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Paper text:
meckel 's diverticulum ( md ) is a commonly encountered congenital anomaly of the small intestine .
autopsy studies estimate overall incidence of 2% . about 4% of patients with an md develop complications that include bleeding , perforation , inflammation , or obstruction .
we report an extremely unusual case of an axially torted , gangrenous md presenting as acute intestinal obstruction .
the present case is about a 26-year - old male patient who presented to our emergency department with 3 days history of abdominal pain , distention and bilious vomiting .
he had no previous surgery and did not recollect similar episodes in the past . on examination , he was afebrile and hemodynamically stable .
plain x - ray abdomen showed dilated small bowel loops with multiple air fluid levels [ figure 1 ] .
he was taken up for urgent laparotomy with a clinical diagnosis of acute intestinal obstruction .
intra - operatively there was minimal hemorrhagic fluid localized in right iliac fossa and small bowel loops were dilated .
a md was seen attached to the mesentery of nonadjacent small bowel by a peritoneal band , which was arising from its tip .
in addition there was compression of ileum by the peritoneal band resulting in intestinal obstruction , which was relieved on dividing the band [ figure 2 ] .
plain x - ray showing small bowel obstruction gangrenous meckels diverticulum causing obstruction of small bowel ( after releasing the peritoneal band causing obstruction )
md is a true diverticulum derived from a persistent vitellointestinal duct and was first described by johann meckel in the year 1812 .
md occurs on the antimesenteric border of the ileum and in the majority of the cases , within 90 cm from the ileoceacal valve .
a patient with md has only 4% chance of developing a complication in his lifetime . though the most common complication that occurs in md is bleeding followed by obstruction and inflammation ,
literature states that men are more likely than women to be symptomatic ( male / female ratio of 2:1 to 5:1 ) . bleeding and intestinal obstruction are the two most common presentations in children and are seen in 25 - 50% and 25% of children respectively . bleeding is the most common complication in adults .
literature review states that peritoneal bands , littre 's hernias , diverticular strictures , enterolith or bezoars lodged in the diverticulum in a y - shaped
we expected this combination of gangrenous meckel 's due to axial torsion and intestinal obstruction to be extremely rare , but a literature search on pubmed could unearth three similar reports . in a study by cartanese et al . reported that the cause for obstruction was a peritoneal band arising from the tip of the diverticulum attaching to the surrounding mesentery
studies describe that diverticular length and diameter of the base are the two important factor , which increases the risk for axial torsion .
an elongated md with a narrowed neck is far more likely to result in torsion . in our patient ,
the diverticulum was 6 cm long and 3 cm wide , perhaps predisposing it for torsion .
the varied clinical presentation of md makes preoperative diagnosis often difficult , with only 6 - 12% of cases being diagnosed correctly .
tomography scans and sonograms may aid in the diagnosis of such uncommon pathology and should be considered in cases of intestinal obstruction with no clear etiology .
the use of tc 99-m pertechnetate or tc 99-m sulfur colloid is primarily for investigating gastrointestinal bleeding and may not be applicable in a case of intestinal obstruction . in patients with doubtful diagnosis laparoscopy
is a safe and effective surgical modality for diagnosing md and has a therapeutic role that results in an excellent cosmetic result .
treatment of md is always surgical . a simple excision in the transverse axis of the ileum to avoid luminal stenosis is usually the recommended procedure .
although treatment outcome is generally good , pre - operative diagnosis is often difficult . it may be a rewarding experience to develop a high index of suspicion of md in patients with atypical presentations of abdominal pain or obstruction .
meckel 's diverticulum ( md ) is a commonly encountered congenital anomaly of the small intestine . 
 we report an extremely unusual case of an axially torted , gangrenous md presenting as acute intestinal obstruction . a 26-year - old male patient presented to our emergency department with 3 days history of abdominal pain , distention and bilious vomiting . 
 on laparotomy , there was minimal hemorrhagic fluid localized in right iliac fossa and small bowel loops were dilated . 
 a md was seen attached to the mesentery of nonadjacent small bowel by a peritoneal band . 
 the diverticulum was axially torted and gangrenous . 
 in addition , there was compression of ileum by the peritoneal band resulting in intestinal obstruction , which was relieved on dividing the band . 
 resection and anastomosis of the small bowel including the md was performed . 
 we hereby report a rare and unusual complication of a md . 
 although treatment outcome is generally good , pre - operative diagnosis is often difficult .