Clinical Manifestations of Meckel's Diverticulum: A Case Series

Background: Meckel’s Diverticulum (MD) is the most common congenital malformation of the gastrointestinal tract. The pathophysiology of MD stems from embryological origins. The typical developing anatomy of a fetus involves the vitelline or omphalomesenteric duct, which connects the midgut to the yolk sac. This duct normally involutes around the 5th-6th week of gestation as the bowel settles into the abdominal cavity. Meckel’s Diverticulum is relatively uncommon, affecting around 2% of the population. MD typically involves males more commonly than females. The location of Meckel’s diverticulum can vary; however, it is typically found in the middle to distal ileum. While MD can affect patients of any age, 25-50% of symptomatic patients present under 10 years. In this case series we present two cases of Meckel’s Diverticulum that led to different complications at Kanti Children’s Hospital in Kathmandu, Nepal, one being an intestinal obstruction and the other intussusception. Case presentation: A 3-year-old female with no prior medical history presented to Kanti Children’s Hospital with three days of subjective fever, cough, vomiting, tachypnea, and one day of periumbilical abdominal pain. The patient was initially admitted for additional workup for pneumonia. Review of imaging suggested findings of multiple dilated loops throughout the peritoneal cavity with few loops showing edematous walls, consistent with features of an acute intestinal obstruction.

Additionally, a 6-year-old male presented to Kanti Children’s Hospital with ten days of abdominal pain and five days of vomiting. On the physical exam there was no fever or abdominal distension noted. CT scan of the abdomen suggested acute ileo-ileal intussusception.

Both patients were taken to the operating theater and the abdominal cavity was accessed via supraumbilical incisions. Once the abdominal cavity was accessed, volvulus and Meckel’s Diverticulum was observed in the 3-year-old, who had resection and anastomosis performed. Wedge resection with ileo-ileal anastomosis for ileo-ileal intussusception secondary to Meckel’s Diverticulum was performed in the 6-year-old patient. Postoperative course was uneventful in both cases and each patient was discharged home in improved condition.

Discussion: Meckel’s Diverticulum can be challenging to identify given its non-specific presentation and findings, as well as several different complications that can arise. Asymptomatic MD can be found incidentally on imaging or, more commonly, while undergoing abdominal surgery for another GI pathology. Symptomatic MD typically presents with acute abdominal pain and distension, potentially mimicking appendicitis. Among symptomatic patients, 2-4% will potentially develop complications. One case series of 286 patients, 35% of patients presented with rectal bleeding or melena, 20% with perforation, 14% with intestinal obstruction, and 12% with intussusception. Both patients presented in this case series were treated surgically with traditional open laparotomy. In areas such as the United States, these cases are typically performed laparoscopically or via a hybrid approach. Interestingly, a retrospective review of the National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped) database did not find differences in operating time, postoperative complications, or readmissions when comparing laparoscopic vs open resections. Additionally, this review found that up to 27% of laparoscopic cases required transition to an open approach.

Keywords: , ,