ATYPICAL ACUTE ABDOMEN OF MECKEL’S DIVERTICULUM BY Dr. T.Y.VISWARUPACHARI MS; FICS; FAIS S.V.B. NURSING HOME NANDYAL – KURNOOL 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 – I Perforation 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 – III Gangrene of Meckel’s Diverticulum in a gangrenous Volvulus of small Bowel. CASE - IV Meckel’s Diverticulum with a band connected to Umbilicus causing 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 gms%, Group – ‘B’ +ve Widal - +ve O – 1:320 H – 1:160 Paratyphi – ‘A’ – 1:40 Paratyphi – ‘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 COMPLICATION AND MANAGEMENT Developed Fecal Fistula on 8 th P.O. Day. On 10 th 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 : Negative URINE : 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 pus 2. 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 ERECT GASEOUS 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 M C 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 – IV INVESTIGATIONS Blood : HB 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.