Meckel’s Diverticulitis can Mimic Acute Appendicitis

A girl with lower abdominal pain. (iStockphoto/Thinkstock)
A girl with lower abdominal pain. (iStockphoto/Thinkstock)

A specimen of acutely inflamed Meckel’s diverticulum.

It was nine o’clock in the evening. I was on-call for the general surgery group. After a busy day at the office and the hospital, and after a late supper, I had just sat down to watch some news on TV. The phone rings. My wife answers. She says to me, “It’s for you, honey. It’s the hospital emergency.”

The ER physician had just examined an ill looking seven-year old boy with right sided abdominal pain, nausea, vomiting and fever. The ER doctor wanted me to come and give a surgical opinion. The question I will be asked in ER is, “Does this boy have an acute appendicitis and does he need to go to OR for surgery this evening?”

After going through the boys history and physical examination, I came to the conclusion that the kid was quite sick with abdominal signs of acute appendicitis. Possibly perforated appendicitis and peritonitis. He was dehydrated. Intravenous fluids were given, preoperative antibiotics were given and he was taken to OR.

In the OR, as soon as the kid’s belly was opened, a large amount of purulent fluid poured out. The appendix looked normal. There was a hole in the small bowel where it meets the cecum (beginning of colon) where the appendix is located. The appendix, the terminal part of the small bowel and cecum were all stuck together due to the acute inflammation. To stop the leak from the small bowel, there was no choice but remove the terminal part of the small bowel, appendix and the cecum (called right hemicolectomy).

Postoperatively the child did very well. He went home nine days after surgery. Pathology of the specimen showed normal appendix, Meckel’s diverticulum with gastric mucosa with ulceration and perforation in the adjacent small bowel and peritonitis. Acid secretion from the gastric mucosa in the diverticulum had caused the ulceration and perforation.

A Meckel’s diverticulum is a true congenital diverticulum (bulge) in the small intestine present at birth. It is a vestigial remnant of the omphalomesenteric duct (also called the vitelline duct or yolk stalk), and is the most frequent malformation of the gastrointestinal tract.

It was first described by Fabricius Hildanus in the sixteenth century and later named after Johann Friedrich Meckel, who described the embryological origin of this type of diverticulum in 1809.

It is not that common. It is anti-mesenteric (on the free margin of the small bowel). For a medical student, the best memory aid is the rule of 2s: two per cent of the population, two feet from the ileocecal valve, two inches in length, two per cent are symptomatic, two types of common ectopic tissue (gastric and pancreatic), two years is the most common age at clinical presentation and two times more boys are affected.

Most people who are born with this have no symptoms. The most common presenting symptom is painless rectal bleeding such as black offensive stools, followed by intestinal obstruction, volvulus (torsion) and intussusception where a part of the intestine has invaginated into another section of intestine, similar to the way in which the parts of a collapsible telescope slide into one another. Over the years, I have seen examples of each one of the complication.

If a patient has symptoms and clinical diagnosis is not clear then it is worth doing a Meckel’s scan using technetium-99m (99mTc). This scan detects gastric mucosa; since approximately 50 per cent of symptomatic Meckel’s diverticula have ectopic gastric or pancreatic cells contained within them. Treatment is surgery.

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If cholecystectomy is the most common elective general surgical procedure then what is the most common emergency general surgical procedure?

Well, this time it was Tamara’s turn to find out!

One night, Tamara could not sleep. She tells her mom, Susan, that she is having tummy ache. In the morning, Tamara has no desire for breakfast and reluctantly goes to school

Before lunch, Susan gets a phone call from Tamara’s school. Tamara has fever, tummy ache and vomiting. Susan takes Tamara to the Emergency Department. The physician on duty finds that Tamara is very tender in the right lower quadrant of the abdomen. In fact, slight pressure on the area causes Tamara to jump.

The ER physician makes a provisional diagnosis of acute appendicitis and consults the general surgeon on call. The surgeon confirms the clinical impression of the ER physician and explains to Tamara and her mom that the best treatment for this condition is emergency removal of the appendix.

“Doctor, what about tests to confirm the diagnosis?” asks anxious Susan.

Although most patients with this kind of clinical picture end up having blood and urine tests and plain abdominal x-rays, the diagnosis of acute appendicitis remains a clinical one. These tests are valuable when the diagnosis is not clear. That happens in about 20 percent of cases.

“Doctor, can the surgery wait till tomorrow?”

No. Once the diagnosis of acute appendicitis is made then the appendix should be removed within the next few hours, depending on the condition of the patient. If ruptured appendix or abscess is suspected then the procedure should be undertaken within couple of hours. If the patient is not “toxic”, then 4 to 6 hours’ wait is reasonable. But the surgeon makes the call on the timing of the procedure. With his experience, he will be right most of the time.

“Doctor, what is the risk of delaying surgery?”

Perforation (ruptured appendix), peritonitis and death from “toxic shock”. From time to time, people have died from ruptured appendix. The reasons are: delay in presentation to a doctor (quite often people think it is flu and stay home and self-medicate), and unusual presentation leading to delay in diagnosis.

Once the diagnosis of acute appendicitis is made then it is better to remove a normal one then risk perforation and subsequent complications. About 10 to 20 percent normal appendectomies are acceptable in a surgeon’s carrier.

“Doctor, don’t we need an appendix? What happens after it is removed? Is Tamara going to feel anything different?”

No, we do not need the appendix. Its function in the immune system is not clear. It does not serve any useful purpose as a digestive organ in humans. It is believed to be gradually disappearing in the human species. Absence of appendix causes no adverse effects.

About 110 appendectomies are done at Medicine Hat Regional Hospital each year. Historically, appendectomies have been done since 1880. Leonardo da Vinci was the first to describe and illustrate the appendix in 1492.

Tamara has a successful uncomplicated appendectomy. Couple of days in the hospital and one week at home should get her back to school feeling happy and healthy. Most patients have uncomplicated recovery. Hopefully, Tamara will not be an exception.

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

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