VCU DEATH AND COMPLICATIONS CONFERENCE. HPI 26 yo man with no PMH/PSH, presented to the ED with 10...

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