ATYPICAL ACUTE ABDOMEN OF MECKEL’S DIVERTICULUM

BYDr. T.Y.VISWARUPACHARI

MS; FICS; FAIS

S.V.B. NURSING HOMENANDYAL – 518 501KURNOOL Dt. A.P.

MECKEL’S DIVERTICULUM

IS

AN INTESTINAL REMNANT OF

VITELLO INTESTINAL DUCT

COMMON LESIONS OF MECKEL’S DIVERTICULUM

a) Ulceration, Hemorrhage, Perforation - due to ectopic gastric epithelium.

b) Inflammation • Symptoms are those of Acute Appendicitis.• Pain-felt around Umbilicus.

c) Intussusception – due to Heterotopic Epithelium at the mouth of Meckel’s Diverticulum.

d) Intestinal Obstruction – by band from Meckel’s to umbilicus directly pressing over

a bowel loop.

e) Volvulus of Bowel – axial rotation of bowel loop around the band.

ATYPICAL & UNCOMMON LESIONS PRESENTED HERE

CASE – IPerforation of Meckel’s Diverticulum in Typhoid Enteritis with peritonitis.

CASE – II Perforation of Meckel’s Diverticulum by a Foreign Body (Bone Chip - 2”x2”x2” Triangular )-presenting as “APPENDICULAR MASS”

CASE – IIIGangrene of Meckel’s Diverticulum in a gangrenous Volvulus of small Bowel.

CASE - IVMeckel’s Diverticulum with a band connected to Umbilicuscausing volvulus of small bowel with INTERNAL FISTULA at the twist

CASE – I PATIENT PARTICULARS

• RAMAIAH - S/o. Sri. Pullaiah

• 25 years; Male

• Hindu; Cultivator

• Native of Amadala (Village)

• Koilakuntla (Mandal)

• Kurnool (Dt).

CASE – I

COMPLAINTS

• Pain Abdomen.

• Distension.

• Vomitings.

• Constipation.

• Fever - 102°F - 15 Days

2 Days

CASE – I

HISTORY

• Past H/O Appendicectomy 1 Year ago.• No H/O Tuberculosis.

CASE – I

EXAMINATION

• Moderately Built and Nourished.• Not Anemic, Febrile.• Toxic; Temp - 102°F; B.P. -110/80 mmHg.• Dehydrated.• Abdomen – Distended; Guarding +; Free Fluid +;

Intestinal Sounds – Not Heard• Heart & Lungs – Normal

CASE – I INVESTIGATIONS• Blood : HB - 12.2 gms%, Group – ‘B’ +ve

Widal - +ve O – 1:320 H – 1:160

Paratyphi – ‘A’ – 1:40Paratyphi – ‘B’ – 1:40

Urea – 25 mg/dL, HIV – Non Reactive, HBsAg - Negative HCV – Negative

• Urine - Albumin – Nil, Sugar - Nil• X-Ray Abdomen Erect – No Pneumoperitoneum

Ground Glass appearance.• X-Ray Chest PA – Normal• U/S – Abdomen – Free fluid +, With internal echoes

CASE – I

PRE OPERATIVE DIAGNOSIS

ILEAL Perforation with peritonitis of Typhoid (Bowel) Enteritis.

CASE – I

EXPLORATIVE LAPAROTOMY

Incision – R.P.M. – Rectus displacing Under General Endotracheal.

CASE – I

FINDINGS AND PROCEDURE

• 2 Litres of yellowish pus with Bile with Fibrinous flakes Drained.• On search there was no Ileal perforation but Meckel’s perforation Treated by Wedge Rasection and closure.• Specimen – sent for H.P.E.• Wound closed in layers after securing Hemostasis and keeping a drain in the (Lt) loin.

PERFORATED MECKEL’S DIVERTICULUM

NEEDLE POINTING PERFORATION OF MECKEL’S

WEDGE RESECTION OF MECKEL’S AND CLOSURE

AFTER CLOSURE

SPECIMEN OF RESECTED MECKEL’S WITH PERFORATION

CASE – I

POST OPERATIVE COMPLICATIONAND MANAGEMENT

• Developed Fecal Fistula on 8th P.O. Day.• On 10th P.O.Day Treated by Reopening of

Abdomen and closure of Bowel leak with a

Drain in the (Rt) loin.• Wound closed by Tension Sutures.• Recovery complete.

CASE – I

BIOPSY – REPORT

• Non specific infection.• No E/O T.B; Crohns; Ulcerative Colitis or

Malignancy.• No E/O Heterotopic Epithelium of gastric

or pancreatic or colonic origin.

CASE – II

PATIENT PARTICULARS

• Maddilety , Hindu , Male• 30 Years• Koilakuntla (Mandal)

Kurnool (District)

CASE – II

COMPLAINTS :

• Continuous Pain Abdomen• Fever 3 days• Diarrhoea

CASE – II

GENERAL EXAMINATION:

• Moderately Built• Nourished• Not Anemic• No Jaundice• P.R : 100/mt• B.P : 120/80 mm of Hg

CASE – II

ABDOMEN :

• Soft• Ill defined mass - (Rt) Iliac fossa +• Tender• No free fluid• Intestinal sounds - sluggish

HEART & LUNGS : • Normal

CASE – II

INVESTIGATIONS:• Blood Group : 0 +ve• Hb : 13 gm %• Blood Sugar : 112 mg / dl• Blood Urea : 36 mg / dl• HIV : Non reactive• Hbs Ag : Negative• HCV : NegativeURINE : • Albumin : NIL• Sugar : NIL

CASE – II

PROVISIONAL DIAGNOSIS : “ APPENDICULAR MASS”

EXPLORATION OF ABDOMEN :

• Abdomen opened by Macburney’s Incision under Spinal.

CASE – II

FINDINGS : 1. Mass containing Ileal loops and pus2. Meckels – inflammed, Congested

PERFORATED at Base.3.Bone chip (Triangular – 2”x2”x2”) -one angle perforating through base of Meckels.

CASE – II

PROCEDURE : •Pus Mopped dry.•Release of bowel loops•WEDGE RESECTION of MECKLES including Bone chip & CLOSERE.• A corrugated rubber drain kept in Rt lumbar region

CASE – II

P.O. PERIOD : •Recovered fully without any complications.

CASE – III

PATIENT PARTICULARS

• VENKATRAMUDU• 25 Years, Male• Hindu, Cultivator• Native of Nallagatla (Village) Allagadda (Mandal) Kurnool District. A.P.

CASE – III

COMPLAINTS • Pain Abdomen• Distension• Vomitings• Constipation• Fever

2 Days

CASE – III

HISTORY – No past H/O similar pain

Abdomen.

CASE – III

EXAMINATION

• Moderately Built and Nourished.• Not Anemic; Not Jaundiced• No significant lymphadenopathy• P.R. – 120/mt; B.P. – 130/80 mmHg, • Toxic; Dyspnoeic; Temp - 102°F• Abdomen - Distended, Guarding +, Free Fluid +;

Intestinal Sounds – Sluggish.• Heart and Lungs – Normal.

CASE – III

INVESTIGATIONS

• Blood : HB - 13 gms%, Group – ‘O’ Rh +ve Urea – 29 mg/dL, HIV – Non Reactive, HBsAg - Negative HCV – Negative

• Urine - Albumin – Nil, Sugar – Nil• X-Ray Chest PA – Normal• X-Ray Abdomen Erect – Distended small Bowel loops with gas and fluid levels (TOP-SIGN)• U/S – Abdomen – Free fluid +, Gas and fluid filled Bowel loops.

X-RAY ABDOMEN ERECTGASEOUS DISTENSION OF VOLVULUS SMALL BOWEL (TOP – SIGN)

CASE – III

PRE OPERATIVE DIAGNOSIS

“Acute Intestinal Obstruction”

with S/O Strangulation.

CASE – III

EXPLORATIVE LAPAROTOMY

Incision – R.P.M. – Rectus displacing

Under General Endotracheal.

CASE – III FINDINGS AND PROCEDURE

• Blood Stained Fluid about 1 ½ lts Drained out.• Gangrenous Meckel’s with a cyst in a Gangrenous Volvulus of small Bowel about 12” long Volvulus untwisted and treated by resection of Gangrenous small Bowel including Gangrenous Meckel’s with cyst and End to end Anastamosis. • Resected Specimen – sent for H.P.E.• Wound closed in layers after securing Hemostasis and keeping a drain in the (Lt) loin.• Recovery – complete and no P.O. complications.

P

MC

D

UNTWISTED GANGRENOUS VOLVULUS SMALL BOWEL WITH GANGRENOUS MECKEL’S

RING OF CONSTRICTION AT THE TWIST OF THE VOLVULUS

AFTER RESECTION AND END TO END ANASTAMOSIS OF GANGRENOUS VOLVULUS OF SMALL BOWEL AND MECKEL’S

SPECIMEN OF RESECTED GANGRENOUS SMALL BOWEL AND MECKEL’S

CASE – III

BIOPSY – REPORT

Non specific Inflammation, No E/O T.B. or Malignancy.

CASE – IV

PATIENT PARTICULARS

• Sri. A. Kannaiah

• Male; 60 Years

• Hindu; Cultivator

• Native of Alvakonda (Village)

• Sanjamala (Mandal)

• Kurnool (District). Andhra Pradesh.

COMPLAINTS

• Pain Abdomen

• Distension

• Vomitings

• Constipation

CASE – IV

2 Days

CASE – IV

HISTORY

• Similar attack one year ago – treated conservatively.

• History of Appendicectomy ten years ago.

• Not a Diabetic or Hypertensive.

• No history of Tuberculosis.

CASE – IV

EXAMINATION

• Moderately built and nourished

• Not anemic, not Jaundiced.

• No significant lymphadenopathy.

• PR = 74/mt, BP = 130/80 mm of Hg

• Temperature – Normal

• Abdomen – Distended, Diffused Tenderness +

Free fluid +, Intestinal Sounds - Sluggish

• Heart and Lungs - Normal

CASE – IVINVESTIGATIONS• Blood : HB - 11.8 gms%, Group – B +ve

Urea – 72 mg%, Sugar – 118 mg/dL HIV – Non Reactive, HBsAg - Negative HCV – Negative

• Urine - Albumin – Nil, Sugar - Nil• E.C.G. – Normal• X-Ray PA – Normal• X-Ray Abdomen Erect – Distended small bowel loops

with gas and fluid levels (top-sign)• U/S – Abdomen – Free fluid +, Paralytic Bowel loops

with fluid and gas.

X-RAY ABDOMEN ERECT (TOP SIGN) GAS AND FLUID LEVELS IN THE DISTENDED SMALL BOWEL

CASE – IV

PRE-OPERATIVE DIAGNOSIS

“Small Bowel Obstruction” due to post operative Adhesions.

EXPLORATIVE LAPAROTOMY

Incision – R.P.M – Rectus displacing Under General Endotracheal

CASE – IV

OPERATIVE FINDINGS

• Serous Fluid about ½ lt with Fibrinous flakes.• Fibrous band – connecting Meckel’s with Umbilicus.• Volvulus of 11/2 ft small bowel loop 4” proximal to Meckel’s.• On Untwisting and seperation of Volvulus Bowel loop.

a) Internal fistula at the twist. b) 4” long strictured and perforated distal end of bowel loop. c) 1” perforation at the proximal end of bowel loop

CASE – IV

D

P

M

U

B

M

STRICTURED AND PERFORATED SEGMENT SMALL BOWEL

M

PROCEDURE

• Serous Fluid – sucked out.• Band connecting the Meckel’s and Umbilicus - divided.• Strictured and perforated segment of distal end of bowel loop including Meckel’s – resected and End to end Anastamosis done.• Wound – closed in layer after securing Hemostasis and keeping a drain in the (lt) loin.• Resected specimen sent for H.P.E.

CASE – IV

PERFORATION AT THE PROXIMAL END OF BOWEL LOOP OF VOLVULUS

M

P

D

RESECTED SPECIMEN OF STRICTURED AND PERFORATED SEGMENT INCLUDING

MECKEL’S DIVERTICULUM

BIOPSY – REPORT

• Nonspecific Ulceration at the Perforation.• There is no evidence of Tuberculosis; Crohns; Ulcerative colitis or Malignancy.

CASE – IV

CONCLUSION

SURGICAL EMERGENCIES DUE TO MECKEL’S DIVERTICULUM ARE

UNCOMMON AND FOUND ACCIDENTALLY.CAREFUL EXPLORATION NEEDED

TO DEAL WITH THEM EFFECTIVELY.