Teaching Case

24-year-old male patient presented to emergency department complaining of severe abdominal pain associated with nausea and vomiting since one day.

On examination: severe tenderness and guarding all over the abdomen mainly in the central part was noted.

CT images of the abdomen and pelvis obtained at different levels with oral and intravenous contrast material showed a blind-ending fluid-filled tubular diverticulum with associated fat stranding and lack of wall enhancement in the post-contrast study suggestive of inflamed gangrenous Meckel’s diverticulum. Images also showed multiple, dilated, contrast-filled loops of the small bowel proximally (faecal matter sign), consistent with partial small bowel obstruction.

The appendix was identified separately, was normal and filled with oral contrast material.

There were no fat stranding or fluid collections around the appendix.

Patient was sent to surgery and the diagnosis of Meckel’s diverticulum was proven.

Meckel’s diverticulum is the most common congenital structural abnormality of the gastrointestinal tract, affecting 2% of the general population [1]. It is known to develop from incomplete obliteration of the omphalomesenteric canal causing the creation of a true diverticulum in the small bowel [2].

Most cases of Meckel’s diverticulum remain clinically silent during the entire lifetime. The most common presentation in childhood is bleeding, the most widespread complication of Meckel’s diverticulum in adults is bowel obstruction [3].

Intestinal obstruction resulting from Meckel’s diverticulum occurs via distinct mechanisms such as: Meckel’s diverticulitis, intussusception, volvulus, an internal hernia around a diverticulum associated with a fibrotic band attached to the abdominal wall [1, 3, 10].

Clinical symptoms are nonspecific; patients may have abdominal pain and distention, vomiting and constipation. Symptoms of Meckel’s diverticulitis may be indistinguishable from that of acute appendicitis, patients are presenting with right lower quadrant pain, fever, and vomiting [3].

Ultrasonography has limited value and may demonstrate an inflamed Meckel’s diverticulum as a blind-ending, thick-walled, tubular, non-compressible, cystic lesion with a “gut signature” of the wall communicating with the small bowel, with surrounding mesenteric echogenic inflammatory change [1, 6, 8].

CT is the modality of choice in imaging patients with suspicion of Meckel’s diverticulum and presenting acute abdominal pain. Meckel diverticulum is demonstrated on CT as an outpouching blind-ended tubular digestive structure arising from the antimesenteric side of the terminal ileum. Mural wall thickening and enhancement are seen with surrounding inflammatory changes in the adjacent fat as well as small reactive mesenteric lymph nodes. Wall enhancement will be absent in gangrenous Meckel diverticulum. Identification of a normal appendix strengthens the confidence of diagnosis [1, 3, 8, 10].

Surgical removal of a Meckel’s diverticulum is the current management of choice in a patient symptomatic for a Meckel’s diverticulum or for any of its complications. Elective surgery is not recommended for cases where the diverticulum is discovered incidentally on radiological imaging [8, 10].

The Meckel’s diverticulum is the most common anomaly of the gastrointestinal tract and can present with a wide range of clinical and imaging manifestations from benign indolent findings to acute life-threatening conditions [8]. Hemorrhage, small intestinal obstruction, and diverticulitis are the most frequent complications [1, 10].

Familiarity of the radiologist with the embryologic, clinical, pathologic, and radiologic characteristics of Meckel diverticulum complications will aid in the early and accurate diagnosis in emergent settings [6, 10].