Bowel Obstruction due to Multiple Retained Foreign Bodies in a Meckel Diverticulum
A
10-year-old male with autism spectrum disorder presented to the emergency department with complaints of acute onset of abdominal pain and bilious vomiting for 2 days. The pain was poorly characterized and localized; no triggering or alleviating factors were identified. There was no fever, diarrhea, or constipation. On physical exam, he was found to be agitated and uncooperative. The exam was significant for diffuse abdominal tenderness to palpation and voluntary guarding. Perianal examination was negative for fissures, fistulae, or skin tags. Complete blood count and serum electrolytes were normal. Abdominal radiographs showed evidence for obstruction with dilated small bowel with air fluid levels. Computed tomography scan revealed foreign objects (Figure 1) in the distal small bowel with dilation of the proximal intestine and decompressed bowel distally. Exploratory laparotomy was performed where a Meckel diverticulum (4-cm 5-cm) was found containing multiple foreign object; several other foreign objects discovered in the distal ileum were milked back into the diverticulum. Resection of the diverticulum containing all the objects was accomplished (Figure 2; available at www.jpeds.com). Meckel diverticuli occur in approximately 2% of the population and may remain asymptomatic throughout life. Complications of Meckel diverticuli include bleeding, inflammation, perforation, and small bowel obstruction. Children more commonly present with painless rectal bleeding, and adults are more likely to experience obstruction. Obstruction may arise because of intussusception, volvulus, post-inflammatory adhesions, and incarceration within a hernia. A rare cause of obstruction is a bezoar, typically consisting of hair or poorly digestible fruits or vegeta-
bles. Foreign bodies also can become incarcerated in the diverticulum, leading to obstruction or perforation. Proposed mechanisms for foreign bodies entering the diverticulum include disordered motility at the diverticulum 1 and wide-based opening of the diverticulum into the intestinal lumen.2 The most common foreign body causing perforation in a Meckel diverticulum is ingested bone fragments (58%), followed by wood splinters (14%), food (12%), pin/needles (9%), and miscellaneous (7%).3 Ingestion of multiple foreign bodies is more commonly seen in individuals with psychiatric illness or intellectual disabilities. n Paul Redmond, MD Department of Pediatrics
David Sawaya, MD Division of Pediatric Surgery
Michael Nowicki, MD Division of Pediatric Gastroenterology Blair E. Batson Children’s Hospital Children’s Healthcare of Mississippi Jackson, Mississippi
References 1. Sorensen JB, Ghani A. Phytobezoar obstruction of a Meckel’s diverticulum. Am Surg 1992;58:61-4. 2. Mares AJ, Finaly R, Mordechai J, Motovic A. “Pantaloon” phytobezoar: an unusual cause of intestinal obstruction associated with Meckel’s diverticulum. Isr J Med Sci 1993;29:683-5. 3. Halverson JM, Butterman MK, Legier JF, Mann WJ Jr, Hoefer RA Jr. Perforation of a Meckel’s diverticulum caused by ingestion of a coin. South Med J 1994;87:823-4.
Figure 1. Computed tomography scan showed multiple foreign bodies in a Meckel diverticulum (*) with proximal small bowel dilation (arrow).
J Pediatr 2014;165:639. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.04.034
639
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 165, No. 3
Figure 2. The surgical specimen consisted of the resected Meckel diverticulum and 10 foreign bodies, including (left to right) a piece of irregularly-shaped plastic, part of a rubber hose, irregularly-shaped object of indeterminant origin, a black marble, an iridescent black bead, a yellow rock, a rectangular piece of black plastic, a “pressed” penny, an oblong plastic toy, and a plastic heart (center).
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Redmond, Sawaya, and Nowicki
A
10-year-old male with autism spectrum disorder presented to the emergency department with complaints of acute onset of abdominal pain and bilious vomiting for 2 days. The pain was poorly characterized and localized; no triggering or alleviating factors were identified. There was no fever, diarrhea, or constipation. On physical exam, he was found to be agitated and uncooperative. The exam was significant for diffuse abdominal tenderness to palpation and voluntary guarding. Perianal examination was negative for fissures, fistulae, or skin tags. Complete blood count and serum electrolytes were normal. Abdominal radiographs showed evidence for obstruction with dilated small bowel with air fluid levels. Computed tomography scan revealed foreign objects (Figure 1) in the distal small bowel with dilation of the proximal intestine and decompressed bowel distally. Exploratory laparotomy was performed where a Meckel diverticulum (4-cm 5-cm) was found containing multiple foreign object; several other foreign objects discovered in the distal ileum were milked back into the diverticulum. Resection of the diverticulum containing all the objects was accomplished (Figure 2; available at www.jpeds.com). Meckel diverticuli occur in approximately 2% of the population and may remain asymptomatic throughout life. Complications of Meckel diverticuli include bleeding, inflammation, perforation, and small bowel obstruction. Children more commonly present with painless rectal bleeding, and adults are more likely to experience obstruction. Obstruction may arise because of intussusception, volvulus, post-inflammatory adhesions, and incarceration within a hernia. A rare cause of obstruction is a bezoar, typically consisting of hair or poorly digestible fruits or vegeta-
bles. Foreign bodies also can become incarcerated in the diverticulum, leading to obstruction or perforation. Proposed mechanisms for foreign bodies entering the diverticulum include disordered motility at the diverticulum 1 and wide-based opening of the diverticulum into the intestinal lumen.2 The most common foreign body causing perforation in a Meckel diverticulum is ingested bone fragments (58%), followed by wood splinters (14%), food (12%), pin/needles (9%), and miscellaneous (7%).3 Ingestion of multiple foreign bodies is more commonly seen in individuals with psychiatric illness or intellectual disabilities. n Paul Redmond, MD Department of Pediatrics
David Sawaya, MD Division of Pediatric Surgery
Michael Nowicki, MD Division of Pediatric Gastroenterology Blair E. Batson Children’s Hospital Children’s Healthcare of Mississippi Jackson, Mississippi
References 1. Sorensen JB, Ghani A. Phytobezoar obstruction of a Meckel’s diverticulum. Am Surg 1992;58:61-4. 2. Mares AJ, Finaly R, Mordechai J, Motovic A. “Pantaloon” phytobezoar: an unusual cause of intestinal obstruction associated with Meckel’s diverticulum. Isr J Med Sci 1993;29:683-5. 3. Halverson JM, Butterman MK, Legier JF, Mann WJ Jr, Hoefer RA Jr. Perforation of a Meckel’s diverticulum caused by ingestion of a coin. South Med J 1994;87:823-4.
Figure 1. Computed tomography scan showed multiple foreign bodies in a Meckel diverticulum (*) with proximal small bowel dilation (arrow).
J Pediatr 2014;165:639. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.04.034
639
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 165, No. 3
Figure 2. The surgical specimen consisted of the resected Meckel diverticulum and 10 foreign bodies, including (left to right) a piece of irregularly-shaped plastic, part of a rubber hose, irregularly-shaped object of indeterminant origin, a black marble, an iridescent black bead, a yellow rock, a rectangular piece of black plastic, a “pressed” penny, an oblong plastic toy, and a plastic heart (center).
639.e1
Redmond, Sawaya, and Nowicki
