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Perforation of Meckel’s diverticulum by an intact fish bone: a case report and literature review A 42-year-old man presented to the emergency department of Gold Coast University Hospital with a 1-day history of migratory periumbilical to the right iliac fossa pain, associated with nausea and decreased appetite. Physical examination revealed a tender, locally peritonitic right iliac fossa. Laboratory results revealed a raised C-reactive protein and white cell count. The preliminary diagnosis of acute appendicitis was made. A contrast computed tomography (CT) abdomen was ordered to exclude an underlying malignancy; however, this revealed a prominent, inflamed terminal ileum, with a mildly dilated tip of appendix and periappendiceal inflammation. The patient was transferred to the medical admission unit with the diagnosis of terminal ileitis for further investigation. The differentials of inflammatory bowel disease, gastroenteritis and appendicitis with adjacent terminal ileal inflammation were further investigated by the gastroenterology unit. Despite 4 days of intravenous antibiotics, oral steroids and bed rest, the patient’s pain persisted, with progressive signs of localized peritonism. The decision was made to perform a diagnostic laparoscopy. On laparoscopy, the distal ileum and appendix were adherent to the anterior abdominal wall, surrounded by oedematous omentum, all of which appeared inflamed, with abundant fibrin. Further exploration revealed a perforated distal ileal diverticulum with surrounding fibrin and pus about 5 cm from the ileocaecal junction (Fig. 1). The diverticulum had been perforated by a sharp, needle-like foreign body (Fig. 2). The foreign body was retrieved
and a laparoscopic appendicectomy and segmental bowel resection with side to side anastomosis was performed. The foreign body appeared to be a fish bone (Fig. 3). Following histological examination, the diagnosis of Meckel’s diverticulitis (as opposed to a pulsion diverticulum) was confirmed. The foreign body had histological features consistent with bone; the patient admitted that he often swallowed fish bones. The patient recovered without complication, being discharged 4 days post-operatively. Merkel’s diverticulum is the most common congenital anomaly affecting the gastrointestinal tract with an overall incidence of approximately 2.2%. Hildanus was the first to describe the presence of Merkel’s diverticulum in 1598; however, Meckel was the first to identify the anatomic abnormality necessary for its development in 1809. It is a true enteric diverticulum encompassing all layers of the bowel wall. It is caused by failure of regression of the omphalomesenteric duct following physiological herniation of the midgut through the umbilicus during the fourth week of fetal development. It is usually an incidental finding during a laparotomy for management of other abdominal pathology. Complications are rare, present usually in childhood and include haemorrhage, bowel obstruction, diverticulitis, intussusception and rarely perforation. Haemorrhage is most common in children whereas obstruction and inflammation occur mostly in adults.1 The rule of twos is the classic description of the essential features of Merkel’s diverticulum. It occurs 2 feet from the ileocecal valve, is
Fig. 1. Terminal ileal Meckel’s diverticulum with surrounding inflammation and organized fibrin and pus.
Fig. 2. On closer inspection, the diverticulum was found to be perforated by a foreign body of organic origin and was later confirmed to be a fish bone.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
that complicated Meckel’s diverticula should be managed by surgery, either via diverticulectomy or segmental bowel resection with primary anastomosis, as in this case.1 Complications of Meckel’s diverticulum are uncommon and can be difficult to diagnose. Early recognition and appropriate operative management must be utilized in order to obtain the best outcomes. A perforation by a foreign body is very rare but must be considered in the differential diagnosis of any patient presenting with an acute abdomen or symptoms mimicking appendicitis.8,9 Surgeons should consider a complicated Meckel’s diverticulitis in patients presenting with atypical right iliac fossa pain and when evaluating any preoperative CT scan.10
References Fig. 3. The fish bone was retrieved post-segmental resection of the diverticulum.
about 2 inches long, 2% of patients develop a complication over their lifetime, it contains two types of ectopic tissue (gastric and pancreatic) and it affects males twice as often as females.2 Our patient developed clinical signs suggestive of localized peritonism but the CT scan only showed signs of terminal ileitis and no evidence of a fish bone or perforation. Accurate preoperative diagnosis continues to remain a major challenge, as most patients do not remember ingesting a foreign body. Despite improvements in CT technology, the definitive diagnosis is not reached until surgical intervention in many cases. One study quoted sensitivity between 27 and 58% when a CT was obtained perioperatively.3 A very small percentage of foreign bodies can cause perforation, with the most common site being the terminal ileum and colon. However, an increased incidence of perforation has been reported in association with Meckel’s diverticulum.4 We performed a literature review using PubMed, Medline and Google Scholar and searched ‘Meckel’s diverticulum and perforation’. In the last 15 years, we found six published reports of Meckel’s diverticulum perforations,1,2,4–7 with three being due to fish bones and three due to chicken bones. The cases that had perforations due to fish bones,1,2,5 all presented with symptoms suggestive of local peritonitis and had a preliminary diagnosis of appendicitis. Other differentials that should be considered include: colonic pathology, inflammatory bowel disease, acute cholecystitis, atypical renal presentations and other gynaecological causes. In this case, a diagnostic laparoscopy for worsening abdominal pain helped to guide subsequent management. There is no doubt
1. Mouawad NJ, Hammond S, Kaoutzanis C. Perforation of Meckel’s diverticulum by an intact fish bone. BMJ Case Rep. 2013; doi: 10.1136/ bcr-2012-008226. 2. Dimitriou I, Evaggelou N, Tavaki E, Chatzitheoklytos E. Perforation of Meckel’s diverticulum by a fish bone presenting as acute appendicitis: a case report. J. Med. Case Rep. 2013; 7: 231. 3. Ward MA, Tews MC. Small bowel perforation secondary to fish bone ingestion managed non-operatively. J. Emerg. Med. 2012; 43: e295–8. 4. Chan KW. Perforation of Meckel’s diverticulum caused by a chicken bone: a case report. J. Med. Case Rep. 2009; 3: 48. 5. Sekmen U, Gungor O, Sagiroglu J. Perforation of Meckel’s diverticulum by a fishbone. ANZ J. Surg. 2008; 78: 1045–6. 6. Yagci G, Cetiner S, Tufan T. Perforation of Meckel’s diverticulum by a chicken bone, a rare complication: report of a case. Surg. Today 2004; 34: 606–8. 7. Su C-H, Lee J-Y, Chang Y-T. Perforation of Meckel’s diverticulum by a peanut presenting as a mesentery abscess. Iran. J. Pediatr. 2012; 23: 223–5. 8. Emre A, Akbulut S, Yilmaz M, Kanlioz M, Aydin BE. Double Meckel’s diverticulum presenting as acute appendicitis: a case report and literature review. J. Emerg. Med. 2013; 44: e321–4. 9. Chiu J-J, Chen T-L, Zhan Y-L. Perforation of the transverse colon by a fish bone: a case report. J. Emerg. Med. 2009; 36: 345–7. 10. Sagar J, Kumar V, Shah DK. Meckel’s diverticulum: a systematic review. J. R. Soc. Med. 2006; 99: 501–5.
Luca Daniele,* BSci, MBBS Devlin Elliott,* MBChB Man Shun Wong,† MBBS Jason Free,† MBBS, FRACS *Orthopaedics Department Southport, Gold Coast University Hospital, Gold Coast, Queensland, Australia and †General Surgery Department Southport, Gold Coast University Hospital, Gold Coast, Queensland, Australia doi: 10.1111/ans.13125
© 2015 Royal Australasian College of Surgeons
Perforation of Meckel’s diverticulum by an intact fish bone: a case report and literature review A 42-year-old man presented to the emergency department of Gold Coast University Hospital with a 1-day history of migratory periumbilical to the right iliac fossa pain, associated with nausea and decreased appetite. Physical examination revealed a tender, locally peritonitic right iliac fossa. Laboratory results revealed a raised C-reactive protein and white cell count. The preliminary diagnosis of acute appendicitis was made. A contrast computed tomography (CT) abdomen was ordered to exclude an underlying malignancy; however, this revealed a prominent, inflamed terminal ileum, with a mildly dilated tip of appendix and periappendiceal inflammation. The patient was transferred to the medical admission unit with the diagnosis of terminal ileitis for further investigation. The differentials of inflammatory bowel disease, gastroenteritis and appendicitis with adjacent terminal ileal inflammation were further investigated by the gastroenterology unit. Despite 4 days of intravenous antibiotics, oral steroids and bed rest, the patient’s pain persisted, with progressive signs of localized peritonism. The decision was made to perform a diagnostic laparoscopy. On laparoscopy, the distal ileum and appendix were adherent to the anterior abdominal wall, surrounded by oedematous omentum, all of which appeared inflamed, with abundant fibrin. Further exploration revealed a perforated distal ileal diverticulum with surrounding fibrin and pus about 5 cm from the ileocaecal junction (Fig. 1). The diverticulum had been perforated by a sharp, needle-like foreign body (Fig. 2). The foreign body was retrieved
and a laparoscopic appendicectomy and segmental bowel resection with side to side anastomosis was performed. The foreign body appeared to be a fish bone (Fig. 3). Following histological examination, the diagnosis of Meckel’s diverticulitis (as opposed to a pulsion diverticulum) was confirmed. The foreign body had histological features consistent with bone; the patient admitted that he often swallowed fish bones. The patient recovered without complication, being discharged 4 days post-operatively. Merkel’s diverticulum is the most common congenital anomaly affecting the gastrointestinal tract with an overall incidence of approximately 2.2%. Hildanus was the first to describe the presence of Merkel’s diverticulum in 1598; however, Meckel was the first to identify the anatomic abnormality necessary for its development in 1809. It is a true enteric diverticulum encompassing all layers of the bowel wall. It is caused by failure of regression of the omphalomesenteric duct following physiological herniation of the midgut through the umbilicus during the fourth week of fetal development. It is usually an incidental finding during a laparotomy for management of other abdominal pathology. Complications are rare, present usually in childhood and include haemorrhage, bowel obstruction, diverticulitis, intussusception and rarely perforation. Haemorrhage is most common in children whereas obstruction and inflammation occur mostly in adults.1 The rule of twos is the classic description of the essential features of Merkel’s diverticulum. It occurs 2 feet from the ileocecal valve, is
Fig. 1. Terminal ileal Meckel’s diverticulum with surrounding inflammation and organized fibrin and pus.
Fig. 2. On closer inspection, the diverticulum was found to be perforated by a foreign body of organic origin and was later confirmed to be a fish bone.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
that complicated Meckel’s diverticula should be managed by surgery, either via diverticulectomy or segmental bowel resection with primary anastomosis, as in this case.1 Complications of Meckel’s diverticulum are uncommon and can be difficult to diagnose. Early recognition and appropriate operative management must be utilized in order to obtain the best outcomes. A perforation by a foreign body is very rare but must be considered in the differential diagnosis of any patient presenting with an acute abdomen or symptoms mimicking appendicitis.8,9 Surgeons should consider a complicated Meckel’s diverticulitis in patients presenting with atypical right iliac fossa pain and when evaluating any preoperative CT scan.10
References Fig. 3. The fish bone was retrieved post-segmental resection of the diverticulum.
about 2 inches long, 2% of patients develop a complication over their lifetime, it contains two types of ectopic tissue (gastric and pancreatic) and it affects males twice as often as females.2 Our patient developed clinical signs suggestive of localized peritonism but the CT scan only showed signs of terminal ileitis and no evidence of a fish bone or perforation. Accurate preoperative diagnosis continues to remain a major challenge, as most patients do not remember ingesting a foreign body. Despite improvements in CT technology, the definitive diagnosis is not reached until surgical intervention in many cases. One study quoted sensitivity between 27 and 58% when a CT was obtained perioperatively.3 A very small percentage of foreign bodies can cause perforation, with the most common site being the terminal ileum and colon. However, an increased incidence of perforation has been reported in association with Meckel’s diverticulum.4 We performed a literature review using PubMed, Medline and Google Scholar and searched ‘Meckel’s diverticulum and perforation’. In the last 15 years, we found six published reports of Meckel’s diverticulum perforations,1,2,4–7 with three being due to fish bones and three due to chicken bones. The cases that had perforations due to fish bones,1,2,5 all presented with symptoms suggestive of local peritonitis and had a preliminary diagnosis of appendicitis. Other differentials that should be considered include: colonic pathology, inflammatory bowel disease, acute cholecystitis, atypical renal presentations and other gynaecological causes. In this case, a diagnostic laparoscopy for worsening abdominal pain helped to guide subsequent management. There is no doubt
1. Mouawad NJ, Hammond S, Kaoutzanis C. Perforation of Meckel’s diverticulum by an intact fish bone. BMJ Case Rep. 2013; doi: 10.1136/ bcr-2012-008226. 2. Dimitriou I, Evaggelou N, Tavaki E, Chatzitheoklytos E. Perforation of Meckel’s diverticulum by a fish bone presenting as acute appendicitis: a case report. J. Med. Case Rep. 2013; 7: 231. 3. Ward MA, Tews MC. Small bowel perforation secondary to fish bone ingestion managed non-operatively. J. Emerg. Med. 2012; 43: e295–8. 4. Chan KW. Perforation of Meckel’s diverticulum caused by a chicken bone: a case report. J. Med. Case Rep. 2009; 3: 48. 5. Sekmen U, Gungor O, Sagiroglu J. Perforation of Meckel’s diverticulum by a fishbone. ANZ J. Surg. 2008; 78: 1045–6. 6. Yagci G, Cetiner S, Tufan T. Perforation of Meckel’s diverticulum by a chicken bone, a rare complication: report of a case. Surg. Today 2004; 34: 606–8. 7. Su C-H, Lee J-Y, Chang Y-T. Perforation of Meckel’s diverticulum by a peanut presenting as a mesentery abscess. Iran. J. Pediatr. 2012; 23: 223–5. 8. Emre A, Akbulut S, Yilmaz M, Kanlioz M, Aydin BE. Double Meckel’s diverticulum presenting as acute appendicitis: a case report and literature review. J. Emerg. Med. 2013; 44: e321–4. 9. Chiu J-J, Chen T-L, Zhan Y-L. Perforation of the transverse colon by a fish bone: a case report. J. Emerg. Med. 2009; 36: 345–7. 10. Sagar J, Kumar V, Shah DK. Meckel’s diverticulum: a systematic review. J. R. Soc. Med. 2006; 99: 501–5.
Luca Daniele,* BSci, MBBS Devlin Elliott,* MBChB Man Shun Wong,† MBBS Jason Free,† MBBS, FRACS *Orthopaedics Department Southport, Gold Coast University Hospital, Gold Coast, Queensland, Australia and †General Surgery Department Southport, Gold Coast University Hospital, Gold Coast, Queensland, Australia doi: 10.1111/ans.13125
© 2015 Royal Australasian College of Surgeons
