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Special Feature
May 01, 2007

Image of the Month—Diagnosis

Arch Surg. 2007;142(5):486. doi:10.1001/archsurg.142.5.486
Answer: Internal Hernia

In the left iliac fossa, a Meckel diverticulum was identified. Its tip was adherent to the retroperitoneum. A segment of terminal ileum had herniated through the loop formed by the diverticulum, retroperitoneum, and adjacent bowel. Subsequently, it had become incarcerated and obstructed, resulting in gross dilation of the proximal small bowel. The Meckel diverticulum itself had perforated at its base. The affected segment of ileum was resected with the perforated Meckel diverticulum. Histological analysis confirmed the diagnosis of Meckel diverticulum containing ectopic gastric mucosa. The peritoneal cavity was thoroughly irrigated. Finally, a temporary double-barrel ileostomy was made. The patient had a good and uneventful recovery.

Meckel diverticulum is the most common congenital gastrointestinal malformation; it is found in up to 2% of the population.1It is the remnant of the vitellointestinal tract, which disappears in the fifth to sixth week of gestation. The diverticulum is classically located 2 ft (60 cm) from the ileocecal junction along the antimesenteric border and is 2 inches (5 cm)2long. One large retrospective study3found that 84% of diverticula were asymptomatic. Of the 16% that were symptomatic, the commonest presentations were diverticulitis, bleeding, and perforation.3It has also been reported that the Meckel diverticulum may present as a focus for intussusception or a volvulus, thus causing obstruction.3This particular case in which a Meckel diverticulum has caused obstruction and perforation as a result of internal herniation of the bowel through a loop formed by the diverticulum and the retroperitoneum is most unusual. To our knowledge, there are very few cases of this in the literature. We believe it to be only the second documented case of its kind in the adult population.4In this case, the pathological abnormality arose predominantly as a result of the adhesions created following this patient's appendicitis 4 years previously. It is important to remember that adhesive disease of the peritoneal cavity, following surgery, or inflammation may complicate the presentation of Meckel diverticula.

Box Section Ref ID

Submissions

The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

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Article Information

Correspondence:Chika Edward Uzoigwe, MRCS, Department of Surgery, Bradford Royal Infirmary, Bradford, Yorkshire, BD9 6RJ, England (chika@doctors.org.uk).

Accepted for Publication: April 19, 2006.

Author Contributions:Study concept and design: Uzoigwe, Bitra, Munot, Griffith, and Davies. Acquisition of data: Uzoigwe, Bitra, Munot, Griffith, and Davies. Analysis and interpretation of data: Uzoigwe, Bitra, Munot, Griffith, and Davies. Drafting of the manuscript: Uzoigwe, Bitra, and Munot. Critical revision of the manuscript for important intellectual content: Munot, Griffith, and Davies. Administrative, technical, and material support: Uzoigwe, Bitra, Munot, Griffith, and Davies. Study supervision: Munot, Griffith, and Davies.

Financial Disclosure:None reported.

References
1.
Peoples  JBLichtenberger  EJDunn  MM Incidental Meckel's diverticulectomy in adults. Surgery 1995;118649- 652
PubMedArticle
2.
Jay  GD  IIIMargulis  RRMcGraw  ABNorthrip  RR Meckel's diverticulum: a survey of 103 cases. Arch Surg 1950;61158- 169
PubMedArticle
3.
Park  JJWolff  BGTollefson  MKWalsh  EELarson  DR Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg 2005;241529- 533
PubMedArticle
4.
Dalinka  MKWunder  JFWolfe  RD Internal hernia through the mesentery of a Meckel's diverticulum. Radiology 1970;9539- 40
PubMedArticle
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