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.     

Intermittent small bowel obstruction caused by Meckel’s enterolith

A 56-year-old man presented with small bowel obstruction after a 6-week history of intermittent resolving subacute small bowel obstruction. After investigations, he underwent laparotomy. A mobile, narrow-necked Meckel’s diverticulum packed with enteroliths pressing against proximal small bowel was discovered. A small bowel resection was performed.     

Acute appendicitis with unusual dual pathology

INTRODUCTION

Meckel''s diverticulum is a rare congenital abnormality arising due to the persistence of the vitelline duct in 1–3% of the population. Clinical presentation is varied and includes rectal bleeding, intestinal obstruction, diverticulitis and ulceration; therefore diagnosis can be difficult.

PRESENTATION OF CASE

We report a case of acute appendicitis complicated by persistent post operative small bowel obstruction. Further surgical examination of the bowel revealed an non-inflamed, inverted Meckel''s diverticulum causing intussusception.

DISCUSSION

Intestinal obstruction in patients with Meckel''s diverticulum may be caused by volvulus, intussusception or incarceration of the diverticulum into a hernia. Obstruction secondary to intussusception is relatively uncommon and frequently leads to a confusing and complicated clinical picture.

CONCLUSION

Consideration of Meckel''s diverticulum although a rare diagnosis is imperative and this case raises the question “should surgeons routinely examine the bowel for Meckel''s diverticulum at laparoscopy?”     

Phytobezoar in Meckel's diverticulum: A rare cause of small bowel obstruction

IntroductionMeckel's diverticulum (MD) is the prevailing anomaly of the gastrointestinal tract, found in about 2% of the population; it rarely gives rise to symptoms and its discovery is usually accidental. Phytobezoar is a concretion of poorly digested fruit and vegetable fibres that is found in the alimentary tract and rarely can be the cause of small intestinal obstruction. Herein we report a rare case of intestinal obstruction due to phytobezoar formation into a MD.Presentation of caseA 50 year-old patient, was admitted to author's institution with an history of abdominal pain, nausea and multiples episodes of vomiting. Plain X-ray showed dilated small-bowel loops. Computed tomography (CT) revealed jejunal loops with air-fluid levels. The patient underwent explorative laparotomy where we found a giant Meckel's diverticulum, filled by a phytobezoar that caused small bowel compression. We performed a segmental ileal, resection, containing the MD. The histological exam confirmed Meckel's diverticulum.DiscussionBowel obstruction due to a phytobezoar in a Meckel's diverticulum is rare: only 7 cases have been reported in literature. MD complications are rare and phytobezoar is one of them with only few cases described in literature.ConclusionThe conventional x rays studies were inconclusive whereas abdominal contrast enhanced CT led to a definitive diagnosis. Explorative laparotomy or laparoscopy is mandatory in these cases.     

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.     

A rare case of ileus caused by ileum endometriosis

IntroductionWe report our experience involving a rare case of ileum endometriosis complicated with small bowel obstruction.Presentation of case33 years old female patient, admitted to emergency service with abdominal pain, abdominal distension, and vomiting. Abdominal X-ray showed dilated small bowel loops. Computerized tomography scan showed dilated small intestine segments excepting last ileum loop, gastric distension, enlarged ovaries.Emergency laparotomy was performed, showing acute bowel obstruction due to a stenotic tumor placed on the terminal ileum, cecum tumors, multiple tumors in Douglas pouch, multiple mesenteric enlarged lymph nodes. Right colectomy is performed with an ileo-transverso stomy placed in right hypochondrium. Postoperative evolution without complication, patient discharged after 13-days hospitalization. After hormonal treatment, she returned for a second look and ileotransverso anastomosis.DiscussionGastrointestinal involvement of endometriosis has been found in 3%–37% of menstruating women. Ileum localization is very rare (1%–7%), causing intestinal obstruction 7%–23% of cases. Intraoperative differential diagnosis is difficult, predisposing at confusion with other types of tumors. In the absence of fast microscopic exam, the tumor was considered malignant and imposed a right hemicolectomy.ConclusionIntestinal obstruction due to ileum endometriosis is a rare condition, however, it should always be considered in the differential diagnosis in women of reproductive age.     

Small bowel obstruction secondary to Meckel diverticulum detected and treated laparoscopically--case report

A 13-year-old man with no history of abdominal surgery was admitted to Saisei Kai Sendai Hospital complaining of acute abdominal pain. Abdominal computed tomography revealed distal small bowel obstruction of unknown etiology. Abdominal symptoms worsened and emergency surgery was performed. To determine the cause of bowel obstruction, laparoscopy was performed. At Trendelenburg position using endoscopic bowel forceps, the focus of the obstruction was explored. The dilated ileum was incarcerated at 10 cm proximal to the ileocecal region. Laparoscopic exploration revealed that the appendix was tightly attached to Meckel diverticulum (MD) and comprised an internal hernia orifice, in which the small bowel was incarcerated. Intra-abdominal surgical space was insufficient to release the bowel obstruction intracorporally. After a 5 cm of midline incision was made in the lower abdomen, a LAP-Disc (Hakko Co, Japan) was applied. Opening of the internal hernia orifice, normograde appendectomy, and resection of MD with a suturing instrument were performed. The hernia orifice between MD and the appendix was released and the incarcerated bowel was normalized. The patient was discharged without postoperative complications. Laparoscopic procedures are useful in identifying rare causes of bowel obstruction and to determine an appropriate access point for treatment.     

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.     

A case of intestinal obstruction caused by a mesodiverticular band in Meckel's diverticulum with ectopic pancreas treated by laparoscopic surgery

IntroductionWe report a case of a patient who underwent laparoscopic surgery for intestinal obstruction caused by the mesodiverticular band of Meckel's diverticulum, with pathological specimens showing ectopic pancreas.Presentation of caseA 56-year-old woman presented to our hospital with complaints of abdominal pain and vomiting. Upon close examination, we suspected strangulated intestinal obstruction, and performed an emergency surgery. An internal hernia with a band leading to a Meckel's diverticulum was noted. Focusing on the attachment of the band, leading to the Meckel's diverticulum, we suspected a mesodiverticular band and deemed it necessary to be resected. Surgery was completed with resection of the band to relieve the intestinal obstruction, with simultaneous resection of the Meckel's diverticulum. It was necessary to resect Meckel's diverticulum simultaneously for histopathological examination. Histopathological examination revealed a mesodiverticular band in the resected band and ectopic pancreas in the Meckel's diverticulum.DiscussionWe chose to perform a complete laparoscopic resection because of the presence of simple intestinal obstruction caused by mesodiverticular bands or diverticula. We believe that small laparotomy can be opted in less severe cases, regardless of laparoscopic completion.ConclusionWe suspected adherent bowel obstruction and detected a band. We focused on band attachment and determined that the band should be resected if it was attached to Meckel's diverticulum. The resection method should be carefully selected, and the specimen should be histopathalogically examined.     

Small bowel intussusception with the Meckel's diverticulum after blunt abdominal trauma: a case report

Intussusception with the Meckel's diverticulum is a rare but well-known cause of small bowel obstruction in the adult. After blunt abdominal trauma, intussusception is exceedingly rare and has been reported previously only in few cases. We present a case of a previously healthy 28-year-old man developing four days after blunt abdominal trauma signs of small bowel obstruction. Ileo-ileal intussusception was suggested by computed tomography. Exploration revealed ileo-ileal intussusception with Meckel's diverticulum. A diverticulectomy with small bowel resection was performed.     

Giant Meckel’s diverticulum compressing root of mesentery – A rare cause of ileal gangrene – Case report and review of literature

IntroductionMeckel’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 presentationA 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.DiscussionThis 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.ConclusionAppropriate 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.     

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.     

Meckel’s cocoon: A rare case of abdominal cocoon with Meckel’s diverticulum

Abdominal cocoon syndrome (ACS), also known as sclerosing encapsulating peritonitis, is a rare cause of intestinal obstruction in which there is partial or total encapsulation of abdominal viscera within a dense fibrous membrane. It was first described by Foo et al. [1] in 1978. This condition was thought to be related to retrograde menstruation. However, sporadic cases have been reported in both children and men, hence the exact aetiology remains unknown. This disease is characterized as either primary (idiopathic) or secondary to other causes. It is often confused with peritoneal encapsulation (PE) which is a congenital anomaly. It invariably presents as an acute or subacute intestinal obstruction with or without a mass. Diagnosis is mostly made after exploratory laparotomy and histopathological analysis of the sac. Herein, we present the case of a 38-year-old male who presented with features of acute intestinal obstruction. At laparotomy, small bowel loops were found encased in a cocoon with a tight ring at the base which resulted in bowel wall necrosis; Meckel’s diverticulum was also present within the cocoon. Resection of the cocoon and anastomosis was performed. A better awareness of these conditions will facilitate proper management when encountered as an emergency.     

Prospective Evaluation of Oral Gastrografin® in the Management of Postoperative Adhesive Small Bowel Obstruction

Oral Gastrografin®, a hyperosmolar water-soluble contrast medium, may have a therapeutic effect in adhesive small bowel obstruction. However, findings are still conflicting, as some authors did not find a therapeutic advantage. So, this prospective, randomized, and clinical trial study was designed to determine the value of Gastrografin in adhesive small bowel obstruction. The primary end points were the evaluation of the operative rate reduction and shortening the hospital stay after the use of Gastrografin. A total of 84 patients were randomized into two groups: the control group received conventional treatment, whereas the study group received in addition of 100 mL Gastrografin meal. Patients were followed up within 4 days after admission, and clinical and radiological (if needed) improvements were evaluated. Although the results showed that Gastrografin can decrease the need for surgical management by 14.5 %, no statistically significant differences were observed between the two groups (P = 0.07). Nevertheless, the length of hospital stay revealed a significant reduction from 4.67 ± 1.18 days to 2.69 ± 1.02 days (P = 0.00). The use of Gastrografin in adhesive small bowel obstruction is safe and reduces the length of hospital stay. As a result, the cost of hospital bed occupancy is reduced. Hence, if there was no indication of emergency surgery, administration of oral Gastrografin as a nonoperative treatment in adhesive small bowel obstruction is also recommended.Keyword: Abdominal surgery, Adhesion, Small bowel obstruction, Gastrografin®, Hospital stay     

Intestinal obstruction by an enterolith from a perforated giant Meckel's diverticulum: diagnosis with CT reconstructed images

Complications caused by Meckel's enteroliths are very rare. Diagnosis is not usually made before surgery because symptoms are often of little value and imaging may be difficult to interpret. Computed tomography (CT) scanning, which is increasingly performed in emergency situations, could help make the diagnosis. We describe a 37-year-old man with intestinal obstruction caused by an enterolith resulting from a giant Meckel's diverticulum. The diagnosis was suggested preoperatively through the use of abdominal CT scanning with reconstructed pictures. A resection of the small bowel and diverticulum was performed with immediate anastomosis. The postoperative course was uneventful. Diagnosis of enterolith from Meckel's diverticulum can be suggested by CT frontal reconstructed sections in patients with small bowel obstruction and abdominal calcified opacities. This procedure could reduce the delay between onset of symptoms and adequate treatment before perforation and peritonitis occur.     

Abdominal sonography for the diagnosis of large bowel obstruction

To evaluate the clinical usefulness of abdominal sonography in the diagnosis of large bowel obstruction, the sonography findings of 39 patients with a large bowel obstruction, in the form of a simple obstruction in 36 patients and a sigmoid volvulus in 3, were reviewed in comparison with their plain X-ray findings. Abdominal sonography showed a large bowel obstruction in 33 patients, and an obstructing lesion in 14 of these patients. However, in the other 6 patients, including the 3 with a sigmoid volvulus, the image was disturbed by extensive colonic gas. Although the plain abdominal X-ray films showed no gaseous colonic dilatation, isolated small bowel dilatation was seen in six patients with a large bowel obstruction proximal to the splenic flexure. In five of these six patients, abdominal sonography revealed a dilated colon filled with fluid and feculent contents which was difficult to evaluate on the plain X-ray films. Consequently, abdominal sonography was proven to be useful, especially for detecting X-ray-negative colonic dilatation.     

Difficult diagnosis of a double omental hernia that led to extensive small bowel infarction

A 47-year-old female complained of abdominal pain in the epigastrium for about 2 h after a meal. At the initial abdominal radiograph, there were no findings of remarkable bowel loops. On the following day of hospitalization, the pain became worse; moreover, it could not be controlled by medicine. Also, a dilated bowel loop was detected on the imaging studies. When exploring the peritoneal cavity, we found a strangulated small bowel that protruded through the lesser omental sac within the defects of the gastrocolic or gastrohepatic ligaments. After performing manual reduction, the restoring viability of herniated small bowel failed; consequently, extensive small bowel resection was mandatory. Herein we reported a case of extensive small bowel hemorrhagic infarction due to a double omental hernia that was not diagnosed at the time of visiting the emergency department.     

Jejunal diverticular disease with unborn enterolith presenting as a small bowel obstruction: a case report

Jejunal diverticuli are rare and usually asymptomatic. More commonly, they are seen as incidental findings on CT images, enteroclysis, or during surgery. Complications such as bleeding, perforation, obstruction, malabsorption, diverticulitis, blind loop syndrome, volvulus, and intussusception may warrant surgical intervention. An interesting case of an unborn enterolith (enclosed calculus) from a jejunal diverticulum presenting as a small bowel obstruction is presented. The patient is a 66-year- old woman with no prior history of abdominal surgery who presented with a high-grade bowel obstruction. CT with intravenous barium contrast confirmed the presence of a transition point from dilated to decompressed small bowel in the mid jejunum. At laparotomy, a freely mobile mass was found in this area leading to the bowel obstruction. The mass was removed by making a small enterotomy in the jejunum. While running the small bowel proximally, a small segment of jejunum, approximately 8 cm, containing several diverticuli was found. This bowel obstruction was the result of an unborn enterolith from this segment of bowel. The patient's hospitalization was benign and she was discharged home on postoperative day 4.     

Resolution of Gallstone Ileus with Spontaneous Evacuation of Gallstone: A Case Report

Gallstone ileus is an infrequent complication of cholelithiasis. The formation of a fistula between the gallbladder and duodenum may allow a gallstone to enter the gastrointestinal (GI) tract. Gallstone ileus generally occurs in the elderly patients and is associated with significant mortality. Spontaneous resolution of gallstone ileus after passage of gallstone per rectally, though rare, has been reported Farooq et al. (Emerg Radiol 4(6):421–423, 2007). We describe a 60-year-old woman who presented with a 3-day history of vomiting, pain, distension and constipation .Radiological investigations revealed dilatation of small bowel loops with multiple air fluid levels with a large lamellated radio-opaque density measuring 4.4 cm × 4 cm seen in the right iliac fossa. A possibility of gallstone ileus was kept. Because of co-morbid conditions (post-myocardial infarct with cardiac failure), surgery could not be done and patient was kept on conservative management. Three days later patient had sudden relief of her symptoms after passing a large calculus per rectally suggesting a spontaneous evacuation of gallstone. This case highlights the possibility of spontaneous resolution of gallstone ileus after the passage of gallstone. It has been reported in stones less than 2.5 cm. However, to the best of our knowledge, this is the first time in which a large stone measuring 4 cm × 3.8 cm passed spontaneously.     

Laparoscopic management of terminal ileal volvulus caused by Meckel’s diverticulum

Complications from a Meckel’s diverticulum include diverticulitis, bleeding, intussusception, bowel obstruction, a volvulus, a vesicodiverticular fistula, perforation or very rarely as a tumour. We report a case where a Meckel’s diverticulum presented with a terminal ileal volvulus in a 32-year-old man without the presence of a typical vitelline band or axial torsion of the diverticulum causing the volvulus. It was successfully managed laparoscopically.