A 4-year-old female patient brought to emergency department with severe abdominal pain and vomiting of 3 days duration. On examination, abdomen was tender in the right iliac fossa. Bowel sounds were hyperactive. No masses were palpable. Laboratory findings showed leukocyte count of 20x109 /L.
Ultrasonography of the abdomen and pelvis showed dilated small bowel loops measuring 3.2 cm and heterogeneously hypoechoic round cystic structure in the right lower peritoneal cavity with peripheral increased vascularity. Moderate amount of free fluid also seen in the right lower abdominal cavity. Appendix was not visualised separately.
Contrast-enhanced CT demonstrated dilated duodenum, jejunum and proximal ileum with transition point in the distal ileum. Fluid-filled distended structure similar to distended ileum with avidly enhancing nodule noted adjacent to transition point. Moderate intra-abdominal free fluid seen. Distal ileum and large bowel loops are collapsed. Diagnostic laparotomy was performed to reveal inflamed Meckel’s diverticulum twisted at the base with early ischemic changes at the twisted portion as a result of strangulation. Histopathology of the resected specimen confirms Meckel’s diverticulum with gastric heterotopia. The avidly enhancing nodule seen in CT corresponds to the gastric heterotopia.
Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal system found in 1% to 3% of general population . Meckel’s diverticulum frequently located in right lower quadrant is a true diverticulum along the antimesenteric border of distal ileum that results in incomplete atrophy of the omphalomesenteric duct in fetal development. Its lining usually consists of normal small bowel mucosa. Ectopic tissue are seen in 12.2% of the Meckel's diverticulum . Ectopic tissues identified include gastric or pancreatic mucosa. There is no known association with other congenital anomalies and occurs nearly equal frequency in both boys as in girls. While the majority of the Meckel‘s diverticulum are asymptomatic, the symptoms are almost always due to complication. Complications from Meckel‘s diverticulum occur before the age of 2 years in 2% of all patients. Common presenting symptoms are abdominal pain, nausea, vomiting and rectal bleeding. The most common presenting complications are bowel obstructions and haemorrhage. In the patients presenting with haemorrhage, ectopic gastric mucosa is almost always present which results from ulceration within the gastric mucosa or the adjacent ileum. In such cases typically pain is less severe compared to others [1,3]. Bowel obstruction secondary to Meckel‘s diverticulum can occur as a result of diverticulitis, volvulous, inversion of diverticulum into bowel lumen or inclusion of diverticulum into a hernia. Clinical presentation may mimic acute appendicitis. Hence imaging plays important role in visualisation of normal appendix as well as identifying ileum at the base of diverticulum. USG may shows Meckel’s diverticulum as tubular blind-ended loop of bowel. CT stands as one of the most useful tools in the evaluation especially when appendix is not visualised on ultrasonography and when complicated by small bowel obstruction. However in emergency situations identification of the Meckel’s diverticulum within the clustered dilated bowel is a serious challenge for the radiologists. Hence most of the time diagnosis is made after laparotomy. Angiography of superior mesenteric artery may show arterial blush of heterotopic tissue in the Meckel's diverticulum. Technetium-99m scans provide additional diagnostic value as radionucleotide is taken up by the heterotopic gastric mucosa . The treatment of the symptomatic Meckel’s diverticulum is surgical resection hence early diagnosis in patients presenting with acute abdomen is crucial for uncomplicated recovery. Often misdiagnosed as acute appendicitis, clinically it is important to consider the imaging findings of complicated Meckel’s diverticulum in emergency cases.
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