Mesodiverticular band of Meckel’s diverticulum resulting in small bowel obstruction: A case report

A 23-year-old non-febrile male with no previous history of abdominal surgery presented with complaint of epigastric pain, abdominal distension without passage of faeces and flatus for 1 day and two episodes of vomiting. Abdomen was distended with hyperactive sounds without any palpable masses with normal laboratory investigations.

Ultrasound revealed dilated fluid-filled small bowel loops. Erect x-ray abdomen showed dilated small bowel loops with multiple air-fluid levels. He was admitted in the surgery ward with a provisional diagnosis of partial small bowel obstruction. Contrast-enhanced Computed Tomography of  Abdomen and pelvis showed fluid-filled dilated jejunum and proximal ileum with abrupt transition in the distal ileum about  7 cm proximal to the ileocaecal junction, with a swirled configuration.  A band like lesion was seen adjacent to mesentery at the region of swirled configuration. Distal to the swirled appearance the distal ileum and all large bowel loops were collapsed. However, any structure with blind tubular ending was not visualised.

So the diagnosis of midgut volvulus with small intestinal obstruction likely due to mesodiverticular band was made in CT scan of abdomen and pelvis.

Meckel's diverticulum is the most common congenital abnormality of the small bowel. [1] It arises from the antimesenteric border of ileum due to incomplete obliteration of the vitelline duct.[1] The risk of complications due to Meckel’s diverticulum is approximately 4-40%. [2] The frequent complications are haemorrhage, small bowel obstruction and diverticulitis. [3] Partial bowel obstruction due to mesenteric diverticular band is one of the rarest complications of Meckel’s diverticulum. [4]

The yolk sac in fetal life is supplied by two vitelline arteries, one of them degenerates and the other one develops into the superior mesentery artery. [5]  Failure of degeneration of vitelline artery results in development of peritoneum covered fibrous band or mesodiverticular band. [5] It usually extends from tip of the diverticulum to the ileal mesentery. [5] Development of small bowel volvulus around the band or compression of small bowel by the band results in small bowel obstruction. [6] In our case, obstruction is caused by both mechanisms that are, compression of a portion of small bowel loop by the presence of mesodiverticular band with small bowel volvulus around the diverticular band.  

Ultrasonography shows a fluid-filled structure in the right lower quadrant having the appearance of blind-ending, segmental thickening of the intestinal walls. [7]. Computed Tomography is a reliable modality for assessment of complications of Meckel’s diverticulum. It can confirm the presence of intussusception and distinguish between lead point and non-lead point intussusceptions. [8] We also have to assess for the transitional zone or the point where there is abrupt change in the calibre of small bowel loop diameter. The swirled sign of mesenteric vessels around the transition zone gives us the idea of midgut volvulus. Sometimes the band can be visualized as a linear band as in our case.

As the mesodiverticular band causing intestinal obstruction is a rare complication of Meckel’s diverticulum; it is usually not considered as a causative agent for small bowel obstruction. It is usually difficult to diagnose it radiologically as the direct visualization of the band and non-infected diverticulum can be difficult. The mesodiverticular band should always be kept in the differential diagnosis of small bowel obstruction in a patient without history of previous abdominal surgery.