Meckel Diverticulum

Case History: A 20-year-old male was admitted with three-day history of central, colicky abdominal pain, distension, vomiting and constipation. The abdomen was distended, and resonant, with no signs suggestive of peritonitis. There was no palpable lump. Routine lab investigations were normal.The abdominal plain film showed dilated small bowel loops, with air-fluid levels. A diagnosis of small bowel obstruction was made, and CT was done.

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Figure 1: A: Axial CECT shows dilated jejunal loops with air-fluid levels (white arrow). Large bowel is collapsed. B: Proximal ileal loops are dilated (blue arrow), while distal ileum is collapsed (yellow arrow), suggesting zone of transition at ileal level.

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Figure 2: Serial axial sections (craniocaudal) demonstrate a blind-ending loop, filled with fluid and air, seen in relation to the umbilicus distally, and proximally merging into a distal ileal loop, consistent with Meckel diverticulum.

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Figure 3: Serial coronal MPR images show the Meckel diverticulum, amongst the dilated jejunal and ileal loops.

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Figure 4: Serial sagittal MPR images show the Meckel diverticulum, in relation to the anterior abdominal wall and the distal ileal loops.

Diagnosis: Meckel diverticulum

CECT confirmed the presence of small bowel obstruction, with zone of transition at the ileal level. There was a blind ending loop, which was in relation to the umbilicus at its distal end, while proximally terminating into a distal ileal loop. Minimal interbowel loop fluid was seen. Meckel diverticulum was suggested as the probable cause of small bowel obstruction.

At laparotomy, the Meckel diverticulum was found to arise about 50 cm proximal to the ileocecal valve from the distal ileum, and attached to the abdominal wall by a very short thin fibrous cord. It had trapped and engaged a distal ileal segment across it, leading to obstruction. The diverticulum was resected, and end-to-end anastomosis of the bowel was performed. The post-operative period was uneventful.

Discussion: Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract, and is due to the persistence of vitello-intestinal duct, which normally obliterates by the 5th embryonic week. The rule of 2s : it occurs in 2 percent of population, symptomatic usually before age 2, located within two feet of ileocecal valve, and has a length of 2 inches.

Children usually present with painless GI bleeding secondary to ulceration (in 95 percent due to heterotopic gastric mucosa). Older patients are more likely to present with intussusception or small bowel obstruction than with GI bleeding. Plain abdominal radiographs may show obstruction, which - if it has led to volvulus and infarction - may be associated with air in the bowel wall or portal vein or even with free intraperitoneal air. Contrast studies are of little use.

Parthasarathy Ganesan, MD, GTB Hospital, Delhi, India