Acta chir belg, 2007, 107, 64-66

Intestinal Obstruction due to Meckels Diverticulum : A rare presentation

G. N. S. Srinivas*, P. Cullen** Torbay Hospital*, Torquay, Devon ; The Queen Elizabeth Hospital**, Kings Lynn, Norfolk, UK.

Key words. Meckels Diverticulum ; enteroliths ; small bowel obstruction. Abstract. Meckels diverticulum occurs in about 1-3% of general population. The majority of them are asymptomatic and incidentally found at laparotomy. The most common complication due to Meckels diverticulum in adults is intestinal obstruction. The frequency of symptoms decreases with age. Enteroliths are rarely formed in a Meckels diverticulum and are known to cause intestinal obstruction. These should be considered in the differential diagnosis of radioopaque shadows in the plain abdominal films. We describe a rare presentation of Meckels diverticulum in an elderly woman.

Background Meckels diverticulum is the most common congenital anomaly of the gastrointestinal tract, occurring in 1-3% of the general population (1). Majority of them are asymptomatic with only 16% giving rise to symptoms (2). The most common presentation in adults is intestinal obstruction. Enteroliths are a rare feature in Meckels diverticulum. We present an unusual case of intestinal obstruction in an 84 year old female patient due to Meckels diverticulum with enteroliths. Case report An 84 year old woman presented with a 2-day history of colicky central abdominal pain, distension, vomiting, and constipation. She denied any recent change in bowel habit or weight loss. Her past medical history included hypertension, angina and an abdominal hysterectomy 32 years ago for fibroid uterus. On examination, she was mildly dehydrated with no clinical signs of sepsis. The abdomen was distended and resonant with no signs of peritonitis. The bowel sounds were exaggerated. There was no evidence of incisional or groin hernias. Rectal examination was unremarkable. Laboratory testing revealed a mild leukocytosis (12, 100 white blood cells/mm3, 86% neutrophils), normal haemoglobin, electrolytes, creatinine and liver function tests. An erect chest film was unremarkable. The abdominal plain film (Fig. 1A & B) showed grossly dilated small bowel loops with paucity of gas in the colon. There were multiple radio-opaque shadows in the right lower abdomen with peripheral calcification and central radiolucency, the significance of which was unclear preoperatively. A diagFig. 1 An 84 year old lady presented with small bowel obstruction : Preoperative Imaging. A. Plain abdominal film showing dilated small bowel loops and paucity of colonic gas. The arrow points to calcific shadows in the right lower abdomen. B. Close-up view of the above film showing the peripheral calcification of the stones with radiolucent centres (Arrow). The arrow heads point to the surgical clips from previous hysterectomy.

nosis of small bowel obstruction was made, a nasogastric tube was inserted and intravenous fluids were administered. At laparotomy there was small bowel obstruction due to a Meckels diverticulum with a band adhesion from the fundus of the diverticulum to the mesentery of the ileum (mesodiverticular band). The mechanism of obstruction appeared to be due to acute angulation of small bowel caused by short, fibrous mesodiverticular band, with proximal dilatation leading to an axial twist

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over 52 yrs, PARK et al. have noted that 84% were asymptomatic and 16% were symptomatic (2). The mean age of patients with a symptomatic Meckels diverticulum was 31. The frequency of symptomatic Meckels diverticulum decreased with age. The malefemale ratio was approximately 3:1. 29% of all Meckels diverticula contained ectopic or abnormal tissue. The lifetime risk of complications in patients with a Meckels diverticulum is estimated to be 4% (4). In adult patients intestinal obstruction is the most common complication (40%) and in children, gastrointestinal haemorrhage. A Meckels diverticulum may result in small bowel obstruction by a variety of mechanisms : by entangling a loop of small bowel around a fibrous cord or within a mesodiverticular band, intussusception, volvulus, incarceration within a hernia sac (Littres hernia), chronic Meckels diverticulitis, foreign body, or neoplasm (4). Enteroliths are a rare complication of Meckels diverticulum ; the incidence of enteroliths was quoted as 6% (2) and 10% (5). The exact incidence of enteroliths in Meckels diverticulum causing intestinal obstruction is unknown ; about 5 case reports were found in literature (6). However to our knowledge the combination of enteroliths in Meckels diverticulum and intestinal obstruction due to mesodiverticular band has not been reported. In general, calculi formation in the small bowel rarely occurs except when there is stasis e.g. in blind pouches in side to side anastomosis, or above the level of a stricture, e.g. Crohns disease. It is known that most of Meckels diverticula have wide necks, and since these are true diverticula with smooth muscle in the wall capable of peristalsis, the chances of stasis are generally low. In addition, Meckels diverticula may have ectopic gastric mucosa, which creates an acid environment and prevents the precipitation of calcium salts. Meckels enteroliths were reported to be radioopaque in 88% of the cases (5, 7). The differential diagnosis of the calcifications at abdominal radiography includes biliary and urinary calculi, calcified lymph nodes, calcified fibroids, mesenteric fat necrosis, teratoma and enteroliths. In the small bowel, a Meckels diverticulum is the most common site of enterolith formation, which is a rare complication of this diverticulum. Enteroliths in a Meckels diverticulum are usually triangular and flat and have a radiolucent centre (8). The calcified structures can be misinterpreted as teeth-like calcifications, which suggest the diagnosis of teratoma (9). A correct preoperative diagnosis of intestinal obstruction from Meckels diverticulum, however, is possible with the help of computerised tomography (1, 7). Our case illustrates the rare combination of enteroliths and intestinal obstruction due to Meckels diverticulum in an elderly woman.

Fig. 2 Meckels diverticulum causing small bowel obstruction : A. Operative photograph after releasing adhesive band causing obstruction, showing the Meckels diverticulum measuring approximately 6 cm at the largest diameter, with a relatively narrow neck. B. Meckels diverticulum showing enteroliths. C. The enteroliths mostly in the triangular shape showed underlying vegetable skins on a closer look.

of the small bowel. The diverticulum was situated at 70 cm from ileocaecal junction, measured about 6 cm in maximum diameter with a narrow base and contained multiple enteroliths. The diverticulum as well as the small intestine was viable. There was no evidence of an internal hernia or any other cause for a mechanical small bowel obstruction. The diverticulum was resected (Fig. 2A) with a sufficient margin and the defect was closed in single layer interrupted extra-mucosal absorbable sutures. There were 17 stones and some debris in the diverticulum (Fig. 2B & C). A closer look of the enteroliths showed vegetable skins with peripheral calcification. Postoperative recovery was uneventful. The histology showed normal small intestinal mucosa without ectopic gastric mucosa in the diverticulum. Discussion Meckels diverticulum, the most common congenital anomaly of gastrointestinal tract with a reported incidence of 2-3% at autopsy, represents a persistence of vitellointestinal ( omphalomesenteric) duct, and consists of a blind diverticular pouch arising from the ileum usually 30-100 cm proximal to the ileocaecal valve (3). It measures approximately 5 cm and is situated on the ante-mesenteric border of the ileum. It is a true diverticulum and hence has all the layers of the gastrointestinal tract, unlike sigmoid diverticula which lack smooth muscle layer. In a large series of 1476 cases of Meckels diverticulum found during the operation, from a single institute

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Conclusions Meckels diverticulum that contained enteroliths, causing mechanical small bowel obstruction from a mesodiverticular band has not been reported. A preoperative diagnosis was not possible in view of non-specific nature of the clinical and radiological findings. Peripheral calcified stones or, less commonly, laminated stones when detected in the lower abdomen on a plain film should raise the possibility of Meckels enteroliths in the differential diagnosis. References
1. Frazzini V. I. Jr., English W. J., Bashist B., Moore E. Case report. Small bowel obstruction due to phytobezoar formation within Meckel diverticulum : CT findings. J Comput Assist Tomogr, 1996, 20 (3) : 390-2. 2. Park J. J., Wolff B. G., Tollefson M. K., Walsh E. E., Larson D. R. Meckel diverticulum : the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg, 2005, 241 (3) : 529-33. 3. Kusumoto H., Yoshida M., Takahashi I., Anai H., Maehara Y., Sugimachi K. Complications and diagnosis of Meckels diverticulum in 776 patients. Am J Surg, 1992, 164 (4) : 382-3.

G. N. S. Srinivas and P. Cullen

4. Prall R. T., Bannon M. P., Bharucha A. E. Meckels diverticulum causing intestinal obstruction. Am J Gastroenterol, 2001, 96 (12) : 3426-7. 5. Pantongrag-Brown L., Levine M. S., Buetow P. C., Buck J. L., Elsayed A. M. Meckels enteroliths : clinical, radiologic, and pathologic findings. AJR Am J Roentgenol, 1996, 167 (6) : 144750. 6. Gamblin T. C., Glenn J., Herring D., McKinney W. B. Bowel obstruction caused by a Meckels diverticulum enterolith : a case report and review of the literature. Curr Surg, 2003, 60 (1) : 63-4. 7. Mortele K. J., Govaere F., Vogelaerts D., Pattyn P., Ros P. R. Giant Meckels diverticulum containing enteroliths : typical CT imaging findings. Eur Radiol, 2002, 12 (1) : 82-4. 8. Maglinte D. D., Herlinger H. Small bowel radiography. An overview. Dig Dis Sci, 1984, 29 (11) : 1057-9. 9. Ewing H. P., Gear M. W. Enteroliths in Meckels diverticulum misinterpreted as teeth. Br J Surg, 1984, 71 (2) : 157.

G. N. S. Srinivas, M.S., F.R.C.S. Staff-grade Surgeon Torbay Hospital Torquay Devon, UK TQ2 7AA E-mail : gandrapu.srinivas@nhs.net