Congenital diaphragmatic hernia, Meckel's diverticulum and malrotation in a 3-month-old infant

Meckel’s Diverticulitis in a Teenager With Unknown Intestinal Malrotation: A Case Report and Review of the Literature

The clinical presentation of congenital abnormalities in adult life is a rare condition since they usually make their appearance in early childhood. A combination of two different congenital deformities is even more infrequent, a fact that might complicate the differential diagnosis of acute abdomen. This is a case report of an inflamed Meckel’s diverticulum in a 16-year-old male with intestinal malrotation presented in an acute setting, and a review of the literature. The patient presented at the emergency department with an atypical abdominal pain located in the right abdomen and quite elevated inflammatory markers. Computed tomography revealed Meckel’s diverticulitis in combination with intestinal malrotation, findings that were confirmed intraoperatively. A partial enterectomy with a side-to-side anastomosis was performed, and the patient was discharged uneventfully. Only a few cases of this combination have been reported in the literature till nowadays. This article indicates the importance of the computed tomography scan in the differential diagnosis of abdominal pain since it might reveal rare clinical entities and determine the further therapeutic plan. Furthermore, it is a reminder that congenital abnormalities might make their clinical appearance not only in early childhood but also in adult life, pointing out the ability of the general surgeon to deal with such cases.

Malrotation in Congenital Diaphragmatic Hernia: Is It Really a Problem?

INTRODUCTION

 Congenital diaphragmatic hernia (CDH) has been associated with other congenital malformations, such as intestinal rotation abnormalities. However, there is no standard evaluation and treatment of intestinal rotation during initial CDH repair. This study evaluates intestinal malrotation in CDH patients.

MATERIALS AND METHODS

 All patients with a CDH treated in a high-volume center between 2000 and 2015 were retrospectively evaluated. Demographics, gastrointestinal characteristics, surgical treatment, and abdominal outcomes (acute surgery, small bowel obstruction, and volvulus) were described.

RESULTS

 A total of 197 CDH patients were surgically repaired. In 76 (39%) patients, a malrotation was described at initial CDH repair, in 39 (20%) patients, a normal rotation, but 82 patients (42%) had no report on intestinal rotation. During follow-up (range: 2-16 years), 12 additional malrotations were diagnosed, leading to a prevalence of at least 45% (n = 88). These were mostly diagnosed due to acute small bowel obstruction, of which three had a volvulus. Of the 12 later diagnosed malrotations, 58% required acute surgery, compared to 3% of the 76 initially diagnosed patients (p < 0.001).

CONCLUSION

 Malrotation is associated with CDH, with a prevalence of at least 45% and in 21% a normal intestinal rotation. "Missed" malrotations have a higher risk on need for acute surgery later in life.

Short bowel syndrome as an unusual complication of strangulated congenital diaphragmatic hernia: Case report

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Congenital diaphragmatic hernia is a rare cause of neonatal bowel obstruction.

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Congenital diaphragmatic hernia is associated with many long-term complications involving multiple systems.

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Only few cases in the literature has reported a strangulated congenital diaphragmatic hernia and even a fewer ones required bowel resection.

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Short bowel syndrome is an unlikely outcome of strangulated congenital diaphragmatic hernia, requiring feeding by total parenteral nutrition.

Introduction

Strangulation is a rare complication of congenital diaphragmatic hernia (CDH). There are few cases in the literature describing strangulated CDH. However, none of them was a recurrence of a previously repaired defect nor resulted in short bowel syndrome.

Presentation of case

We report an unusual case of newborn presenting with CDH that was repaired shortly after birth but developed recurrence with strangulation few months after, requiring a massive resection, resulting in short bowel syndrome (SBS). It was managed via total parenteral nutrition feeding for three months until the patient was able to tolerate orally.

Discussion

There were one familiar case in the reported literature by Woolley of an infant developing bowel infraction as a result of CDH where he later developed short bowel syndrome.

Conclusion

Short bowel syndrome is an unlikely outcome of strangulated CDH. Early repair of the defect should be promoted to avoid the devastating consequences of an CDH similar to the ones encountered in our case. High index of suspicion should be kept during the follow-up of patients with CDH post repair to detect early signs of recurrences.

A Rare Case of Acquired Transthoracic Littre's Hernia

Introduction  The Littre hernia is a rare complication of Meckel's diverticulum. Meckel's diverticulum is vestigial remnant of the omphalomesenteric duct occurring in approximately 2% of the general population with an estimated 4 to 16% risk of complications. Usual sites of the Littre hernia include inguinal (50%), umbilical (20%), and femoral (20%). We report a case of an acquired transthoracic Littre's hernia occurring through the left part of the diaphragm triggered by a history of traumatic rib fractures associated with alcohol abuse. Case Report  A 71-year-old man presented with 4-day history of worsening shortness of breath, colicky lower abdominal pain, and inability to open bowels despite passing flatus, without nausea or vomiting. His past medical history was remarkable for multiple traumatic rib fractures caused by falls which were associated with excessive alcohol consumption. A noncontrast computed tomography (CT) scan of the abdomen and pelvis showed distended jejunal loops containing air/fluid levels likely resulting from herniated jejunum between the left chest wall and left diaphragm. An urgent laparotomy was performed which revealed small bowel and omentum herniating through a small defect in the left posterior hemidiaphragm. The contents of the sac were reduced and a Meckel's diverticulum was found inside the sac, characteristic of Littre's hernia. The diaphragmatic defect was closed and the Meckel diverticulum stapled and excised. Discussion  Herniation of Meckel's diverticulum through the diaphragm most commonly occurs in the pediatric population. Acquired transthoracic Littre's hernia is rare and may arise following thoracobdominal trauma caused by surgery, motor vehicle accidents, and falls from height. Left-diaphragmatic tears are characteristically more clinically apparent and symptomatic than the right since the liver often has a protective effect on the right part of the diaphragm. Herniation of abdominal contents in the chest cavity causes respiratory distress and requires urgent surgical correction. Diagnosis is often delayed since diaphragmatic hernia tends to present very late after the initial trauma, subjecting the patient to possible life-threatening complications. While it is easier to reduce the herniated contents and repair the diaphragm via a thoracic approach, laparotomy is often preferred in cases of acute trauma associated with intra-abdominal injuries. Repair of Littre's hernia then consists of resection of the diverticulum and herniorraphy. Conclusion  Internal Littre's hernia is usually of congenital origin. This is the first case of a transthoracic Littre's hernia caused by traumatic rib fractures. Hence, it is of utter importance that a clinician is aware of such uncommon pathology.

Transthoracic Littre's hernia presenting with faecopneumothorax following perforation of the Meckel's diverticulum: a late complication of oesophagectomy

A Littre's hernia is an unusual phenomenon where a Meckel's diverticulum protrudes through a potential abdominal opening. We wish to present a unique case of a 79-year-old man with respiratory distress following a fall from standing, initially managed as a haemothorax. After a chest drain was placed, bowel contents were drained from the pleural cavity and he was taken to theatre. He had a history of minimally invasive oesophagectomy for cancer and had subsequently developed a diaphragmatic hernia. A blind ending diverticulum with a perforation at its tip was found in the left oblique lung fissure that was subsequently confirmed histologically as a perforated Meckel's diverticulum. The patient had a prolonged stay on the intensive care unit with a left-sided empyema that was managed radiologically prior to discharge. Unfortunately 4 months postoperatively, he passed away from hospital-acquired pneumonia on a rehabilitation ward.