Small bowel obstruction secondary to Meckel's diverticulum impacted with phytobezoar.

Abstract

A 21-year-old female presented to emergency with a one-day history of severe colicky central abdominal pain associated with nausea and vomiting. She reported no other infective or gastrointestinal symptoms such as diarrhoea or rectal bleeding. She denies any family history of inflammatory bowel disease or past medical history. Her only medication was the oral contraceptive pill. Abdominal examination showed severe tenderness of the lower abdomen with no guarding. Initial blood investigations revealed no abnormality and an ultrasound pelvis was performed to rule out appendicitis or ovarian pathology. The ultrasound revealed a moderate amount of free fluid with a thickened cervix of unusual significance. She was initially treated conservatively with analgesia and admitted for observation. On reassessment the following day, the abdominal pain worsened, and repeat blood investigations revealed a raised white cell count of 11.7. A computed tomography aortogram was performed to rule out an aortic dissection but showed a distal small bowel obstruction with suspicion of an internal hernia, as identified in Fig. S1. A decision for diagnostic laparoscopy was made with view of possible laparotomy and small bowel resection. On diagnostic laparoscopy, a Meckel's diverticulum was identified with distended bowel proximally. No fibrous bands were identified causing an internal hernia. The laparoscopy was converted to open laparotomy and a 10 cm section of small bowel was resected including the diverticulum, measuring 5 cm in length and 5 cm in diameter, as illustrated in Fig. S2. The ends of small bowel were anastomosed using hand sewn end-to-end anastomosis with polydioxanone sutures. The patient recovered well post-operatively with no issues related to surgery on follow-up. Gross pathology of the specimen revealed a phytobezoar within the diverticulum. Histopathology showed no inflammation of the diverticulum, with no heterotropic tissues or dysplasia. Meckel's diverticulum is a common congenital abnormality of the gastrointestinal tract resulting from an incomplete obliteration of the vitello-intestinal duct that causes a true diverticulum of the bowel involving all layers. Other anomalies that result from incomplete obliteration include: an umbilicointestinal fistula, an umbilical sinus, or a fibrous cord extended from the umbilicus to bowel. The rule of two's is a useful mnemonic for clinical features: present in 2% of the population, within two feet from the ileocecal valve, two inches in length, containing possibly two types of heterotropic mucosa, and presentation before the age of two.1 The two types of heterotropic mucosa are gastric or pancreatic tissue, with the former being more common.2 These features are not present in all presentations, as in this case. Children and adults present differently. Children commonly present with bleeding due to erosion of gastric heterotropic mucosa eroding into bowel vessels. Adults typically present with intestinal obstruction. Intestinal obstruction usually results from volvulus or entrapment due to a fibrous mesodiverticular band. Other causes include intussusception; or Meckel's diverticulitis that can present similarly to acute appendicitis resulting in chronic inflammation leading to stricture.2 In this case, obstruction from impaction of foreign material is a rare cause with only a handful of case reports thus far. Most cases have mainly reported bezoars of plant material3 and very rarely, foreign bodies of plastic, rocks, beads and rubber.4 Meckel's diverticulum can be diagnosed non-invasively with a Meckel's scan. Pentagastrin and H2-receptor antagonists are used to reduce false negative rates by enhancing accumulation or reducing release of technetium in ectopic gastric mucosa.2 However, this method is only sensitive to diverticula containing gastric mucosa and is still limited. The gold standard in diagnosis is still laparoscopy. In diverticula containing gastric heterotropic mucosa, adequate resection margins are crucial to ensure inclusion of the ulcer causing bleeding. Daniel Yee Lee Ng: Writing – original draft. Bruce Wilkie: Writing – review and editing. Daniel Peter Chubb: Supervision; validation; writing – review and editing. Figure S1. Computed tomography scan showing dilated loops of bowel and faecalization with transition point. Figure S2. Operative photograph demonstrating the Meckel's diverticulum. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.