Dr.Sruthi Suresh, Dr.Naveen Viswanath (Pediatric surgery),Dr.Pramod Pillai (Pediatric surgery), Dr.C.Jayakumar
AIMS, Kochi
Four year old male child presented to emergency room with complaints of right sided abdominal pain of two days duration associated with non-bilious non-projectile vomiting of two days and high grade fever of one day duration. He was nil per oral. Labs were told to be normal. As USG abdomen didn’t confirm acute appendicitis referral to AIMS was done.
On examination he was in severe pain but with stable vitals. Abdomen examination revealed no distension or local rise of temperature. There was severe tenderness over the right iliac fossa and he was not allowing deep palpation owing to the pain. Bowel sounds were audible.
At this point differential diagnosis were acute appendicitis, mass over the right iliac fossa and intestinal obstruction.
Blood investigations showed normal counts with negative inflammatory markers. USG abdomen was inconclusive, however a thin walled mass was noted in the right iliac fossa and was advised CT abdomen for further evaluation. CT abdomen showed features of small bowel obstruction with a probable transition point at the ileo-coecal region with adjacent nodes and fluid, where appendix could not be visualised separately.
As a definite diagnosis could not be obtained from imaging and patient’s symptoms were worsening, it was decided to take up the child for diagnostic laparoscopy. He thus underwent diagnostic laparoscopy which revealed intestinal obstruction due to torsion of Meckels diverticulum.
Following which adjacent bowel resection and anastomosis was done.
Meckels diverticulum results from incomplete obliteration of the most proximal part of the vitelline duct.
Twisting of Meckel’s diverticulum along its axis, a rare complication, occurs when the diverticulum rotates around itself without affecting the attached ileal ring or mesentery. This rotation can disrupt blood supply, potentially leading to tissue gangrene. Several factors contribute to the susceptibility of Meckel’s diverticulum to twisting, including its attachment to the intestinal mesentery or umbilical cord, the presence of mesodiverticular bands, and the diverticulum’s larger size, length, or narrow base, which are predisposing factors.
Abdominal pain in the lower right quadrant, which varies in duration, is a common symptom associated with torsion. If the twisted tissue becomes gangrenous or perforates, it can lead to peritonitis and sepsis, underscoring the critical importance of timely diagnosis.
Pre-operative diagnosis is difficult as it may be confused with appendicitis. It is difficult to diagnose with imaging alone and needs exploratory laparotomy.
Treatment of choice is surgical excision of the diseased Meckels diverticulum.
The key takeaway from a case of right-sided abdominal pain resulting from torsion of Meckel’s diverticulum causing intestinal obstruction is the importance of considering rare anatomical anomalies in the differential diagnosis of abdominal pain. Meckel’s diverticulum torsion is a rare but serious condition that can lead to significant complications such as intestinal obstruction, gangrene, and peritonitis if not promptly diagnosed and managed.
Clinicians should maintain a high index of suspicion for unusual causes of abdominal pain, particularly when symptoms are atypical or persist despite conservative management. Early recognition and intervention are crucial in preventing serious complications and improving patient outcomes in such cases.