CASE REPORT OPEN ACCESSInternational Journal of Surgery Case Reports 10 (2015) 1719

Contents lists available at ScienceDirect

International Journal of Surgery Case Reports

journa l h omepage: www.caserepor ts .com

Meckels diverticulum mesentery along with its bhernial sac: A rare case of internal herniation

Paras K. P andDivya Sha Department o ab Department o

a r t i c l

Article history:Received 5 OcReceived in reAccepted 4 MaAvailable onlin

Keywords:Adhesion bandInternal herniationMeckels diverticulumMesentery of MeckelsObstruction

is ttic. Ittussue of iy of Mls di

. Diveanastomosis was done.DISCUSSION: Internal herniation by MD leading to SBO is an extremely rare complication. In literature,cases of internal hernia through mesentry of Meckels diverticulum, through mesodiverticular band,adhesion of inamed end of MD to corresponding base of mesentry, brous cord extending upto umblicalwall have been reported but in our case, patient had both adhesion band along with internal herniation

1. Introdu

Meckelsmalformatiof omphaloweek of geswho develobe bowel oother umbicommon prtomatic cas

Corresponical College &

E-mail add

http://dx.doi.o2210-2612/ (http://creativinto sac formed by unusual mesentry of the meckels diverticulum and the adhesion band. Preoperativediagnosis is often difcult with only 612% of cases diagnosed correctly. Surgical intervention is indicatedfor patients with intestinal obstruction or high risk of incarceration.CONCLUSION: Meckels diverticulum causing internal hernia is rare event. Its presentation due to hernia-tion of bowel loops into sac formed by mesentery attached to diverticulum and the adhesion is rarest, withnon specic signs and symptoms. Early diagnosis and prompt treatment prevent further complications.

2015 Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access articleunder the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

ction

diverticulum (MD) is the most common congenitalon of gastrointestinal tract [14]. It is the remanantmesenteric duct which is normally obliterated by 7thtation. Most patients are asymptomatic. Those patientsps symptoms are due to its complications which couldbstruction, hemorrhage, diverticulitis, perforation orlical lesions [1,3,4]. Small bowel obstruction is the mostesentation in adults accounting for 1/3rd of all symp-es [4].

ding author at: Associate Professor Department of Surgery, Govt. Med-Rajindra Hospital Patiala, India. Tel.: +91 9814507559.ress: drpandovepk@yahoo.co.in (P.K. Pandove).

2. Case report

A 14 year old male presented to Emergency with complaint ofpain abdomen with history of constipation with passage of atus,vomiting (56 episodes) and mild abdominal distension since 3days. Patient also gave history of minor blunt trauma abdomen4 days back and subsequently, a day later patient developed thesymptoms. On abdominal examination, the abdomen was soft, nontender and bowel sounds were present with soft stools on per rectalexamination. Ultrasound abdomen revealed dilated gut loops withuid in pelvis suggestive of SBO. X-ray abdomen revealed multipleair uid levels.

Fluid resuscitation and antibiotics were started and patient wasput on conservative management and patient had relief of symp-toms with passage of stools and atus but again after 2 daysdeveloped the features of SBO for which exploratory laparotomywas undertaken for the persistent feature of SBO. Intra-operatively,jejunum was collapsed with proximal ileal loop distension. About50 cm s away from ileo-caecal junction, was herniated loops ofbowel through unusual mesentery of Meckels extending from base

rg/10.1016/j.ijscr.2015.03.0052015 Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND licenseecommons.org/licenses/by-nc-nd/4.0/).andovea,, Ashish Moudgil a, Megha Pandovea, Chardab, Vijay K. Shardaa

f Surgery, Rajindra Hospital/Government Medical College, Patiala 147001, Punjab, Indif Obs & Gynecology Rajindra Hospital Patiala, India

e i n f o

tober 2014vised form 4 March 2015rch 2015e 7 March 2015

a b s t r a c t

INTRODUCTION: Meckels diverticulumever, only 2% of cases are symptomavolvulus, adhesions, Littres hernia, inCASE PRESENTATION: An unusual casnia sac formed by unusual mesenterband, extending from tip of the Meckeing to small bowel obstruction (SBO)and forming a

rashekhara,

he most common congenital gastrointestinal anomaly. How- can cause intestinal obstruction by various mechanisms assception.nternal herniation of small bowel loops into complete her-eckels diverticulum which was present upto the adhesive

verticulum to the adjacent mesentery of small intestine lead-rticulectomy with resection of adjacent ileum with ileo-ileal

CASE REPORT OPEN ACCESS18 P.K. Pandove et al. / International Journal of Surgery Case Reports 10 (2015) 1719

Fig. 1. Showinloops and uid

Fig. 2. Anothehernial sac and

Fig. 3. Showinadhesion bandmouth.

of diverticucent mesena complete lum along win such a w

Careful mand the banwith its metomy with ileo-ileal antoneal toilePost operattomatic in sectopic gas

fter rattachg hernial sac formed by the unusual mesentery with herniated bowel and Meckels diverticulum encircling the sac.

Fig. 4. Aand the r view showing Meckels diverticulum arising from ileum along with its contents.

g two parts of sac with its content, one formed by mesentery along with its mouth and other by mesentery along diverticulum with its

lum to the band which was running from its tip to adja-try encircling the herniated loops of intestine forminghernial sac (Figs. 13). The attachment of the diverticu-ith its adhesive band was rotated over the hernial sac

ay thus giving the appearance of bilobed sac (Fig. 5b).anual reduction of herniated loops was done (Fig. 4)

d was released which revealed Meckels diverticulumsentery forming the hernial sac (Fig. 5a). Diverticulec-its mesentery and adjacent portion of the ileum withastomosis was done in single layer. After proper peri-ting, abdomen was closed over an abdominal drain.ive period was uneventful and patient remained asymp-ubsequent follow ups. Biopsy of diverticulum revealedtric and pancreatic tissue with inammatory cells.

Fig. 5. (a) Aftetery. (b) Show

3. Discussi

Meckelsduct. It norfetal life. If includes Meto the abdoor an umbligenital gast13% of the[3] but symdiverticuluerotrophic the ileum, s[6] and recartery [7]. Mnding at laplications wbleeding, deduction of hernial contents, showing diverticulum, adhesion banded mesentery.r division of the band showing the diverticulum and attached mesen-ing bilobed appearance of the sac.

on

diverticulum is the remnant of the Vitello intestinalmally regresses between the fth and seventh week ofthis regression fails, various anomalies can occur whichckels diverticulum with/without brous cord attached

minal wall, an umblical intestinal stula, enterocystomacal adenoma [3,4]. Of these MD is the most common con-rointestinal anomaly. MD is present in approximately

population with equal incidence in males and femalesptoms are commonly present in males [5]. It is a truem containing all layers of the ileal wall containing het-tissue [5]. It arises from the anti-mesenteric border ofituated between 30 and 150 cm s from ileo-caecal valveeiving its blood supply from a remnant of the vitellineost of these are clinically silent and often an incidentalparotomy. Symptoms arises when associated with com-hich occurs in 4% of cases [5] including gastrointestinal

iverticulitis, and small bowel obstruction [25]. Clinical

CASE REPORT OPEN ACCESSP.K. Pandove et al. / International Journal of Surgery Case Reports 10 (2015) 1719 19

manifestations of complicated M.D. are frequently non specic andcan mimic other pathologic conditions such as appendicitis, crohnsdisease, cholecystitis and peptic ulcer [7]. Various mechanisms bywhich it can cause intestinal obstruction [3,5,6].

Volvulus of small intestine around brous band extending fromMeckels diverticulum to umbilicus.

Intussusception. Littres hernia: incarceration of the diverticulum in inguinal and

femoral hernia. Entrapment of small bowel beneath mesodiverticular band. Adhesions secondary to diverticulitis. Enterolithiasis causing impaction inammation. Herniation of gut through loop formed by adhesion band extend-

ing between the diverticulum and base of the mesentery. Neoplasm obstruction. Bezoar lodged in diverticulum in Y shaped pantaloons pattern [7].

Internal accounts oncommonly,herniation tion [8] andsymptoms, inal surgerydiverticulumcases have binamed engas et al. [7Jain and Sahing upto umBut in our cof diverticution of gut diverticulumnot been reoften difcuAbdominal which can center ultracystic lesionThe use of bthe obstrucstandard imof obstructiing of bowevessels maysituation ancomplicatiotomy. Surgiobstructionsurgical resherniation.

4. Conclusion

Meckels diverticulum causing internal hernia and intestinalobstruction is rare event. Its presentation due to herniation ofbowel loops into sac formed by mesentery attached to diverticulumand the adhesion is rarest, with non specic signs and symptoms.Therefore, there is high mortality rates associated with this type ofinternal hernia [2]. Early diagnosis and prompt treatment preventfurther complications and prolonged hospitalization.

Conict of interest

There is no conict of interest among all the authors.

Presentation details

None.

g de

fund

t of

ittentionritt

journ

nces

. Lin, d of M. Maiaerticuarjis,lt: Me. Aggagnosisging 3ain, S.erticu.S. Srire preapaziatzid

erticu. Chenrnal h. Dali

Meck. Hawrnal h

scint940

Open AccesThis article undepermits un any mcredited.hernia caused by entrapment of the small intestinely 0.54.1% of intestinal obstruction cases [1]. Most

it occurs through mesentry of small intestine. Internalby MD leading to SBO is an extremely rare complica-

it should be considered in patients with obstructiveespecially in younger people without previous abdom-. A case of internal hernia through mesentry of Meckels

has been reported by Dalinka et al. [9]. Several othereen reported of internal herniation due to adhesion ofd of MD to corresponding base of mesentry by Papazio-] and Lin et al. [1], through mesodiverticular band byi [5] and Srinivas and Cullen [6], brous cord extend-blical wall by Maia et al. [2] and Aggarwal et al. [4].

ase patient had both adhesion band extending from tiplum to adjacent mesentry along with internal hernia-into a sac formed by unusual mesentry of the meckels

and the adhesion band. Such unusual presentation hasported so far in the literature. Preoperative diagnosis islt with only 612% of cases diagnosed correctly [10].radiographs may be useful if enteroliths are present,be seen as peripheral calcication with a radiolucentsonograms may suggest evidence of a round or tubular, however, this can often mimic a dilated bowel loop.arium studies is limited, due to poor barium lling of

ted bowel [7]. Computed tomography is usually the goldaging modality however, identifying MD as the causeon can be difcult. Though, in internal hernia, cluster-l loops and stretched crowded and engorged mesenteric

be suggestive features [2]. However, due to emergencyd limitations of the imaging modalities in identifyingns of MD, typically the diagnosis is made only at laparo-cal intervention is indicated for patients with intestinal

or high risk of incarceration. The treatment option isection with diverticulectomy and reduction of internal

Fundin

Self

Consen

Wrpublicaof the wof this

Refere

[1] C.Wban

[2] D.Sdiv

[3] Y. Nadu

[4] B.KdiaIma

[5] V. Jdiv

[6] G.Na ra

[7] B. PAtmdiv

[8] C.Ainte

[9] M.Kof a

[10] H.Binteand938

s is published Open Access at sciencedirect.com. It is distributed restricted non commercial use, distribution, and reproduction in tails

ed.

patient

informed consent was obtained from the patient for of this case report and accompanying images. A copyen consent is available for review by the Editor-in-Chiefal on request.

S.M. Kuo, G.Y. Diau, K.C. Chen, Internal herniation of ileum caused byeckels diverticulum, J. Med. Sci. 31 (2) (2011) 079080., M. Ferreira Junior, R.G. Viegas, et al., Bowel obstruction in Meckellum, Arq. Bras. Cir. Dig. 26 (JulySeptember (3)) (2013) 244245.

H. Halfadl, A. Agourram, K. Rabbani, A rare internal herniation inckels diverticulum, Indian J. Surg. 76 (February (1)) (2014) 57.rwal, S. Rajan, A. Aggarwal, R. Gothi, R. Sharma, V. Tandon, CT

of Meckel diverticulum in a paracolic internal hernia, Abdominal0 (2005) 5669.

Sahi, A rare fatal case of internal hernia caused by Meckelslum in a paediatric patient, Open J. Paediatr. 1 (2011) 1719.nivas, P. Cullen, Intestinal obstruction due to Meckels diverticulum:sentation, Acta Chir. Belg. 107 (2007) 6466.ogas, I. Makris, P. Tsiaousis, G. Chatzimavroudis, G. Paraskevas, K.is, An unusual case of intestinal obstruction by a Meckelslum, AUMJ 34 (1) (2007) 5559., L.H. Lin, T.F. Chen, S.H. Huang, Congenital mesenteric defect witherniation: a case report, Fu-Jen J. Med. 8 (2) (2010) 123127.nka, J.F. Wunder, R.D. Wolfe, Internal hernia through the mesenteryels diverticulum, Radiology 95 (April (1)) (1970) 3940.kins, Jr. J.D Slavin, R. Levin, R.P. Spencer, MEckels diverticulum:ernia and adhesions without gastrointestinal bleedingultrasoundigraphic ndings, Clin. Nucl. Med. 21 (December (12)) (1996).

r the IJSCR Supplemental terms and conditions, whichedium, provided the original authors and source are

Meckels diverticulum mesentery along with its band forming a hernial sac: A rare case of internal herniation1 Introduction2 Case report3 Discussion4 ConclusionConflict of interestPresentation detailsFunding detailsConsent of patientReferences