Perforation of a Meckel’s diverticulum secondary to chronic NSAID use: case report and review of the literature

Meckel´s diverticulum is an abnormality in the development of the gastrointestinal system, its origin and clinical significance was first described by Johan Friedrich Meckel in 1809. It is a remnant of the omphalomesenteric duct which is usually observed following the rule of 2’s, located 2 feet proximal to the ileocecal valve, before 2 years of age in approximately 2% of the population, and is twice as common in male population. It is considered a true diverticulum because it presents all the histopathological layers of the bowel; 6% of the cases present with heterotopic tissue, mainly pancreatic, gastric, colonic or jejunal. We present the case of a 37-year-old patient who presented with acute onset epigastric pain which migrated to the right iliac fossa, he had a history of chronic non-steroidal anti-inflammatory drugs (NSAIDs) usage for articular pain. He underwent abdominal contrast tomography (CT) scan with double iodine contrast enhancement, which revealed the presence of a perforated Meckel´s diverticulum in the antimesenteric portion of the terminal ileum. The patient underwent laparoscopic diverticulectomy with no complications and was discharged 72 hours after the procedure. Histopathological confirmation of a perforated meckel’s diverticulum with heterotopic gastric mucosa confirmed the clinical suspicion of perforation secondary to chronic NSAIDs usage.

Divertículo de Meckel complicado como presentación de abdomen agudo: reporte de un caso y revisión de la literatura / Complicated meckel´s diverticulum presenting as acute abdomen. Case report and a review of the literature

El divertículo de Meckel (DM) es la regresión incompleta del conducto onfalomesentérico y representa la malformación congénita gastrointestinal más común, en alrededor de 2% de la población. Hasta un 4 a 6% se puede complicar, incluyendo sangrado gastrointestinal, obstrucción o inflamación diverticular. Al realizar una apendicectomía en blanco, debe explorarse como diagnóstico diferencial en el intraoperatorio. Se presenta el caso de un paciente operado por abdomen agudo de probable origen apendicular, sin embargo en el intraoperatorio se evidenció el apéndice cecal sano, pero cursando con una diverticulitis de Meckel. Se presenta además, una breve revisión de la literatura.

Meckel´s diverticulum is the most common congenital gastrointestinal malformation, present in 2% of the population, and is formed through incomplete regression of the omphalomesenteric duct. 4 to 6% show symptoms such as gastrointestinal bleeding, intestinal obstruction or diverticular inflammation. It should be considered in the differential diagnosis during surgery for suspected appendicitis. We present the case of a patient undergoing acute abdomen surgery for suspected appendicitis whose cecal appendix was healthy but who was found to have Meckel´s diverticulitis. We also present a brief review of the literature.

Frecuencia de diverticulo de Meckel en el diagnostico preoperatorio de la apendicitis aguda / Frequency of Meckel diverticulum in the pre-operative diagnosis of acute appendicitis

Introducción: La incidencia del Divertículo de Meckel es del 1-3% en la población general. Presentan complicaciones como hemorragia, perforación u obstrucción intestinal que en ocasiones simulan una apendicitis aguda. Objetivo: Determinar la frecuencia de esta enfermedad, en pacientes con diagnóstico pre-operatorio de apendicitis aguda, así como el tratamiento y morbimortalidad. Diseño: Estudio descriptivo, retrospectivo y observacional. Pacientes y metodo: Se revisaron 1552 fichas, de pacientes con diagnóstico pre-operatorio de apendicitis aguda, de las que se analizaron 14 casos de Divertículo de Meckel , que fueron el hallazgo quirúrgico, de marzo 2000 a febrero 2015. Resultados: n: 14 pacientes. Fueron del sexo masculino 13 pacientes y del femenino 1. La edad promedio de 27 años. El tiempo de evolución en promedio fue de 14,5 hs (5-24hs), el motivo de consulta fue el dolor abdominal, en todos los casos, los síntomas fueron el dolor en fosa ilíaca derecha y vómitos. Todos presentaron leucocitosis, en la intervención quirúrgica se constató perforación del divertículo en 8 casos, se realizó resección y anastomosis ileal termino-terminal, en 6 casos diverticulectomía. Se realizó la apendicectomía incidental en todos los pacientes. El estudio anatomopatológico informó divertículo de Meckel con áreas de mucosa gástrica heterotrópica. Tuvimos como complicación: 2 infecciones del sitio quirúrgico, una de ellas con evisceración grado I. El tiempo de internación estuvo comprendido entre 6 y 8 días. No tuvimos óbitos. Conclusiones: El Divertículo de Meckel presentó una frecuencia de 0,9%, de pacientes con diagnóstico pre - operatorio de apendicitis aguda, el tratamiento fué quirúrgico en todos los casos y la morbilidad del 14%.

Introduction: The incidence of Meckel’s diverticulum is 1-3% in the general population. There are complications such as hemorrhage, perforation or intestinal obstruction that sometimes simulate acute appendicitis. Objective: To determine the frequency of this disease, in patients with pre-operative diagnosis of acute appendicitis, as well mortality and morbidity. Design: Descriptive, retrospective and observational. Patients and method study: revised 1552 chips, of patients with a pre-operative diagnosis of acute appendicitis, of which analyzed is 14 cases of Meckel’s Diverticulum, which were the surgical finding, from March 2000 to February 2015. Results: n: 14 patients. 13 patients were male and female 1. The average age of 27 years. The time evolution in average was 14.5 hours (5-24 hs), the reason for consultation was abdominal pain, in all cases, the symptoms were pain in the right iliac fossa, and vomiting. All showed Leukocytosis, in surgery it was found in 8 cases diverticulum perforation, resection and end-terminal ileal anastomosis, in 6 cases Meckel. Incidental appendectomy was performed in all patients. The anatomopathologic study reported Meckel’s diverticulum with heterotropica gastric mucosa areas. We had as a complication: 2 infections in the surgical site, one with evisceration grade I. The time of internment was comprised between 6 and 8 days. We had no deaths. Conclusions: Meckel’s diverticulum presented a frequency of 0,9%, of patients with diagnostic pre - surgery for acute appendicitis, the treatment was surgical in all cases and morbidity of 14%.

Intususcepción intestinal secundaria a divertículo de Meckel invaginado: reporte de un caso / Intussusception obstruction secondary for Meckel’s diverticulum invaginated: case report

INTRODUCCIÓN: La intususcepción intestinal se produce cuando un segmento de intestino y su mesenterio se invaginan en la luz de un segmento intestinal adyacente. La intususcepción constituye el 1 por ciento de todas las causas de oclusión intestinal en adultos. La mayoría de las intususcepciones ocurren en niños, presentándose sólo un 5 por ciento en el adulto. El divertículo de Meckel es la anomalía congénita más frecuente del tracto intestinal afectando al 2-3 por ciento de la población general, pero la intususcepción derivada de la invaginación de éste, es una de las causas más infrecuentes de obstrucción intestinal secundaria. PRESENTACIÓNDEL CASO: A continuación reportamos el caso de un paciente de 8 años con una obstrucción intestinal secundaria a divertículo de Meckel complicado, intervenido de urgencia con el diagnóstico intraoperatorio. DISCUSIÓN: La invaginación íleo-ileal por un divertículo de Meckel también invaginado es algo muy poco común a la edad del paciente.

INTRODUCTION: Intestinal intussusception occurs when a segment of bowel and mesentery invaginate in the light of an adjacent intestinal segment. Intussusception accounts for 1 percent of all cases of intestinal obstruction in adults. Most intussusceptions occurs in children, occurring only 5 percent in the adult. Meckel’s diverticulum is considered the most common congenital anomalies of the intestinal tract affecting 2 percent to 3 percent of the general population to be even rarer intussusception resulting from it. CASE REPORT: We report a case of an 8 years old children with a bowel obstruction secondary to complicated Meckel’s diverticulum, surgical repair with preoperative diagnosis. DISCUSSION: The ileo-ileal intussusception by an invaginated Meckel’s diverticulum is also something very uncommon for the patient’s age”.

Volvo do íleo em torno de cordão fibroso do divertículo de Meckel / Ileal volvulus around the fibrous band of the Meckel?s diverticulum

Relata-se o caso de um homem com 16 anos deidade que apresentou torção do íleo ao redordo cordão fibroso que unia um divertículo deMeckel à cicatriz umbilical. Embora esse divertículoconstitua o defeito intestinal congênitomais comum, seu volvo axial é considerado umfenômeno raro. No período pré-operatório, nãose estabeleceu o diagnóstico, o qual foi caracterizadona laparotomia. A correção cirúrgica dovolvo e a exérese do divertículo foram realizadascom sucesso.

Ileal volvulus around the fibrous band of the Meckel?s diverticulum A 16-year-old male patient presenting with an ilealvolvulus around the fibrous band that connected to the Meckel?s diverticulum to the umbilicus is reported. Although this diverticulum constitutes the commoner intestinal congenital defect, its axial volvulus is considered a rare phenomenon. Preoperative diagnosis was not obtained, and was characterized during laparotomy. Surgical correction of the volvulus and the diverticulum resection were performed with success.

Divertículo de meckel gigante necrosado por torsión axial / Giant meckel’s diverticula with necrosis due to axial torsion

El presente artículo reporta el caso de un paciente masculino de 73 años que ingresa por cuadro de abdomen agudo y es llevado laparotomía donde se encuentra divertículo de Meckel gigante complicado con necrosis del tejido por torsión axial sobre pedículo de unión al íleon, una de las complicaciones más raras que se ha descrito en la literatura.

This article presents the case of a 73 year old patient who was admitted to the hospital with acute abdominal pain. A midline laparotomy was performed in which a giant Meckel’s Diverticulum was found. It was complicated by necrosis of the diverticular tissue due to axial torsion over its base. This is one of the rarest complications reported in the literature.

Estrangulação de intestino delgado devido a divertículo de Meckel e banda mesodiverticular em égua gestante – relato de caso / Strangulation of the small intestine by Meckel´s diverticulum and mesodiverticular band in a pregnant mare – Case Report

O objetivo deste trabalho é descrever a ocorrência de cólica por estrangulação intestinal ocasionada por banda mesodiverticular (BMD) e divertículo de Meckel (DM) em uma égua no terço final de gestação com histórico de 20 horas de cólica moderada contínua sem resposta à administração de analgésicos. Pela celiotomia constatou-se a presença de BMD e DM medindo 15cm a partir da borda anti-mesentérica, ocasionando estrangulação intestinal distante 150cm do orifício ileocecal. Realizaramse enterectomia de 290cm de alça necrosada, drenagem do conteúdo enegrecido e fétido do intestino remanescente, seguida de by pass do ceco por jejuno-colonostomia. Durante o pós-operatório, o quadro se manteve refratário à terapia intensiva instituída. O animal voltou a ter refluxo pela sonda nasogástrica e ocorreu abortamento após seis dias, sendo praticada a eutanásia após 24 horas. A BMD e o DM são estruturas remanescentes dos componentes onfalomesentéricos vitelinos, e sua ressecção deve ser considerada sempre que essas estruturas forem diagnosticadas durante a cirurgia abdominal em equinos. A égua deste relato viveu cinco anos sem consequências aparentes, até que tais alterações provocaram a estrangulação intestinal.

The objective of this report is to describe the occurrence of intestinal strangulation caused by mesodiverticular band (MDB) and Meckel´s diverticulum (MD) in a mare at the latter third of gestation with a 20 hours history of moderate colic unresponsive to analgesic medication. The celiotomy revealed the presence of 5.9 inches long MD and MDB causing intestinal strangulation 59 inches from the ileocecal valve. It was performed an enterectomy of 115 inches of necrotic loop, drainage of the dark and fetid content of the remaining intestine, followed by cecum bypass through jejunocolostomy. Despite the intensive therapy established during postoperative, the gastric reflux through the nasogastric tube came back, the mare suffered abortion after six days, and the euthanasia was performed after 24 hours. MDB and MD are remaining structures of vitelline omphalomesenteric components and their resection should be considered whenever these structures are diagnosed during abdominal surgery in equines. The mare on this report lived five years without apparent consequences; until the moment these alterations caused intestinal strangulation.