Ryan Robalino, DO, Vadim Meytes, DO, Robert L Davis, MD. NYU Langone Hospital – Brooklyn
Background: Acute abdominal pain caused by small bowel obstruction is amongst the most common entities facing acute care surgeons. The vast majority to these obstructions (>90%) are secondary to adhesions, hernias, and malignancy. Miscellaneous causes, such as Meckel’s diverticulum (MD), make up a small (2-3%) but important sub-group of this disease process. The presence of a MD predisposes to obstruction in a number of ways. The diverticulum can serve as a lead point for intussusception, it could twist around it’s associated fibrous cords (volvulus), it can undergo torsion, or it could become acutely inflamed and narrow the diameter of surrounding bowel. In younger, previously healthy patients with no surgical history or hernias on physical exam it is important to keep in mind the other rarer causes of small bowel obstruction as they are rarely diagnosed pre-operatively.
Case Presentation: The patient is a 46-year-old Caucasian male with no significant past medical history presenting with chief complaint of excruciating abdominal pain associated with nausea and vomiting. Patient was diaphoretic with low grade tachycardia. Physical exam showed distention, diffuse tenderness, and voluntary guarding. A CT was obtained and notable for a large (>15 cm) inflamed tubular, fluid and air containing structure ending blindly in the right upper quadrant. Suspicion was raised for acute infection / inflammation of this tubular structure vs. ischemia. He was taken to the operating room for a diagnostic laparoscopy which an additional bowel segment running in parallel with normal jejunum. Procedure was converted to open exploratory laparotomy with segmental small bowel resection of the blind-ended bowel with primary anastomosis. Surgical pathology later revealed a Meckel’s Diverticulum (with ectopic tissue) and necrosis / ulceration consistent with torsion / obstruction.
Discussion: MD is the most common congenital anomaly of the gastrointestinal tract (prevalence 1.2%). It results from incomplete obliteration of the omphalomesenteric duct during week 5-6 of gestation. It is a true diverticulum off the antimesenteric boarder of normal small bowel often containing metabolically active tissue. In adults, the most common presentation tends to be that of intestinal obstruction/inflammation (vs. GI bleed in children). The mechanism of obstruction includes intussusception, volvulus, torsion, incorporation into a hernia, or diverticular inflammation. The pathogenesis of MD is similar to that of appendicitis. Diverticular obstruction leads to bacterial overgrowth, venous congestion, and ischemia. The associated inflammation leads to decreased luminal diameter of adjacent small bowel which can cause obstructive pathology.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86233
Program Number: P052
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster