Torsion of Atypical Meckel's Diverticulum Treated by Laparoscopic-Assisted Surgery

Appendicitis combined with Meckel's diverticulum obstruction, perforation, and inflammation in children: Three case reports

BACKGROUND

Meckel's diverticulum is a common congenital malformation of the small intestine, with the three most common complications being obstruction, perforation, and inflammation. To date, only a few cases have been reported worldwide. In children, the clinical symptoms are similar to appendicitis. As most of the imaging features are nonspecific, the preoperative diagnosis is not precise. In addition, the clinical characteristics are highly similar to pediatric acute appendicitis, thus special attention is necessary to distinguish Meckel's diverticulum from pediatric appendicitis. Patients with poor disease control should undergo laparoscopic exploration to avoid serious complications, including intestinal necrosis, intestinal perforation and gastrointestinal bleeding.

CASE SUMMARY

This report presents three cases of appendicitis in children combined with intestinal obstruction, which was caused by fibrous bands (ligaments) arising from the top part of Meckel's diverticulum, diverticular perforation, and diverticular inflammation. All three patients, aged 11-12 years, had acute appendicitis as their initial clinical presentation. All were treated by laparoscopic surgery with a favorable outcome. A complete dataset including clinical presentation, diagnostic imaging, surgical information, and histopathologic findings was also provided.

CONCLUSION

Preoperative diagnosis of Meckel's diverticulum and its complications is challenging because its clinical signs and complications are similar to those of appendicitis in children. Laparoscopy combined with laparotomy is useful for diagnosis and treatment.

A Case of Torsion of Meckel's Diverticulum

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. Histologically, it is a true diverticulum comprising all four layers of the intestinal tract. The complications associated with Meckel's diverticulum include bleeding, bowel obstruction, and intussusception. Torsions are an extremely rare complication. The patient was a 15-year-old boy who presented to the emergency department with acute-onset lower abdominal pain and was admitted to the hospital for a follow-up of abdominal pain due to nonspecific imaging findings. The symptoms of the patient worsened 12 hours after admission, and he underwent emergency laparoscopic surgery. A large Meckel's diverticulum with torsion and necrosis was observed 30 cm proximal to the ileocecal valve. The diverticulum was twisted around the base of the neck. Subsequently, wedge resection of the small intestine, including the diverticulum, was performed. Stem torsion is a rare complication of Meckel's diverticulum. As definitive preoperative diagnosis was difficult to obtain through imaging studies, early laparoscopic surgery was considered effective.

Meckel's Diverticulum Strangulation

Meckel's diverticulum is the most common congenital anomaly of the small intestine. It is a true diverticulum containing all layers of the intestinal wall and results from the incomplete resolution of the omphalomesenteric duct. The majority of the cases are asymptomatic; however, diagnostic challenges arise when it becomes inflamed, causes gastrointestinal hemorrhage, intestinal obstruction, or when it protrudes through a potential abdominal opening (Littre's hernia). We present a rare case of strangulated Meckel's diverticulum as a result of axial torsion presenting with right lower quadrant abdominal pain.

Axial Torsion and Gangrene: An Unusual Complication of Meckel's Diverticulum

Meckel’s diverticulum (MD), a congenital abnormality of the gastrointestinal tract, is usually found in the pediatric population younger than two years of age; hence, its incidence in adults is rare. Although MD is mostly clinically silent, in adults, it may present with intestinal obstruction and diverticulitis. The complications of MD include hemorrhage, perforation, enterolith formation, torsion, Littre’s hernia, ulceration and neoplasm. Among these, torsion is one of the rarely reported complications of MD. MD being attached to the ileal mesentery or umbilicus, presence of mesodiverticular band, and the length, breadth and base diameter of the diverticulum contribute as a risk factor for torsion. A similar clinical picture of acute appendicitis must be excluded.

We report a case of a 25-year-old male who presented with signs of intestinal obstruction in whom intraoperative finding of a torted MD with necrotic and twisted base was found upon emergency exploratory laparotomy.