Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1997  |  Volume : 3  |  Issue : 2  |  Page : 99-102
Intussuscepted inverted meckel diverticulum: A case report


1 Department of Pathology, Central Laboratory and Blood Bank, Riyadh, Saudi Arabia
2 Department of General Surgery, Riyadh Medical Complex, Riyadh, Saudi Arabia
3 Department of Radiology, Riyadh Medical Complex, Riyadh, Saudi Arabia

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Date of Submission24-Apr-1996
Date of Acceptance08-Dec-1996
 

How to cite this article:
Baez-Giangreco A, Afzal M, Al Haque, Shakaki MA. Intussuscepted inverted meckel diverticulum: A case report. Saudi J Gastroenterol 1997;3:99-102

How to cite this URL:
Baez-Giangreco A, Afzal M, Al Haque, Shakaki MA. Intussuscepted inverted meckel diverticulum: A case report. Saudi J Gastroenterol [serial online] 1997 [cited 2019 Jul 15];3:99-102. Available from: http://www.saudijgastro.com/text.asp?1997/3/2/99/33935


Meckel diverticulum is considered the most frequent congenital malformation of the alimentary tract and it is the result of persistence of a vestige of the omphalomesenteric duct. It is usually located within 30 cm of the ileocecal valve [1] . Although it is seen in 0.2-3 percent of the population, only approximately 10 percent are symptomatic. Of the patients presenting with cmplications, 60 percent are under two years of age and more than one-third are less than one year old. Bleeding is the most common complication. Mucosal heterotopia is a relatively frequent finding (80% of the cases) and is often the origin of hemorrhagic accidents [2] . Perforations, intestinal obstruction and diverticulitis being less frequently implicated. The principal mechanisms causing obstruction by Meckel diverticulum are due to incarceration of the diverticulum in an inguinal or ventral hernia sac; volvulus around persistent fibrous cord remnant of the vitelline duct, or rarely inversion of the diverticulum with secondary intussusception as occurred in the present case.


   Case report Top


A 16 year-old Saudi boy was admitted to the Riyadh Medical Complex due to acute colicky abdominal pain in the umbilical area radiating to the right iliac fossa (RIF), associated with vomiting and constipation. The patient complained of 20 kgs weight loss in one month associated with diarrhea, abdominal pain, and fever. Melena was noted occasionally.

On physical examination the patient was found to be pale and dehydrated with a temperature of 37°C. and a B.P. of 120/180 mm Hg. The abdomen was scafoid in shape, soft and mild tenderness in the RIF. An ovoid, non tender fixed oval mass was palpated on the RIF. Bowel sounds were increased. Rectal examination was normal. Laboratory examinations revealed RBC 4.86 x 10 6 /ul, Hgb 9.0g/dl, Ht. 37.3%. WBC 5.4 x 10'/ul. Platelets 225 x 10'/ul. Blood urea nitrogen : 22mmol/L, Glucose 4.8 mmol/L, Albumin 40 g/L, SGOT 24 U/L, SGPT 8 U/L, Electrolytes: Sodium 140 milM/L, Potassium 4.3.4 mmol/L, Bilirubin 11.1 milM/L, T.Protein 64.9 G/L, S. Amylase 55. U/L, Creatinine 59 mmol/L. Stool and urine analyzes were normal. Abdominal plain film showed distended loops of small bowel with air fluid levels and absence of colonic gases consistent with small bowel obstruction. No gas under the diaphragm was seen. The ultrasound examination was initially considered unremarkable. The barium enema revealed a smooth outlined polypoidal filling defect in the base of the cecum and the small bowl was seen in continuation [Figure - 1]. Colonoscopy revealed an ileo-cecal intussusception. A clinical diagnosis of intussusception due to tumor was entertained. At laparotomy, a large ileo-ileal­cecal intussusception was seen. Minimal peritoneal fluid was observed. No perfortion was present. The ileum was congestive and markedly distended. No enlarged mesenteric lymph nodes were noted. The ileo-colic intussusception was reduced but there was persistence of the ileal-ileal intussusception; therefore resection of the segment of the obstructed small intestine and appendectomy were performed. The patient had an uneventful recovery. A retrospective review of the ultrasonographic films revealed double target sign compatible with inverted intussuscepted Meckel diverticulum [Figure - 2].


   Pathologic finding Top


The resected segment of small intestine with attached mesentery was evaluated pathologically. The proximal end was dilated and pale, and the distal showed marked congestion. Cross section revealed well defined mobile intraluminal polypoid mass measuring 7.0 x 4.0 x 4.0 cm in diameter obstructing the lumen of the small intestine. The large polypoid structure represented an inverted Meckel diverticulum with an extroverted intestinal mucosa, medially placed muscular coats and centrally located fatty tissue [Figure - 3],[Figure - 4]. The mucosa was partially ulceralted and covered microscopically by metaplastic gastric mucosa [Figure - 5].


   Discussion Top


Intestinal intussusception in adults is uncommon, and represents 16 percent of cases of intestinal obstruction [1] . The usual site of intussusception is just proximal to the ileocecal valve. The pathologic processes identified as causative factors are: tumors (52%), postoperative complication (36%), Meckel diverticulum (4%), and idiopatic in 8% of the cases [2] . In the present case, the intestinal intussusception was secondary to an inverted Meckel diverticulum. Complications of Meckel diverticulum include hemorrhage, inflammation, perforation, inversion, and neoplasma [3],[4] . Inversion is an unusual but potentially serious complication since it can obstruct the bowel lumen, provoke intussusception as observed in this case as well as can compromise the blood supply and produce gangrence. The diagnosis of intestinal obstruction caused by inverted Meckel diverticulum is difficult. The clinical evaluation of the condition is subacute, with painful bouts occurring over several years and puzzling the clinicians [5] . In our patient, the clinical diagnosis was intestinal obstruction due to malignant tumor since the patient considerably lost weight (20 kg) in one month and the abdominal mass palpated on the RIF was not tender. Barium enema and colonoscopy were helpful in the diagnosis of intestinal obstruction. Recently, distinctive features observed on radiographic images on computerized tomography, ultrasonography as well as plain film radiography have been recognized as valuable diagnostic tools in precise diagnosis of intussusception with inverted Meckel diverticulum. The radiographic images are based on the presence of fatty tissue in the center of a mass with well defined contours. During the inversion of the Meckel diverticulum the serosal fat in the stroma of the omphalomesenteric duct becomes centrally placed surrounded by extroverted mucosa and muscular coats. The fat density observed in this inverted anatomical structures gives a peculiar image on plain film [5] , computed tomography and ultrasonography examination as "mottled appearance" and "double target signs".

Retrospective review of the ultrasonographic images in our case also revealed the double target sign as was pinpointed by Itagaki et al [6] .

 
   References Top

1.John T.N.P., Wheeler J.R., Johns F.S.: Meckel diverticulum and Meckel diverticulum disease. A study of 154 cases. Ann. Surg. 1959;150:241-56.  Back to cited text no. 1    
2.Agha E.F.: Intussusception in adults. AJR Am. J. Roentgenol. 1986;146(3):527-31.  Back to cited text no. 2    
3.Johson II, J.E., Lorenzetti R.J., Ballard E.T. Plain film identification of inverted Meckel diverticulum: Pediat. Radiol.1993:23:551-2.  Back to cited text no. 3    
4.Phillips F., Maiterth T. Acute abdomen cause by inflammation of a Meckel diverticulum containing stone. Aktuelle-Radiol. 1992;2(4):243-5.  Back to cited text no. 4    
5.Black M.L., Ros R.R., Smirniotopoulos J.G., Olmsted W.W., Sobin L.H. Intussuscepted Meckel diverticulum: Radiologic-Pathologic correlation. Computerized Radiol. 1987;245:8.  Back to cited text no. 5    
6.Itagaki A., Uchida M., Ueki K., Kajii T. Double targets sign in ultrasonic diagnosis of intussuscepted Meckel divertidculum. Pediatr.Radiol.1991;21:148-9  Back to cited text no. 6    

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Correspondence Address:
Atilio Baez-Giangreco
P.O. Box 60179, Riyadh - 11545
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864803

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]



 

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