P1976 - A Rare Cause of Abdominal Pain in an Adult: Meckel’s Diverticulitis

Nehal Patel, MD¹, Swetha Paduri, MD¹, Rodney Boyum, MD, PhD², Paul Roach, MD^3
1Rosalind Franklin University of Medicine and Science, North Chicago, IL; ²University of Minnesota Medical School, Duluth, MN; ³Captain James A. Lovell Federal Health Care Center, North Chicago, IL

Introduction: Meckel’s Diverticulum (MD) is a congenital malformation of the gastrointestinal tract usually identified in the pediatric population. MD is classically described by the rules of two: occurrence in 2% of population, 2:1 male to female ratio, symptomatic in the first 2 years of life, and located within two feet of the ileocecal valve. Typically MD is asymptomatic, less than 0.05% of those with MD develop complications and it carries a lifetime complication risk of 4.2%. Due to its non-specific presentation, Meckel’s diverticulitis is often mis-diagnosed in adults. This is a case of abdominal pain mimicking as appendicitis with the ultimate diagnosis of acute Meckel’s diverticulitis.

Case Description/Methods: A 56-year-old-male presented with progressively worsening right lower quadrant abdominal pain. On examination, heel-tap test and rebound tenderness was elicited to the right lower and mid quadrants. Initial laboratory investigations were unremarkable and CT imaging demonstrated an enlarged appendix with air in the distal tip and inflammation of the small bowel. An emergency laparoscopic appendectomy revealed serosal injection of the appendix with exudates near the cecum and appendix. However, the specimen was noted to be soft with no gross evidence of inflammation. With an unclear diagnosis, the procedure was converted to an open exploratory laparotomy, 15-cm of inflamed thickened small bowel with a diverticulum at its center was identified and resected. Histopathology showed a focal acute serositis in the appendix and ulcerated MD. The patient tolerated the procedure without any peri-operative complications and reported no subsequent episodes of abdominal pain.

Discussion: The diagnosis of Meckel’s diverticulitis is challenging due to the overlap of presentation to many other comparable conditions like appendicitis, enteritis, colitis, small bowel obstruction and diverticulitis. Adding to the complexity of the diagnosis, traditional imaging may not always confirm the diagnosis. Although the occurrence is rare, Meckel’s diverticulitis should be considered in the differentials for acute abdominal pain.


Figure: Figure A: Blind-ending structure in the right lower pelvic small bowel loops.
Figure B: Inflammation of the small bowel loops and the right mid-abdomen in the lower pelvis.
Figure C: Gross image of resected Meckel’s diverticulum. The Meckel’s diverticulum is present extending left from the lower mid portion of this resected segment of the small intestine. Inflammatory exudate is visible as light-colored material on the distal aspect of the Meckel’s diverticulum and adjacent surface of the small intestine (left side of image). Also note the dark red congestion at the distal tip of the Meckel’s diverticulum.
Figure D: Meckel’s diverticulum, low power magnification (20X). In this section, taken from the mid portion of the diverticulum, the normal anatomic layers of the small intestine are apparent. From top to bottom in the image: mucosa, muscularis mucosa, submucosa, muscularis propria (composed of two layers of perpendicularly arranged smooth muscle) and serosa. Note that the serosal surface is inflamed, edematous, and congested. The serosal surface is notable for inflammation, edema and vascular congestion.
Figure E: Distal tip of Meckel’s diverticulum, low power magnification (20X). The lower half of the right side of the image shows a portion of intact muscularis propria. The left side of the image, which corresponds to the distal tip of the Meckel’s diverticulum, shows the mucosal ulceration overlying an attenuation/disruption in the muscularis propria.
Figure F: Appendix, low power magnification (20X). The appendix mucosa and muscular wall are unremarkable. There is minimal focal inflammation on the serosal surface of the peri-appendiceal adipose tissue (upper left of image).


Disclosures:
Nehal Patel indicated no relevant financial relationships.
Swetha Paduri indicated no relevant financial relationships.
Rodney Boyum indicated no relevant financial relationships.
Paul Roach indicated no relevant financial relationships.


Nehal Patel, MD¹, Swetha Paduri, MD¹, Rodney Boyum, MD, PhD², Paul Roach, MD³. P1976 - A Rare Cause of Abdominal Pain in an Adult: Meckel’s Diverticulitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.