Purpose or Case Report:
A 3-year-old male presents to the ED with two days of abdominal pain, cramping, anorexia, bilious emesis, RLQ tenderness on exam, and leukocytosis on CBC, refractory to trial of antiemetics, antipyretics, IV fluids, and analgesics. RLQ US and KUB showed an obstructive pattern. MRI demonstrated an inflamed RLQ fluid signal structure, suggesting appendicitis. CT identified a normal appendix and localized a RLQ transition point confirming high-grade SBO. After a trial of bowel rest, a repeat KUB revealed progression. Laparoscopy visualized a RLQ transition point coinciding with a twisted ileum segment due to a Meckel's diverticulum leadpoint. Segmental bowel resection and ileoileal anastomosis was performed. Hemorrhagic necrosis of a true diverticulum was confirmed histologically.
Meckel's is a common congenital GI anomaly, a vestigial structure from the embryologic omphalomesenteric duct. It has a prevalence of 2% and the complication rate is 6%, to include SBO such as in this case. Presentation is typically in the first 2 years of life. Meckel’s are true diverticula which have mucosal, muscularis, and serosal elements, unlike pseudodiverticula. The presence or absence of a muscularis propria layer cannot be determined on imaging alone, yet is evident on histology. Pseudodiverticula, which are more common along the mesenteric side, can originate anywhere in the GI tract.
Meckel's diverticulum has a narrow imaging differential. The appendix is another true diverticula in the right lower quadrant, although Meckel's originates from the distal ileum rather than the cecum. Diverticulosis often presents later with multiple pseudodiverticula in the left hemicolon. Enteric duplication cysts are another, albeit less common, fluid-filled formation located close to the colon. In contradistinction, communication with the intestinal lumen is unusual.
When a single diagnosis cannot be made and surgery is not warranted, a probabilistic presumptive diagnosis is often used in the absence of histology, particularly in cases where management is the same. Asymptomatic Meckel's diverticulum cases don't require treatment. In complicated yet stable patients, expectant management can be employed. If symptoms progress, surgical management may be needed for diagnosis and treatment.
This case highlights the essential role of imaging along with clinical context to differentiate Meckel's diverticulum from similar entities, in order to guide management.
Methods & Materials:
Results:
Conclusions: