Perforated Meckel Diverticulum Caused by Vegetal Food Entrapment: A Rare Case Report and Literature Review

Introduction

Meckel diverticulum is a true diverticulum that includes all layers of the small bowel wall. It arises from the antimesenteric surface of the middle-to-distal ileum and typically involutes between the fifth and sixth weeks of gestation as the bowel settles into its permanent position within the abdominal cavity. Although Meckel diverticulum is often clinically silent, it presents with gastrointestinal bleeding or acute abdominal symptoms related to bowel obstruction, Meckel’s diverticulitis, or perforation in approximately 4 to 6% of cases [1–5].

Here, we present a case of a male patient who was initially diagnosed with acute appendicitis. During surgical exploration, a perforated Meckel diverticulum caused by a foreign body was discovered.

Case Report

A 62-year-old male patient, in good health and with no history of surgery, was admitted to our department for abdominal pain in the right iliac fossa persisting for 24 hours, accompanied by nausea. There were no changes in bowel transit, fever, or chills.

Initial physical examination revealed a soft abdomen, painful in the right iliac fossa with local rebound tenderness. Laboratory tests revealed elevated C-reactive protein and a mild increase in leukocytes. Abdominal ultrasound showed signs of acute appendicitis (Figure 1), leading to the decision to perform laparoscopic surgical resection.

During exploratory laparoscopy, a small amount of cloudy fluid was observed in the Douglas space. The appendix was completely free of inflammation. Upon inspection of the small bowel, an inflamed Meckel diverticulum was found 35 cm from the ileo-caecal valve. Given the extent of inflammation, it was not possible to perform a linear stapler resection of the diverticulum alone, and an infra-umbilical, median laparotomy was performed. A segmental small bowel resection with a manual ileo-ileal, latero-lateral anastomosis was performed. The postoperative period was uneventful, and the patient was discharged after 3 days.

The histopathology report showed a Meckel diverticulum perforated at the tip by a foreign body, specifically a plant stem (Figure 2).

Discussion

Meckel diverticulum is the most common congenital gastrointestinal anomaly, affecting 1.2% of the general population [6,7], and is more common in men than in women by a 3: 1 ratio. It results from incomplete obliteration of the vitelline duct between the fifth and sixth weeks of gestation [1], leading to the formation of a true diverticulum of the small intestine that arises from the antimesenteric border of the ileum and includes all layers of the small bowel.

In a large study involving 600 patients [8], the mean distance from the diverticulum to the ileocecal valve was 67 cm in adults aged 21 years and older. In our case, the diverticulum was found 35 cm above the ileocecal valve. An average Meckel diverticulum is approximately 3 cm long [7–10]; the histopathology report from our pathology institute described a 4-cm-long diverticulum with a maximal diameter of 2 cm. Up to 60% of Meckel diverticulum cases harbor heterotopic mucosa, of which more than 60% contain gastric mucosa [8]. Other heterotopic tissues include pancreatic tissue, Brunner’s glands, colonic mucosa, or hepatobiliary tissue [7–10].

Treatment of an incidental finding of a Meckel diverticulum during abdominal surgery remains controversial. In 2020, Rahmat et al performed a literature review, and out of 31 studies, 4 recommended no resection, 12 recommended resection, 5 made no clear recommendation, and 10 proposed individually based decisions, with the most common high-risk criteria being patient’s age (mean age <45), sex (male), and diverticulum size over 2 cm.

However, complications related to a Meckel diverticulum warrant a resection. Meckel diverticulitis occurs in about 20% of patients and can be clinically indistinguishable from acute appendicitis. Like in acute appendicitis, diverticular obstruction results in distal inflammation, necrosis, or even perforation, leading to abscess or peritonitis [11]. Meckel diverticulum may be treated by open or laparoscopic surgery. In both cases, the resection of Meckel diverticulum is recommended [12]. Surgical treatment options are diverticulectomy or segmental ileal resection.

To reduce the risk of ongoing or recurrent hemorrhage in cases of bleeding Meckel diverticulum, not only should the diverticulum itself be removed, but small bowel resection should be performed to resect the bleeding ileum and ensure removal of all heterotopic mucosa [11,13]. Moreover, as Blouhos et al suggest, resection should be performed when the base of the diverticulum is edematous, inflamed, or perforated [12], as in the present case. However, there may be a higher risk of bleeding due to a longer staple line by a stapled small bowel anastomosis [14].

On the other hand, performing diverticulectomy avoids a gastrointestinal anastomosis, and is associated with shorter length of hospital stay [15] and may reduce time to return of bowel function, postoperative infection, and operative time.

Varcoe et al demonstrated that a long Meckel diverticulum, defined as more than twice the length of its diameter, will not possess ectopic mucosa in its base. Therefore, it could be removed by a linear stapler placed across its base. Conversely, small bowel resection is required to remove a short Meckel diverticulum because of the wide distribution of ectopic mucosa including the base [13,16]. In our case, the diverticulum was 4 cm long with a maximal diameter of 2 cm, the limit established by Varcoe et al, separating short from long Meckel diverticula. Based on the inflamed aspect and the size of the Meckel diverticulum in our case, the choice of a segmental small bowel resection seemed appropriate. The pathology report showed no ectopic tissue.

Various foreign bodies have been reported to cause perforation, such as fish bones, chicken bones, or even batteries [17–20]. Apart from reports of perforations by peanut or bay leaf [21,22], our case appears to be among the few cases describing perforation by a foreign body of plant origin.

Another point of discussion is whether an appendectomy should be performed. Yan et al presented a retrospective cohort study of 20 pediatric patients in which Meckel diverticulitis was discovered during surgery prompted by clinical and radiological signs of acute appendicitis. In all patients, the diverticulum was resected, but only 2 appendectomies were performed, in both cases due to an inflamed aspect of the appendix [23]. Due to the scarcity of data in the literature, the decision of whether an appendectomy should be performed is based on the surgeon’s judgment. In our case, the appendix was healthy and we decided not to carry out an appendectomy.

Conclusions

In conclusion, segmental small bowel resection with anastomosis was considered the safest option for managing a perforated Meckel diverticulum in our case. The Meckel diverticulum we found was large and perforated, due to entrapment of a foreign body of plant origin. To effectively treat the inflamed diverticulum and mitigate postoperative complications, we opted for a segmental small bowel resection with a manual ileo-ileal latero-lateral anastomosis.