulum was axially rotated by 720°, which caused small bowel obstruction and diverticular necrosis. About 20 cm of the small bowel with Meckel's diverticulum was resected. The postoperative course was uneventful and the patient was discharged on the fifth postopera-tive day. We recommend CT-scan as the most useful diagnostic tool in bowel obstruction of unknown origin. In cases of Meckel's diverticulum causing small bowel obstruction, prompt surgical treatment is indicated; de-lay in diagnosis and in adequate treatment may lead to bowel necrosis and peritonitis.     

A rare case of segmental small bowel pneumatosis intestinalis: A case report

Introduction

Pneumatosis intestinalis is a rare condition affecting 0.03% of the population. It has a myriad of aetiological causes and hence presentation can vary immensely. The management of symptomatic pneumatosis intestinalis in an acute and outpatient setting remains a challenge to both physicians and surgeons.

Case presentation

We present a case of a 79 year old who presented in a gastroenterology outpatients department with a history suggestive of intermittent small bowel obstruction associated with abdominal pain aggravated by eating and posture. He was found to have signs suggestive of Marfan''s syndrome. Computed tomography demonstrated extensive pneumatosis intestinalis of the small bowel. Due to deterioration in symptoms, an exploratory laparotomy was performed demonstrating segmental small bowel pneumatosis intestinalis secondary to a hypermobile mesentery.

Conclusion

This case highlights the importance of both surgical and gastroenterology expertise in successfully managing symptomatic pneumatosis intestinalis.     

An undigested cherry tomato as a rare cause of small bowel obstruction

Small bowel obstruction due to undigested fibre from fruits and vegetables is a rare but known medical condition. We report a case of small bowel obstruction caused by a whole cherry tomato in a patient without a past medical history of abdominal surgery. A 66-year-old man presented to the emergency department complaining of lower abdominal pain with nausea and vomiting. His last bowel movement had occurred on the morning of presentation. He underwent abdominal computed tomography (CT), which showed a sudden change of diameter in the distal ileum with complete collapse of the proximal small bowel segment. Laparoscopy confirmed a small bowel obstruction with a transition point close to the ileocaecal valve. An enterotomy was performed and a completely undigested cherry tomato was retrieved. To our knowledge, this is the first reported case of a small bowel obstruction caused by a whole cherry tomato.     

Diverticulectomy is inadequate treatment for short Meckel's diverticulum with heterotopic mucosa

BACKGROUND: Meckel's diverticulum is a vestigial remnant of the vitellointestinal duct that may occasionally contain heterotopic gastric mucosa thought to arise from residual yolk sac cells. This may cause significant rectal bleeding, the source of which may be difficult to identify. The present paper addresses the question of whether the choice of resection technique should depend on the macroscopic appearance of the Meckel's diverticulum. METHODS: A retrospective analysis of patients with resected Meckel's diverticulum at Prince of Wales and Sydney Children's Hospitals between 1992 and May 2003 was performed. The external appearance was expressed as a height-to-diameter ratio (HDR) and the presence or absence of macroscopic thickening was recorded. The morphology was then correlated with the presence and site of the heterotopic gastric mucosa (HGM). RESULTS: Seventy-seven patients were identified with an age range between 1 day and 92 years. Fifty-seven (74%) of the patients were men. Presenting symptoms were gastrointestinal bleeding (11.7%), diverticulitis (15.6%), volvulus (2.6%), intussusception (10%) and umbilical fistula (7.8%). Fifty-seven per cent of the resected Meckel's diverticulae were found incidentally. Eight patients underwent a technetium pertechnate nuclear Meckel's scan. The Meckel's scan detected only two of seven patients with HGM on pathological examination. Twenty-nine (38%) patients underwent diverticulectomy and 48 (62%) small bowel resection. Ectopic mucosa was found in 25 (32.5%) patients. Of the Meckel's diverticula that were defined as long (HDR >or=2.0) and containing HGM, five of five (100%) had the ectopic mucosa in the diverticular tip and body only. Of those that were short (HDR <2.0) there was a wide distribution of HGM sites with 12 (60%) involving the whole diverticulum including the base and eight (40%) involving the tip and body only. The presence or absence of macroscopic thickening was described in 18 resected Meckel's diverticula. Thirteen (72%) were described as thickened in the operation report and six of these 13 (46%) were found to have HGM. One of the seven (14%) Meckel's diverticulae with HGM was thought to be of normal appearance and was therefore undetected. CONCLUSION: Simple transverse resection is not recommended for the short Meckel's diverticulum. A HDR of 2.0 is recommended as the cut-off when deciding on the most appropriate operation. The external appearance of the Meckel's diverticulum does not predict the presence of HGM and is therefore an unreliable indicator to aid resection decisions when presented with an incidental Meckel's diverticulum.     

Laparoscopic surgery for small-bowel obstruction caused by Meckel's diverticulum

A 26-year-old woman was referred to our hospital because of abdominal distention and vomiting. Contrastenhanced computed tomography showed a blind loop of the bowel extending to near the uterus and a fibrotic band connecting the mesentery to the top of the bowel,suggestive of Meckel's diverticulum(MD) and a mesodiverticular band(MDB). After intestinal decompression,elective laparoscopic surgery was carried out. Using three 5-mm ports,MD was dissected from the surrounding adhesion and MDB was divided intracorporeally. And subsequent Meckel's diverticulectomy was performed. The presence of heterotopic gastric mucosa was confirmed histologically. The patient had an uneventful postoperative course and was discharged 5 d after the operation. She has remained healthy and symptom-free during 4 years of follow-up. This was considered to be an unusual case of preoperatively diagnosed and laparoscopically treated small-bowel obstruction due to MD in a young adult woman.     

Acute pelvic inflammatory disease as a rare cause of acute small bowel obstruction

Introduction: Small bowel obstruction (SBO) is a common presentation to emergency abdominal surgery. The most frequent causes of SBO are congenital, postoperative adhesions, abdominal wall hernia, internal hernia and malignancy.

Patients: A 27-year-old woman was hospitalized because of acute abdominal pain, blockage of gases and stools associated with vomiting. Abdominal computed tomography showed an acute small bowel obstruction without any obvious etiology. In view of important abdominal pain and the lack of clear diagnosis, an explorative laparoscopy was performed. Diagnostic of pelvic inflammatory disease was established and was comforted by positive PCR for Chlamydia Trachomatis.

Results: Acute small bowel obstruction resulting from acute pelvic inflammatory disease, emerging early after infection, without any clinical or X-ray obvious signs was not described in the literature yet. This infrequent acute SBO etiology but must be searched especially when there is no other evident cause of obstruction in female patients. Early laparoscopy is mostly advised when there are some worrying clinical or CT scan signs.     

Laparoscopic management of a small bowel obstruction of unknown cause

With the expanding indications for minimally invasive surgery, the management of small bowel obstruction is evolving. The laparoscope shortens hospital stay, hastens recovery, and reduces morbidity, such as wound infection and incisional hernia associated with open surgery. However, many surgeons are reluctant to attempt laparoscopy in patients with significantly distended small bowel and a history of multiple previous abdominal operations. We present the management of a patient with a virgin abdomen who presented with a small bowel obstruction most likely secondary to Fitz-Hugh-Curtis syndrome who was successfully managed with laparoscopic lysis of adhesions.