Appendicitis combined with Meckel’s diverticulum obstruction, perforation, and inflammation in children: Three case reports

BACKGROUND Meckel’s diverticulum is a common congenital malformation of the small intestine,with the three most common complications being obstruction,per-foration,and inflammation.To date,only a few cases have been reported world-wide.In children,the clinical symptoms are similar to appendicitis.As most of the imaging features are nonspecific,the preoperative diagnosis is not precise.In addition,the clinical characteristics are highly similar to pediatric acute appendicitis,thus special attention is necessary to distinguish Meckel’s diver-ticulum from pediatric appendicitis.Patients with poor disease control should undergo laparoscopic exploration to avoid serious complications,including intestinal necrosis,intestinal perforation and gastrointestinal bleeding.CASE SUMMARY This report presents three cases of appendicitis in children combined with intestinal obstruction,which was caused by fibrous bands(ligaments)arising from the top part of Meckel's diverticulum,diverticular perforation,and diver-ticular inflammation.All three patients,aged 11-12 years,had acute appendicitis as their initial clinical presentation.All were treated by laparoscopic surgery with a favorable outcome.A complete dataset including clinical presentation,dia-gnostic imaging,surgical information,and histopathologic findings was also provided.CONCLUSION Preoperative diagnosis of Meckel’s diverticulum and its complications is challenging because its clinical signs and complications are similar to those of appendicitis in children.Laparoscopy combined with laparotomy is useful for diagnosis and treatment.

Single-center retrospective study of the diagnostic value of doubleballoon enteroscopy in Meckel’s diverticulum with bleeding

BACKGROUND The study aimed to analyze the characteristic clinical manifestations of patients with intestinal disease Meckel’s diverticulum(MD)complicated by digestive tract hemorrhage.Moreover,we aimed to evaluate the value of double-balloon enteroscopy(DBE)in MD diagnosis and the prognosis after laparoscopic diverticula resection.AIM To evaluate the value of DBE in the diagnosis and the prognosis after laparoscopic diverticula resection for MD with bleeding.METHODS The study retrospectively analyzed relevant data from 84 MD patients treated between January 2015 and March 2022 and recorded their clinical manifestations,auxiliary examination,and follow-up after laparoscopic resection of diverticula.RESULTS(1)Among 84 MD patients complicated with hemorrhage,77 were male,and 7 were female with an average age of 31.31±10.75 years.The incidence was higher in men than in women of different ages;(2)Among the 84 MD patients,65(78.40%)had defecated dark red stools,and 50(58.80%)had no accompanying symptoms during bleeding,indicating that most MD bleeding appeared a dark red stool without accompanying symptoms;(3)The shock index of 71 patients(85.20%)was<1,suggesting that the blood loss of most MD patients was less than 20%–30%,and only a few patients had a blood loss of>30%;(4)The DBE-positive rate was 100%(54/54),99mTcpertechnetate-positive scanning rate was 78%(35/45)compared with capsule endoscopy(36%)and small intestine computed tomography(19%).These results suggest that DBE and 99mTc-pertechnetate scans had significant advantages in diagnosing MD and bleeding,especially DBE was a highly precise examination method in MD diagnosis;(5)A total of 54 MD patients with hemorrhage underwent DBE examination before surgery.DBE endoscopy revealed many mucosal manifestations including normal appearance,inflammatory changes,ulcerative changes,diverticulum inversion,and nodular hyperplasia,with ulcerative changes being the most common(53.70%).This suggests that diverticular mucosal ulcer was the main cause of MD and bleeding;and(6)Laparoscopic dissection of diverticulae was performed in 76 patients,The patients who underwent postoperative follow-up did not experience any further bleeding.Additionally,follow-up examination of the 8 cases who had declined surgery revealed that 3 of them experienced a recurrence of digestive tract bleeding.These findings indicate that laparoscopic diverticula resection in MD patients complicated by bleeding had a favorable prognosis.CONCLUSION Bleeding associated with MD was predominantly observed in male adolescents,particularly at a young age.DBE was a highly precise examination method in MD diagnosis.Laparoscopic diverticula resection effectively prevented MD bleeding and had a good prognosis.

Inverted Meckel’s diverticulum diagnosed using capsule endoscopy: A case report

BACKGROUND Meckel’s diverticulum is a common asymptomatic congenital gastrointestinal anomaly.However,its presentation as an inverted Meckel's diverticulum is a rare complication,of which few cases have been reported in the literature.CASE SUMMARY Here,we report the case of a 33-year-old man with iron deficiency anemia without manifestation of gastrointestinal bleeding.An upper gastrointestinal endoscopy and total colonoscopy were performed,but no abnormalities were found within the observed area.Finally,a capsule endoscopy was performed and offered us a clue to subsequently confirm the diagnosis of inverted Meckel's diverticulum via computed tomography scan.Laparoscopic intestinal resection surgery was performed.The final pathology report described a Meckel’s diverticulum.CONCLUSION Since inverted Meckel's diverticulum is an uncommon disease and its clinical presentation is not specific,it may go undetected by capsule endoscopy.Successful diagnosis and treatment of this disease requires a high index of clinical suspicion.

Laparoscopic Surgery for Meckel’s Diverticulum Presenting as Small Bowel Obstruction: A Case Report

Meckel’s diverticulum is not commonly encountered surgical entity and presents unique challenges for a pediatric surgeon, as it is prone to varied complications. A 14-year-old boy was admitted with us with a 48-hour history of lower abdominal pain and multiple episodes of vomiting. Radiological imaging studies revealed a high-grade partial small bowel obstruction. A fleeting conservative management was tried. The diagnostic laparoscopy revealed a small bowel obstruction secondary to a Meckel’s diverticulum. The diverticulum was resected using an endovascular GIA stapler. The patient was discharged on postoperative day four, tolerating a regular diet. Laparoscopy is a useful diagnostic and therapeutic means for a patient with a small bowel obstruction due to an uncertain etiology.

Inverted Meckel’s diverticulum manifested as adult intussusception: Age does not matter

Adult intussusception due to Meckel’s diverticulum (MD) is an uncommon cause of intestinal obstruction. However, the surgeon should still be suspicious of this condition since the non specific symptoms and the rarity of it make a preoperative diagnosis uncertain. Considering the secondary nature of adult intussusception and the necessity of early surgical intervention to avoid morbidity and mortality, we report two cases of intussusception due to MD in adults. A diverticulectomy using a TA stapler was performed in the first patient. In the second patient extensive fibrosis of the adjacent mesentery and thickening of jejunal mucosa were observed, so a segmental resection of the small bowel or affected ileal part and a hand-sewn anastomosis was performed. The postoperative period along with the long term follow-up was uneventful for both patients. The decision between diverticulectomy vs bowel resection can be based on the intussuscepted bowel condition. Early surgical intervention may ensure a favorable outcome.

Lipoma within inverted Meckel’s diverticulum as a cause of recurrent partial intestinal obstruction and hemorrhage: A case report and review of literature

Lipoma within an inverted Meckel's diverticulum presen- ting with hemorrhage and partial intestinal obstruction is an exceptional clinical entity. We report a case of 47-year-old male with a history of recurrent episodes of partial intestinal obstruction and melena due to a subserosal lipoma located in the base of an inverted Meckel's diverticulum. According to our knowledge, this is the first case of a lipoma within a Meckel's diverticulum giving rise to this clinical scenario without the existence of heterotrophic gastric or pancreatic tissues.

A case of intussuscepted Meckel’s diverticulum

We report colonoscopic features of an intussuscepted Meckel's diverticulum, presenting with hematochezia. A 35-year-old woman presented to the emergency room with acute onset, transient, sharp, severe epi-gastric pain that began 6 h earlier. Colonoscopy re-vealed a reddish, soft, fi st-sized polypoid lesion in the terminal ileum. The lesion was misinterpreted as a hematoma by an inexperienced endoscopist. The pa-tient began to complain of intermittent, severe peri-umbilical pain following the colonoscopic examination. Subsequent computed tomography showed an enteric intussusception. An exploratory laparotomy revealed an intussuscepted Meckel's diverticulum, with trans-mural infarction. Colonoscopy was of little use in as-sessing the intussusception. However, colonoscopic examination may be performed initially, especially in an intussuscepted Meckel's diverticulum present-ing with hematochezia. Endoscopists should note the endoscopic features of an intussuscepted Meckel's diverticulum.

A Rare Fatal Case of Internal Hernia Caused by Meckel’s Diverticulum in a Paediatric Patient

We describe a very rare case of an internal hernia associated with a Meckel’s diverticulum, which lead to the death of a young 3 year old boy. The case describes symptoms of abdominal pain and vomiting, on a background of previous intermittent abdominal pain. The possibility of small bowel obstruction was suspected, and appropriate imaging was performed. This case illustrates the need for a high index of suspicion for small bowel obstruction, with appropriate investigations and review. It also highlights the limitations of imaging modalities in identifying complications of Meckel’s diverticulum. It is important to raise awareness of this fatal cause for small bowel obstruction and to help identify suggestive imaging features, which may point towards a possible complicated Meckel’s diverticulum. Earlier recognition and diagnosis could reduce morbidity and mortality.

Incarceration of Meckel's diverticulum in a left paraduodenal Treitz' hernia

Meckel's diverticula incarcerated in a hernia were first described anecdotally by Littré, a French surgeon, in 1700. Meckel, a German anatomist and surgeon, explained the pathophysiology of this disease 100 years later. In addition, a congenital paraduodenal mesocolic hernia, known as a Treitz hernia, is a rare cause of small bowel obstruction. These hernias are caused by an abnormal rotation of the primitive midgut, resulting in a right or left paraduodenal hernia. We treated a patient presenting with pain and diagnosed extraluminal air in the abdomen after a computed tomography examination. We performed a laparotomy and found a combination of these two seldomly occurring congenital diseases, incarceration and perforation of Meckel's diverticulum in a left paraduodenal hernia. We performed a thorough review of the literature, and this report is the first to describe a patient with a combination of these two rare conditions. We considered the case regarding the variety of terminology as well as the treatment options of these conditions.

Meckel Diverticulum Carcinoid Tumor Complicated by Ileal Invagination. About One Case at Vichy Hospital

Meckel’s diverticulum is a common pathology in children and rare in adults. We present a case of a 79-year-old patient in which a significant gastrointestinal bleeding, whose paraclinical explorations confirmed a fatty tumor of the terminal ileum. The exploratory coelioscopy revealed a tumor of the Meckel diverticulum complicated of intestinal invagination, resected at the same time with resection and extracorporeal anastomosis by mini coelio-guided laparotomy. Histology confirmed the presence of heterotopical tissue of the duodenal mucosa with Brunner cells and a carcinoid tumor. In conclusion, this clinical case shows that coelioscopy can be considered a very important diagnostic and therapeutic tool in this pathology especially in the elderly.

Coexistence of abdominal cocoon, intestinal perforation and incarcerated Meckel's diverticulum in an inguinal hernia: A troublesome condition

Sclerosing encapsulating peritonitis(SEP) is a rare dis-ease entity, in which the small intestine becomes en-cased and mechanically obstructed by a dense, fibrotic membrane. The disorder is characterized as either primary(idiopathic) or secondary to other causes. The idiopathic cases of SEP, which lack any identifiable eti-ology according to clinical, radiological and histopatho-logical findings, are also reported under the designation of abdominal cocoon syndrome. The most frequent presenting symptoms of all SEP cases are nausea, vom-iting, abdominal distention and inability to defecate, all of which are associated with the underlying intestinal obstruction. Persistent untreated SEP may advance to intestinal perforation, representing a life-threatening condition. However, preoperative diagnosis remains a particular clinical challenge, and most diagnoses are confirmed only when the typical fibrous membrane en-casing the small intestine is discovered by laparotomy. Here, we report the clinical presentation of an 87-year-old male with signs of intestinal obstruction and the ul-timate diagnosis of concurrent abdominal cocoon, rightincarcerated Meckel's diverticulum, and gastrointestinal perforation in laparotomy.

Laparoscopic approach to Meckel's diverticulum

AIM: To retrospective review the laparoscopic management of Meckel Diverticulum(MD) in two Italian Pediatric Surgery Centers.METHODS: Between January 2002 and December 2012, 19 trans-umbilical laparoscopic-assisted(TULA) procedures were performed for suspected MD. The children were hospitalized for gastrointestinal bleeding and/or recurrent abdominal pain. Median age at diagnosis was 5.4 years(range 6 mo-15 years). The study included 15 boys and 4 girls. All patients underwent clinical examination, routine laboratory tests, abdominal ultrasound and technetium-99m pertechnetate scan, and patients with bleeding underwent gastrointestinal endoscopy. The abdominal exploration was performed with a 10 mm operative laparoscope. Pneumoperitoneum was establishedbased on the body weight. Systematic overview of the peritoneal cavity allowed the ileum to be grasped with an atraumatic instrument. The complete exploration and surgical treatment of MD were performed extracorporeally, after intestinal exteriorization through the umbilicus. All patients' demographics, main clinical features, diagnostic investigations, operative time, histopathology reports, conversion rate, hospital stay and complications were registered and analyzed.RESULTS: MD was identified in 17 patients, while 1 had an ileal duplication and 1 a jejunal hemangioma. Fifteen patients had painless intestinal bleeding, while 4 had recurrent abdominal pain and exhibited cyst like structures in an ultrasound study. Eleven patients had a positive technetium-99m pertechnetate scan. In the patients with bleeding, gastrointestinal endoscopy did not name the source of hemorrhage. All patients were subjected to a TULA surgical procedure. An intestinal resection/anastomosis was performed in 14 patients, while 4 had a wedge resection of the diverticulum and 1 underwent stapling diverticulectomy. All surgical procedures were performed without conversion to open laparotomy. Mean operative time was 75 min(range 40-115 min). No major surgical complications were recorded. The median hospital stay was 5-7 d(range 4-13 d). All patients are asymptomatic at a median follow up of 4, 5 years(range 10 mo-10 years).CONCLUSION: Trans-umbilical laparoscopic-assisted Meckel's diverticulectomy is safe and effective in the treatment of MD, with excellent results.

Intestinal obstruction caused by torsed gangrenous Meckel's diverticulum encircling terminal ileum

Meckel's diverticulum(MD)is considered the most prevalent congenital anomaly of the gastrointestinal tract. It may result in a number of complications including hemorrhage,obstruction,and inflammation.Obstruction of various types is the most common presenting symptom in the adult population.Loop formations with the end of an MD and adjacent mesentery constricting the distal ileum is an uncommon cause of obstruction. Axial torsion and gangrene of MD is the rarest of the complications.The correct diagnosis of complicated MD before surgery is often difficult because this condition may mimic other acute abdominal pathologies.Delay in the diagnosis of a complicated MD can lead to signifi- cant morbidity and mortality.Here we describe the case of a patient with a very rare form of acute small bowel obstruction secondary to giant torsed gangrenous MD encircling the terminal ileum.To our knowledge, this co-occurrence of axial torsion and a loop-forming mechanism of obstruction has been reported only once in English medical literature.

Giant Meckel's diverticulum: An exceptional cause of intestinal obstruction

Meckel's diverticulum(MD) results from incomplete involution of the proximal portion of the vitelline(also known as the omphalomesenteric) duct during weeks 5-7 of foetal development. Although MD is the most commonly diagnosed congenital gastrointestinal anom-aly, it is estimated to affect only 2% of the population worldwide. Most cases are asymptomatic, and diagno-sis is often made following investigation of unexplained gastrointestinal bleeding, perforation, inflammation or obstruction that prompt clinic presentation. While MD range in size from 1-10 cm, cases of giant MD(≥ 5 cm) are relatively rare and associated with more severe forms of the complications, especially for obstruction. Herein, we report a case of giant MD with secondary small bowel obstruction in an adult male that was suc-cessfully managed by surgical resection and anasto-mosis created with endoscopic stapler device(80 mm, endo-GIA stapler). Patient was discharged on post-operative day 6 without any complications. Histopatho-logic examination indicated Meckel's diverticulitis with-out gastric or pancreatic metaplasia.

Meckel's diverticulum bleeding diagnosed with magnetic resonance enterography:A case report

Although the introduction of double-balloon enteroscopy has greatly improved the diagnostic rate, definite diagnosis of Meckel's diverticulum far from the ileocecal valve is still impossible in most cases. We explored the role of magnetic resonance (MR) enterography in detecting bleeding from Meckel's diverticulum that can not be confirmed via double-balloon enteroscopy. This study describes a case of male patient with bleeding from Meckel's diverticulum diagnosed with MR enterography of the small intestine. No bleeding lesion was found via colonoscopy, anal enteroscopy, or oral colonoscopy. MR enterography of the small intestine revealed an occupying lesion of 3.0 cm in the lower segment of the ileum. The patient was transferred to the Department of Abdominal Surgery of our hospital for surgical treatment. During surgery, a mass of 3 cm × 2 cm was found 150 cm from the ileocecal valve, in conjunction with congestion and edema of the corresponding mesangium. Intraoperative diagnosis was small bowel diverticulum with bleeding. The patient underwent partial resection of the small intestine. Postopera-tive pathology showed Meckel's diverticulum containing pancreatic tissues. He was cured and discharged 7 d after operation. We conclude that MR enterography of the small intestine has greatly improved the diagnosis rate of Meckel's diverticulum, particularly in those patients with the disease which can not be confirmed via double-balloon enteroscopy.

Balloon-assisted enteroscopy for suspected Meckel's diverticulum and indefinite diagnostic imaging workup

Meckel's diverticulum(MD) is estimated to affect 1%-2% of the general population, and it represents a clinically silent finding of a congenital anomaly in up to 85% of the cases. In adults, MD may cause symptoms, such as overt occult lower gastrointestinal bleeding. The diagnostic imaging workup includes computed tomography scan, magnetic resonance imaging enterography, technetium 99 m scintigraphy(99mTc) using either labeled red blood cells or pertechnetate(known as the Meckel's scan) and angiography. The preoperative detection rate of MD in adults is low, and many patients ultimately undergo exploratory laparoscopy. More recently, however, endoscopic identification of MD has been possible with the use of balloon-assisted enteroscopy via direct luminal access, which also provides visualization of the diverticular ostium. The aim of this study was to review the diagnosis by double-balloon enteroscopy of 4 adults with symptomatic MD but who had negative diagnostic imaging workups. These cases indicate that balloonassisted enteroscopy is a valuable diagnostic method and should be considered in adult patients who have suspected MD and indefinite findings on diagnostic imaging workup, including negative Meckel's scan.

Inverted Meckel's diverticulum preoperatively diagnosed using double-balloon enteroscopy

An inverted Meckel's diverticulum is a rare gastrointestinal congenital anomaly that is difficult to diagnose prior to surgery and presents with anemia, abdominal pain, or intussusception. Here, we report the case of 57-year-old men with an inverted Meckel's diverticulum, who was preoperatively diagnosed using doubleballoon enteroscopy. He had repeatedly experienced epigastric pain for 2 mo. Ultrasonography and computed tomography showed intestinal wall thickening in the pelvis. Double-balloon enteroscopy via the anal route was performed for further examination, which demonstrated an approximately 8-cm, sausage-shaped, submucosal tumor located approximately 80 cm proximal to the ileocecal valve. A small depressed erosion was observed at the tip of this lesion. Forceps biopsy revealed heterotopic gastric mucosa. Thus, the patient was diagnosed with an inverted Meckel's diverticulum, and single-incision laparoscopic surgery was performed. This case suggests that an inverted Meckel's diverticulum should be considered as a differential diagnosis for a submucosal tumor in the ileum. Balloon-assisted enteroscopy with forceps biopsy facilitate a precise diagnosis of this condition.

Laparoscopic excision of Meckel's diverticulum in children:What is the current evidence?

Complications aroused from Meckel's diverticulum tend to developed in children.Children presented with abdominal pain,intestinal obstruction,intussusception or gastrointestinal bleeding may actually suffered from complicated Meckel's diverticulum.With the advancement of minimally invasive surgery(MIS) in children,the use of laparoscopy in the diagnosis and subsequent laparoscopic excision of Meckel's diverticulum has gained popularity.Recently,single incision laparoscopic surgery(SILS) has emerged as a new technique in minimally invasive surgery.This review offers the overview in the development of MIS in the management of children suffered from Meckel's diverticulum.The current evidence in different laparoscopic techniques,including conventional laparoscopy,SILS,the use of special laparoscopic instruments,intracorporeal diverticulectomy and extracorporeal diverticulectomy in the management of Meckel's diverticulum in children were revealed.

Meckel's diverticulum incarcerated in a transmesocolic internal hernia

Intestinal obstruction is a common complication associated with Meckel's diverticulum in adults. The diverticulum itself or its fibrous band can lead to an intestinal volvulus, intussusceptions, or closed-loop obstructions,which require surgery. The incarceration of Meckel's diverticulum in either inguinal or femoral hernia sacs(Littre's hernia) is another, less common, etiology underlying intestinal obstruction. This case report describes a 45-year-old man who had an obstruction associated with a Meckel's diverticulum that passed through a congenital defect in the mesocolon into the right subphrenic space. The patient, who had not undergone abdominal surgery previously, came to the emergency room with acute onset of intermittent epigastric pain and abdominal distention. Computed tomography images showed the presence of a segment of the small bowel and a diverticulum in the right subphrenic space and paracolic gutter. The twisted mesentery and the dilated loops of the proximal small bowel were indicative of an intestinal volvulus and obstruction. Meckel's diverticulum complicated by a transmesocolic internal hernia was diagnosed, and this condition was confirmed during emergency surgery. The patient's postoperativerecovery was uneventful. This case report highlights another presentation of Meckel's diverticulum, that is, in combination with a transmesocolic internal hernia. This etiology may lead to an intestinal volvulus and necessitate early surgery.

Torsion of Meckel's diverticulum as a cause of small bowel obstruction: A case report

Axial torsion and necrosis of Meckel's diverticulum causing simultaneous mechanical small bowel obstruc-tion are the rarest complications of this congenital anomaly. This kind of pathology has been reported only eleven times. Our case report presents this very unusual case of Meckel's diverticulum. A 41-year-old man presented at the emergency department with complaints of crampy abdominal pain, nausea and re-tention of stool and gases. Clinical diagnosis was small bowel obstruction. Because the origin of obstruction was unknown, computer tomography was indicated. Computed tomography(CT)-scan revealed dilated small bowel loops with multiple air-fluid levels; the oral con-trast medium had reached the jejunum and proximal parts of the ileum but not the distal small bowel loops or the large bowel; in the right mid-abdomen there was a 11 cm × 6.4 cm × 7.8 cm fluid containing cavity with thickened wall, which was considered a dilated bowel-loop or cyst or diverticulum. Initially the patient was treated conservatively. Because of persistent abdominal pain emergency laparotomy was indicated. Abdominal exploration revealed distended small bowel loops proxi-mal to the obstruction, and a large(12 cm × 14 cm) Meckel's diverticulum at the site of obstruction. Meckel's diverticulum was axially rotated by 720°, which caused small bowel obstruction and diverticular necrosis. About 20 cm of the small bowel with Meckel's diverticulum was resected. The postoperative course was uneventful and the patient was discharged on the fifth postopera-tive day. We recommend CT-scan as the most useful diagnostic tool in bowel obstruction of unknown origin. In cases of Meckel's diverticulum causing small bowel obstruction, prompt surgical treatment is indicated; de-lay in diagnosis and in adequate treatment may lead to bowel necrosis and peritonitis.