Small-Bowel Obstruction by Meckel diverticulum in elderly patient: Hand Assisted Laparoscopic Surgery

Rene A Palomo, MD, Mario Rodarte, MD, Alejandro Rodriguez, MD, Zanndro J Del Real, MD

Hospital San Jose Tecnologico de Monterrey

Background

Intussusception is one of the most common causes of acute abdomen in infancy. It occurs when a portion of the digestive tract becomes telescoped into the adjacent bowel segment. Intussusception is the most common cause of intestinal obstruction in children, however, in adults it is much more rare representing only 5%. Intussusception is an uncommon surgical presentation in the adult population, with only two to three cases per million per annum. In contrast to intussusception in children in whom the cause is idiopathic in 90%, in adults the underlying cause is identified in 70-90% of cases.

Case

An 80-year-old man presents with a history of chronic lymphocytic leukemia, cardiac arrhythmia, appendectomy and prostatectomy. The patient presented to the hospital with abdominal distension and pain. His condition started 24 hours prior to admission with cramping abdominal pain, predominantly in the periumbilical region. He presented with nausea and vomiting of gastric contents 12 hours prior to admission. On physical examination patient presented with skin pallor, dry oral mucosa, distended abdomen, and decreased peristalsis. Initial laboratory values: Leukocytes 53,000, platelets 121,000, Hemoglobin 12.2 mg. CT scan showed small bowel dilation with a point of abrupt change in dilation and angulation in the distal jejunal loop. A small amount of intrabdominal free fluid was present. A small left renal cyst was also identified (fig 1).

Surgery

Diagnostic laparoscopy was performed, finding intussusception 80 cm from the ileocecal valve, secondary to an inverted Meckel’s diverticulum. A 4cm vertical infraumbilical midline incision was made, followed by resection of the diverticulum with primary closure of the small intestine. Patient had a very good post-operative evolution and he was discharged within 5 days after surgery.

Discussion

Intussusception is a rare cause of intestinal obstruction in adults, and even more rare is an intussusception that occurs secondary to a Meckel’s diverticulum. The diagnosis of Meckel’s diverticulum is difficult, because signs and symptoms are not pathognomonic, even when associated with intussusception. It is the most common congenital anomalies of the gastrointestinal tract, affecting 2% of the general population. A Meckel´s diverticulum is usually located within the first 100 cm from the ileocecal valve, however, there are case reports of occurrences up to 70 inches away. The risk of developing complications during life is about 4%. This report highlights the importance of considering a Meckel’s diverticulum as a cause of small bowel obstruction in individuals from all age groups and especially in a person with no previous abdominal pathology or surgery.


Session: Poster Presentation

Program Number: P312

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