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VCUDEATH AND COMPLICATIONS CONFERENCE
HPI
26 yo man with no PMH/PSH, presented to the ED with 10 hours of abdominal pain, which woke him from sleep that morning. The pain was diffuse, severe, and worsening. It was most severe in the periumbilical region. Associated with anorexia, nausea/vomiting, exacerbated by movement. He denied fevers, dysuria, hematuria. Last bowel movement was the previous day.
Physical exam
T 36.8 C BP 141/101 HR 88 RR 16 Sp02 99%
ill appearing young man in moderate distress, lying still, holding onto bedrails
alert, oriented
NSR, CTAB
Abd mildly distended, exquisitely ttp in periumbilical region and lower quadrants R>L, +guarding, +peritoneal signs
DRE normal tone, no gross blood
CBC Hgb 17.0 HCT 49.1 WBC 12.3 PLT 317
Operative Procedure
Diagnostic laparoscopy Meckel’s diverticulum 60cm from terminal
ileum, torsed on a mesodiverticular band from its tip to adjacent mesentery
Open resection of 2cm small bowel containing the diverticulum
Pathology: Segment of ileum with ischemic changes, clinically strangulated Meckel's diverticulum. Contains fecalith, vegetable matter, green/brown mucosa.
Meckel’s Diverticulum
Most common congenital anomaly of GI tract
True diverticulum, all layers of bowel wall
Found on antimesenteric border of distal ileum
Due to incomplete obliteration of vitelline duct during 5th week of fetal development
Rule of 2’s
2% of the population Found within 2ft of ileocecal valve average length 2in usually symptomatic before age 2
Meckel’s Diverticulum
50% contain ectopic gastric mucosa ± pancreatic, duodenal, and colonic
mucosa 90% of cases with bleeding contain
gastric mucosa Presents in adults with diverticulitis
(20%) or intestinal obstruction (40%) Most are short and wide mouthed; mean
length 2.9cm, width1.9cm Giant MD are >5cm
Meckel’s Diverticulitis
About 1/3 of pts with symptomatic Meckel's diverticulum have acute diverticulitis.
Intraluminal obstruction at the base of a Meckel's diverticulum can lead to distal inflammation, gangrene, and subsequent perforation.
Signs and symptoms of Meckel's diverticulitis are virtually indistinguishable from appendicitis, and exploration is both diagnostic and therapeutic.
Treatment
Symptomatic Meckel's diverticula requires open exploration.
Resection antimesenteric wedge excision segmental bowel resection with primary
closure or anastomosis. Laparoscopic dx and mgt also described. Minimal morbidity/mortality unless
intestinal necrosis occurred
Axial Torsion Rare complication of Meckel’s
diverticulum 24 of 1605 cases in one review
Predisposing factors Persistent mesodiverticular band Narrow base Excessive length Neoplasm or inflammation of the
diverticulum
Axial Torsian as a Rare and Unusual Complication of Meckel’s Diverticulum. Journal of Medical Case Reports 2011, 5:118
Meckel’s diverticulum: report of two unusual cases. N Engl Journal of Med, 1947, 237:118-122
Axial Torsion
Twisting of diverticulum at its base can lead to peritonitis, necrosis, perforation
Presentation Abdominal pain, often RLQ, range from
acute to indolent course Mistaken for appendicitis Imaging often not as helpful
Axial Torsian as a Rare and Unusual Complication of Meckel’s Diverticulum. Journal of Medical Case Reports 2011, 5:118
Meckel’s diverticulum: report of two unusual cases. N Engl Journal of Med, 1947, 237:118-122
Learning points
Keep Meckel’s diverticulum in the differential for abdominal pain/acute abdomen.
Look for it if your acute appendicitis is not an appendicitis.
Once identified, resect. Wedge it out or small bowel resection and
anastomosis