Introduction

Meckel’s diverticulum (MD), also termed as an “ileal appendix”, is the most common congenital gastrointestinal anomaly. MD arises from the distal small bowel, typically at a distance of 40-100cm from the ileocecal valve, with a typical length of up to 5cm and a diameter of up to 2cm. It is known that most MD have a wide neck and contain smooth muscle [₁]. The majority of patients with this anomaly remain asymptomatic; however, several complications may occur [₂]. The authors report an axially torsed MD, which is the rarest complication.

Case report

A 5-year-old boy presented with history of abdominal pain and vomiting for 4 days. On physical examination, the axillar temperature was 38°C. His abdomen was soft and mildly distended. White blood cell count was 12.200/µL, with prevalence of neutrophils. Plain abdominal x-ray demonstrated multiple air-fluid levels with absence of motion of radiopacities in the right lower quadrant (Fig 1). Abdominal sonography revealed non-specific signs such as intestinal dilatation and intra-peritoneal free fluid. After 16 hours, we decided to make a laparotomy because of increased mechanical bowel obstruction signs such as abundant nasogastric drainage, abdominal distension, leucocytosis (15.200/µL), and deterioration of general condition.

Figure 1

Figure 1: Plain radiograph of the abdomen showing multiple air-fluid levels and two radiopacities in the right lower quadrant (arrows).

At laparotomy, a necrotic MD was found after detaching omentum that was wrapping it. The diverticulum with 360 degree axial torsion around the narrow base had a necrotic appearance (Fig 2). It was excised. Examination of the surgical specimen revealed that the diverticular lumen included two melon seeds which did not cause luminal obstruction of the diverticular base (Fig 3). No complication was observed after the operation, and the patient was discharged on postoperative day 5.

Figure 2

Figure 2: Intraoperative appearance of the torsed MD.

Figure 3

Figure 3: Transected MD and the melon seeds.

Discussion

MD is a true intestinal diverticulum that results from the failure of the vitelline duct to obliterate during the fifth week of fetal development [₂₃]. It is one of the most common congenital anomalies of the gastrointestinal tract, found in 2% of the general population. However, most persons with MD remain completely asymptomatic throughout their life [₄].

In patients who develop complications, heterogeneous clinical manifestations such as bleeding, diverticulitis, and intestinal obstruction due to volvulus and intussusception have been reported [₅]. Hemorrhage is the most common clinical presentation of MD, especially in children under 10 years of age [₆].

A very rare complication of MD is axial torsion. Only 13 cases have been reported in English literature in the last four decades [_478910111213]. MD with narrow base is a predisposing factor to axial torsion. Some authors [₄₁₁₁₂] mentioned that the torsed MD had a gangrenous appearance while others [₉₁₀] mentioned that it had not. This condition may be associated with the degree of torsion. High-degree torsion may cause arrest of blood flow of MD via venous and arterial obstruction, while low-degree torsion may cause only luminal obstruction. In our case, the MD was about 360 degree torsed and had a necrotic appearance, but was not gangrenous.

Examination of the surgical specimen revealed that the diverticular lumen included two melon seeds. We do not think that the seeds contributed to the pathologic process of MD because they are too light to cause diverticular torsion. In addition, they did not cause obstruction in the diverticular neck.

Diagnosis of the complications of Meckel’s diverticulum is difficult with clinical examination and radiological modalities because it has a mobile structure and mimics other common abdominal conditions [₁₃]. It has been reported that only 5.7% of cases of MD are diagnosed before surgical intervention [₁₄]. In our case, we did not detect any sign that suggests complicated MD. Before operation, we thought that the opacities on right lower quadrant in the x-ray might be a foreign body in the small bowel.

Open surgical intervention is the treatment of choice in complicated MD. In addition, some authors reported that laparoscopy-assisted resection can be used in treatment [₁₄].

In conclusion, we report here a patient with necrotic MD due to axial twisting around its narrow base. This rare complication has non-specific clinical and laboratory findings like other MD complications. Having a high index of suspicion for MD complications can be beneficial for prompt diagnosis and early intervention.