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BMJ Case Rep. 2010; 2010: bcr0120102662.
Published online Aug 16, 2010. doi:  10.1136/bcr.01.2010.2662
PMCID: PMC3028047
Unusual presentation of more common disease/injury
Haemoperitoneum caused by perforation of Meckel's diverticulum in a 5-year-old child
David W Borowski,1 Catherine Hobday,2 and Anil K Agarwal3
1Department of Colorectal Surgery, Freeman Hospital, Newcastle upon Tyne, UK
2Department of Pathology, University Hospital of North Tees, Stockton on Tees, UK
3Department of Surgery, University Hospital of North Tees, Stockton on Tees, UK
Correspondence to Anil K Agarwal, anil.agarwal/at/nth.nhs.uk
Abstract
Common complications of Meckel's diverticulum in children include gastrointestinal haemorrhage, intestinal obstruction or intussuception and diverticulitis. Here, the rare case of a perforated, non-inflamed Meckel's diverticulum causing significant haemoperitoneum in a young child, is reported. The case highlights the potential for rapid deterioration of patients with complications form vitelline duct abnormalities, for which surgical exploration should not be delayed.
Meckel's diverticulum, the remnant of the omphalomesenteric duct, is the most common congenital abnormality of the small bowel and is present in 2% of the population. It may contain heterotopic gastric mucosa or pancreatic tissue with a highly variable reported incidence up to 50% of cases,1 although it is likely that patients with symptomatic diverticuli have a higher incidence of ectopic tissue compared to asymptomatic patients. Common complications of this usually incidentally discovered, benign condition include gastrointestinal bleeding, intestinal obstruction, intussusception and acute diverticulitis. This case reports the rare complication of a significant intraperitoneal haemorrhage from a non-inflamed, perforated Meckel's diverticulum in a young child.
Case presentation
A 5-year-old Caucasian boy with 23 kg body weight and no other medical history or history of trauma presented to the Emergency Department with a 24 h history of central abdominal pain and vomiting. Initial clinical examination revealed no significant abdominal findings; temperature, pulse and blood pressure were within normal range, and the patient was discharged home with no further investigations. However, within 10 h the child returned to hospital with clinical signs suggestive of acute appendicitis including tachycardia (130 beats/min with normal blood pressure), mild fever (37.4 ºC) and right lower abdominal peritonism.
Investigations
Abnormal inflammatory parameters including elevated levels for white cell count (23.1 ×109 cells/litre) and C reactive protein (22.0 mg/litre). Furthermore, the level of haemoglobin was abnormally low (9.9 g/dl).
Differential diagnosis
With deteriorating clinical signs, including increasing pain, respiratory rate and tachycardia, the patient was taken to the operating room with suspected acute appendicitis within 2 h of readmission.
At surgery, carried out through a Lanz incision, 260 ml of fresh blood with clots (15% of the estimated total blood volume) were evacuated from the peritoneal cavity, originating from the mucosal surface of a perforated Meckel's diverticulum (figure 1). A short segment of ileum containing the diverticulum was resected with an end-to-end anastomosis. The macroscopically normal appendix was also excised. Histology confirmed the presence of a perforated Meckel's diverticulum containing heterotopic gastric mucosa with reactive local serosal inflammation, but no signs of underlying diverticulitis (figure 2). The microscopically normal appendix contained a small faecolith.
Figure 1
Figure 1
Operative finding of a perforated Meckel's diverticulum.
Figure 2
Figure 2
Perforation of Meckel's diverticulum with blood and fibrin on surface and ectopic gastric mucosa (arrow). Magnification ×100.
Outcome and follow-up
The patient made an uncomplicated postoperative recovery and was discharged home 3 days later.
Common complications from Meckel's diverticulum include chronic or acute gastrointestinal blood loss (in up to 50%), intestinal obstruction and intussusception. Acute diverticulitis is found in up to 20% of complications arising from Meckel's diverticuli, most commonly in adults, often mimicking acute appendicitis and occasionally leading to perforation and peritonitis.1 In a large case series reporting on the complications from Meckel's diverticuli in children, perforation was uncommon compared to other presentations.2 Acute intraperitoneal haemorrhage from a perforated Meckel's diverticulum is a rare complication,35 in particular in children and in the absence of acute diverticulitis. Intraperitoneal haemorrhage associated with Meckel's diverticulitis without perforation also has been reported.6 In the absence of acute inflammatory changes within the diverticulum, the underlying pathology and cause of the perforation in the here presented case was likely of peptic origin. Considering the potentially life-threatening blood loss in cases of young children with rapidly deteriorating clinical picture and signs of peritoneal irritation, surgical exploration should not be delayed.
Learning points
  • Common complications of Meckel's diverticulum include gastrointestinal bleeding, intestinal obstruction, intussusception and acute diverticulitis.
  • Perforation of a non-inflamed Meckel's diverticulum is a rare and potentially life-threatening complication.
  • Surgical exploration of children presenting with rapidly deteriorating vital signs and peritoneal irritation should not be delayed.
Footnotes
Competing interests None.
Patient consent Obtained.
1. Evers BM. Small intestine – Meckel's diverticulum. In: Townsend CM, Beauchamp RD, Evers BM, et al, eds. Sabiston textbook of surgery. 17th edn. Philadelphia, Pennsylvania, USA: Elsevier Saunders, 2004:1463–5.
2. Vane DW, West KW, Grosfeld JW. Vitelline duct anomalities. Experience with 217 childhood cases. Arch Surg 1987;122:542–47. [PubMed]
3. Fowler CL, Ohlms LA, Reid BS, et al. Hemoperitoneum from perforated Meckel's diverticulum. J Pediatr Surg 1988;23:982–3. [PubMed]
4. Jelenc F, Strlic M, Gvardijancic D. Meckel's diverticulum perforation with intraabdominal hemorrhage. J Pediatr Surg 2002;37:E18. [PubMed]
5. El-Hussuna A, Zeb A, Mogensen AM, et al. [Perforation of Meckel's diverticulum with intraabdominal hemorrhage and periappendicular inflammation]. Ugeskr Laeg 2009;171:3676–7. [PubMed]
6. Burt BM, Tavakkolizadeh A, Ferzoco SJ. Meckel's hemoperitoneum: a rare case of Meckel's diverticulitis causing intraperitoneal hemorrhage. Dig Dis Sci 2006;51:1546–8. [PubMed]
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