Perforated Meckel’s diverticulum in a ten month old infant

Clinical History

A boy, 10 months, presented to ED with 2 days of poor feeding, fevers, grunting, apparent abdominal tenderness, episodic bile-stained vomiting, and drawing up his legs. No diarrhoea or PR blood. Recent visit to Macedonia. He was dehydrated, lethargic, pale, peritonitic, with drawing up of his legs. Intussusception was suspected.

Imaging Findings

A plain radiograph demonstrated an abdominal soft tissue mass centred to the right of midline, without markedly dilated bowel loops. This was considered indeterminate. Ultrasound demonstrated a large volume of peritoneal free fluid, and a mass in the right flank, comprising alternating sonolucent and hyperechoic layers. It was eccentric in shape. Findings appeared atypical for ileocolic intussusception. After clinical discussion, a diagnostic air enema was performed. Air passed rapidly through colon into distal small bowel, excluding ileocolic intussusception. Repeat ultrasound confirmed that the mass persisted, unchanged in appearance. It had a right-sided neck, which was shown on ultrasound to connect to small bowel. Hyperechoic mesenteric fat, and prominent mesenteric lymph nodes were also noted.
A Meckel's diverticulum was resected in theatre, and confirmed pathologically.

Discussion

Meckel's diverticulum is a remnant of the omphalomesenteric duct, occurring in about 2% of the population. Most are asymptomatic, but 4.2%-6.4% of people will develop an acute complication, including GI bleeding, intussusception, perforation, obstruction, strangulation due to a mesodiverticular band, diverticulitis, volvulus, Littre’s hernia and neoplasm [1]. Most of these complications occur in children under 3 years of age. 10% of the complications occurring under 12 months of age are perforation [2]. Plain radiographs of the abdomen and abdominal ultrasound are commonly performed when intussusception is suspected in an infant. It is important to realise when imaging features are atypical, in order to recognise the serious differential diagnosis of intestinal perforation. The differential diagnosis for an acute abdomen in an infant includes complicated Meckel's diverticulum [1,2].

Differential Diagnosis List

Final Diagnosis

Perforated Meckel's diverticulum

URL:	https://www.eurorad.org/case/9137
DOI:	10.1594/EURORAD/CASE.9137
ISSN:	1563-4086