Case data
Patient female, 28 years old. He was admitted to the hospital for one day because of pain in his right lower abdomen accompanied by nausea and low fever. Physical examination revealed deep palpation discomfort in the right lower abdomen. The results of laboratory examination showed that the white blood cell count slightly increased to 1 1.3 k/uL, and the others were normal. Abdominal CT showed fat accumulation in the right lower abdomen, but no appendix was found.
The patient initially chose conservative treatment, and the pain worsened after 6 hours of observation. Diagnostic laparoscopy revealed that the small intestine was twisted, there was necrotic structure in the pelvic cavity, and it was diagnosed as strangulated Meckel's diverticulum with fibrous bands extending to the anterior abdominal wall (Figure 1). Laparoscopic appendectomy, fibrous band excision, torsion reduction of ileum end and strangulated Meckel diverticulum were performed.
Note: white arrow: strangulated Meckel diverticulum; Black arrow: fiber belt; Green arrow: uterus; Blue arrow: fallopian tube
(Figure 1 Diagnostic laparoscopic exploration)
The patient recovered well after operation and no complications occurred.
Analysis and discussion
Meckel's diverticulum is a true diverticulum, which is the most common congenital gastrointestinal abnormality, mainly due to degeneration of vitelline duct, and often occurs at the opposite mesenteric margin of ileum. Ectopic tissues of stomach, pancreas, duodenum and colon will affect the treatment and outcome of diseases, and are usually associated with symptomatic Meckel diverticulum.
Most patients with Meckel's diverticulum are asymptomatic, only 4%-7% patients can have symptoms, and most of them have corresponding clinical manifestations when complications occur. Complications of Meckel's diverticulum in adults include intestinal obstruction, diverticulitis, perforation, intussusception, rare malignant tumor and bladder diverticulum's fistula. In children, bleeding is related to peptic ulcer of ectopic gastric tissue.
As shown here, axial torsional necrosis of Meckel's diverticulum is very rare. Symptomatic Meckel diverticulum is often misdiagnosed as appendicitis, which makes the diagnosis full of challenges. The typical imaging features of Meckel's diverticulum can be displayed by small intestine tracing and CT scanning, including enterography and 99m technetium (99m Tc) isotope scanning.
The treatment of this disease mainly depends on the clinical manifestations. When there are clinical symptoms, the treatment is surgical resection. But in asymptomatic patients, the best treatment has not yet reached a consensus. Some surgeons support preventive removal of accidental macular degeneration because it may lead to serious complications. According to the current literature, if the diverticulum found accidentally meets the following criteria, it should be removed: age 2 cm, extensive diverticulum, fibrous band attached to diverticulum, pathological examination shows ectopic or abnormal tissue.
The clinical manifestations of Meckel's diverticulum lack specificity, and the diagnosis of complications is difficult. A full understanding of its anatomy, clinical manifestations, imaging and pathological features is helpful for early diagnosis and timely intervention to avoid complications.
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