CLINICAL HISTORY: A 52-year-old man presented with abdominal distension for several days. Physical examination revealed diffuse abdominal tenderness. Contrast CT of the abdomen and pelvis was performed. DIAGNOSIS: Bezoar obstruction with Meckel diverticulum. DISCUSSION: CT showed small bowel dilatation down to distal ileum, where an intra-luminal lesion is seen at the transition point.  Small bowel faeces sign and "string of pearls" appearance were present, suggestive of mechanical small bowel obstruction.   A blind-ended tubular structure was seen adjacent to the aforementioned lesion.  Findings were compatible with small bowel obstruction due to bezoar formation adjacent to a Meckel diverticulum, which was confirmed upon laparotomy. Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract. It is a true diverticulum formed by incomplete obliteration of the ileal end of the vitelline duct. It arises from the anti-mesenteric border of the distal ileum, usually within 50-60cm of ileocaecal valve. 50% contain heterotopic gastric +/- pancreatic, colonic or duodenal mucosa. 90% of the cases with bleeding contain gastric mucosa. On Tc-99m pertechnetate scan, it is seen as tracer accumulation in RLQ in synchrony with gastric activity. On angiography, the presence of vitelline artery is pathognomonic. Complications of Meckel diverculum include: Haemorrhage due to acid from ectopic gastric mucosa Intestinal obstruction - intussusception,  volvulus, peritoneal bands, hernias, or bezoars Diverticulitis Littreˇ¦s hernia Malignant transformation (rare) Rule of 2's: 2% of population Male : female ~ 2 : 1 Within 2 feet of ileocaecal valve 2 inches long (on average) Symptomatic usually before age 2 2 main complications in adults: intestinal obstruction (40%) and diverticulitis (20%) A bezoar is a persistent concretion of foreign matter composed of accumulated ingested material in intestines, and is a cause of intestinal obstruction.  Predisposing factors include previous gastric surgery, inadequate chewing, poor dentition, dentures, delayed gastrointestinal transit. Bezoar formation in a Meckel diverticulum is a relatively uncommon complication.  Postulated mechanisms include anatomical distortion, impaired motility, stasis of gut matters within the diverticulum, and lodging of bezoar in the diverticulum in a Y-shaped "pantaloon" fashion. PREVIOUS CASES HOME COMMENTS

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