Answer of July 2013

Clinical History:

This 20 year-old gentleman, with good past health, was presented with central abdominal pain for one day and vomited twice. On admission, the patient was afebrile. Physical examination showed epigastric tenderness +/- gurading. White cell count was mildly elevated. Un-enhanced and contrast-enhanced computed tomography (CT) of abdomen and pelvis was performed as urgent request.

Diagnosis:

Gangrenous change and perforation of Meckel's diverticulum due to twisting at its base with intestinal obstruction.

Discussion:

Meckel's diverticulum is the most common congenital anomaly of the GI tract, seen in ~2% of population. It is an ileal outpouching on the anti-mesenteric border of distal ileum due to persistence of omphalomesenteric or vitelline duct. It is a true diverticulum located within 2 feet of ileocaecal valve with variable sizes.

Most of persons with Meckel's diverticulum remain asymptomatic. Lifetime risk for developing complication is about 4.2-6.4% with the risks decreasing with increasing age. Various complications including gastrointestinal haemorrhage (28%), intussusception (13%), intestinal obstruction (11%), perforation (11%), strangulation due to a mesodiverticular band (8%), diverticulitis (6%), volvulus (5%), Littre's hernia (2%) and neoplasm (1%) are recorded in a series of 776 patients with Meckel's diverticulum. For symptomatic persons, gastrointestinal haemorrhage is the most common presenting symptom during childhood while diverticulitis and intestinal obstruction are more common presenting complications of the condition in adult group.

Risk factors of developing complications include patient age <50 years, male sex, diverticula longer than 2cm, and ectopic mucosa or abnormal features within a diverticulum. For asymptomatic patients, surgery is not recommended due to possible surgical complication (8.5%), especially in female patients who are less likely to develop complications.