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CASE REPORT
Year : 2015  |  Volume : 42  |  Issue : 2  |  Page : 120-122

Isolated perforation of Meckel's diverticulum following blunt trauma abdomen: A rare case report


1 Department of General Surgery, Vijayanagara Institute of Medical Sciences, Bellary, Karnataka, India
2 Department of Paediatric Surgery, Vijayanagara Institute of Medical Sciences, Bellary, Karnataka, India

Date of Web Publication14-May-2015

Correspondence Address:
Syeda Siddiqua Banu
Department of General Surgery, Vijayanagara Institute of Medical Sciences, Bellary - 583 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.157051

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  Abstract 

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract, occurring in about 2% of the population and, in most cases, incidentally being discovered during autopsy, laparotomy, or barium studies. Hemorrhage, obstruction, and inflammation are the complications that can occur in a Meckel's diverticulum. Perforation in a Meckel's diverticulum can occur in the presence of ectopic mucosa which is rare, but perforation following blunt abdominal injury is very rare and only few cases have been reported so far. We report a case of perforation of Meckel's diverticulum in an 8-year-old boy following a blunt abdominal trauma due to fall from a bicycle.

Keywords: Blunt abdominal trauma, Meckel′s diverticulum, perforation


How to cite this article:
Banu SS, Joshi SB, Kinhal VA, Desai MS. Isolated perforation of Meckel's diverticulum following blunt trauma abdomen: A rare case report. J Sci Soc 2015;42:120-2

How to cite this URL:
Banu SS, Joshi SB, Kinhal VA, Desai MS. Isolated perforation of Meckel's diverticulum following blunt trauma abdomen: A rare case report. J Sci Soc [serial online] 2015 [cited 2020 Aug 7];42:120-2. Available from: http://www.jscisociety.com/text.asp?2015/42/2/120/157051


  Introduction Top


Meckel's diverticulum is the most common congenital anomaly of the small intestine occurring due to an incomplete obliteration of the vitello-intestinal duct. It is seen in about 2% of the population with a lifetime complication rate of 4%. [1],[2] It is situated on the anti-mesenteric border of the small intestine, commonly 60 cm from the ileocaecal valve, and is usually 3-5 cm long, and being a true diverticulum, has all three coats of the intestinal wall along with its own blood supply.

It is vulnerable for the following complications: Hemorrhage, obstruction, inflammation, and perforation. [3] Factors associated with increased risk of complications include male sex, age below 50 years, presence of heterotrophic mucosa within the diverticulum, length of diverticulum greater than 2 cm, or a diverticulum height to diameter ratio of greater than 2. [1],[4],[5]

Traumatic rupture of Meckel's diverticulum is very rare, and has been reported previously in few adult patients. [6] However, in children, perforation of Meckel's diverticulum has been reported from ulceration related to ectopic gastric mucosa in the diverticulum and from injury secondary to ingested foreign bodies, but rarely as a consequence of blunt abdominal trauma. [7]


  Case report Top


We report the case of an 8-year-old male child who presented with severe generalized abdominal pain of 3 days duration with no history of vomiting or constipation. The child had sustained blunt abdominal trauma following a fall from bicycle 3 days prior to hospitalization.

There was no history of abdominal pain prior to blunt abdominal trauma. On physical examination, the patient had tachycardia [heart rate (HR): 120/min] and a blood pressure of 100/80 mm Hg. Per abdominal examination revealed abdominal distension with generalized guarding and tenderness and sluggish bowel sounds. Paracentesis yielded straw-colored fluid mixed with blood. On per rectal examination, soft stools were present. Blood investigations and erect X-ray abdomen were unremarkable. Ultrasound abdomen showed mild to moderate accumulation of fluid. There was no solid organ injury.

Emergency laparotomy through a midline incision was performed. Peritoneal cavity was not much contaminated. Straw-colored peritoneal fluid mixed with blood was aspirated. Careful examination of the entire abdomen was done. A broad-based, non-inflammatory Meckel's diverticulum was found with a small perforation measuring 1 cm in size at its base [Figure 1]. The Meckel's diverticulum along with 1 cm of ileum on either side of the diverticulum was resected. Gut continuity was restored by an end-to-end primary anastomosis [Figure 2]. Abdomen was closed after a thorough peritoneal lavage, keeping drains in the right and left Morrison's pouch. Postoperative period was uneventful and the patient recovered well.
Figure 1: Shows Meckel's diverticulum with the arrow pointing at perforated base

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Figure 2: Showing the resected specimen of Meckel's diverticulum

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Histopathologic examination (HPE) report revealed Meckel's diverticulum with minimal inflammation and without any ectopic mucosa [Figure 3].
Figure 3: Shows the histopathologic picture of perforated Meckel's diverticulum with intestinal mucosal glands without infl ammation

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  Discussion Top


Most cases of Meckel's diverticulum are entirely benign being incidentally discovered during autopsy, laparotomy, or barium studies. About 16% of patients may be symptomatic [1] with various nonspecific symptoms ranging from gastrointestinal bleed to obstruction and inflammation. [3] The diagnosis of Meckel's diverticulum may be difficult. Plain abdominal radiography, CT, and ultrasonography are rarely helpful. In children, the single most accurate diagnostic test for Meckel's diverticulum is scintigraphy with sodium 99 mTc pertechnetate.

Blunt trauma abdomen resulting in perforation of Meckel's diverticulum is very rare. More commonly, blunt trauma to abdomen results in solid organ injuries, followed by small bowel injuries, involving jejunum, ileum, duodenum, colon, and stomach in that increasing order of frequency, accounting for 1-7% of the intra-abdominal injuries in children.

Diagnosis of hollow visceral injuries in blunt abdominal trauma presents a significant challenge if patient shows no signs of peritonitis. Thus, despite clinical suspicion, diagnosis in such cases is often delayed, especially in children. Ultrasound cannot diagnose perforation of Meckel's diverticulum. Hence, conservative management of blunt abdominal trauma in such cases may significantly increase the morbidity and mortality. In minimally symptomatic patients, a more aggressive approach is needed to establish the diagnosis. In our case, as ultrasound showed free fluid and diagnostic peritoneal lavage was positive, immediate decision of emergency exploratory laparotomy was taken.

Perforation of Meckel's diverticulum in children mostly occurs due to ulceration related to ectopic gastric mucosa in the diverticulum and from injury secondary to ingested foreign bodies. However, in our case, it is probable that an underlying inflammation of the Meckel's diverticulum, underscored by the abundant Peyer's patches and lymphocytes, facilitated its perforation by the force of the trauma.


  Conclusion Top


Perforation in a Meckel's diverticulum is rare and a preoperative diagnosis can rarely be made. High suspicion and awareness is needed, especially in blunt abdominal trauma to arrive at a possible diagnosis, thus limiting the morbidity associated with delayed management of such a perforation.

 
  References Top

1.
Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR. Meckeldiverticulum: The Mayo clinic experience with 1476 patients 1950-2002. Ann Surg 2005;241:529-33.  Back to cited text no. 1
    
2.
Soltero MJ, Bill AH. The natural history of Meckel's diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel's diverticulum found in King County, Washington, over a fifteen year period. Am J Surg 1976;132:168-73.  Back to cited text no. 2
    
3.
Turgeon DK, Barnett JL. Meckel's diverticulum. Am J Gastroenterol 1990;85:777-84.  Back to cited text no. 3
    
4.
McKay R. High incidence of symptomatic Meckel's diverticulum in patients less than fifty years of age: An indication for resection. Am Surg 2007;73:271-5.  Back to cited text no. 4
    
5.
Varcoe RL, Wong SW, Taylor CF, Newstead GL. Diverticulectomy is inadequate treatment for short Meckel's diverticulum with heterotopic mucosa. ANZ J Surg 2004;74:869-72.  Back to cited text no. 5
    
6.
Sager J, Kumar V, Shah DK. Meckel's diverticulum: A systemic review. J R Soc Med 2006;99:501-5  Back to cited text no. 6
    
7.
McAneny D, Rapo SE, Grindlinger GA. Traumatic hemoperitoneum due to a Meckel's mesodiverticular band: Case report. J Trauma 1989;29:261-2.  Back to cited text no. 7
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    Figures

  [Figure 1], [Figure 2], [Figure 3]


This article has been cited by
1 Traumatic rupture of Meckelęs diverticulum secondary to handle bar injury
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[Pubmed] | [DOI]



 

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