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Meckel diverticula are remnants of the omphalomesenteric duct. They have 2% incidence in the general population, are usually asymptomatic, and tend to be diagnosed incidentally. The generally held principle had been that asymptomatic cases do not require resection, as exemplified by a 2008 systematic review of over 200 studies. However, a recent series reported an increased risk of malignancies, and recommended mandatory resection. We present a case of Meckel diverticulitis with concurrent infiltrative appendiceal carcinoid in a patient with right lower quadrant pain.
A 51-year-old woman with known gastroesophageal reflux disease and no previous surgeries presented with a 24-hour history of vague abdominal pain associated with mild nausea. She denied any emesis, palpitations, flushing, dyspnea, or changes in bowel or bladder habits. On physical examination, she was afebrile with mild to moderate epigastric tenderness. Her white blood cell count was 13000/μL and hemoglobin level was 12.7 g/dL. An enhanced abdominal computed tomography (CT) with oral and intravenous contrast showed a long dilated debris-filled blind-ending loop of bowel (red arrows—Fig. 1) and adjacent mesenteric fluid (green arrow—Fig. 2). The appendix was not visualized.
Given the abdominal tenderness and leukocytosis, a diagnostic laparoscopy was undertaken. A Meckel diverticulum (MD), dilated, severely inflamed, and firmly impacted with stool was identified ~ 60 cm proximal to the ileocecal valve. Further evaluation of the abdomen revealed a 1.5-cm mass at the tip of an uninflamed appendix. Both the MD (together with adjacent small bowel) and appendix were resected laparoscopically. Microscopic examination revealed Meckel diverticulitis as well as an appendiceal carcinoid infiltrating the wall and surrounding adipose tissues, with a positive proximal resection margin. The patient subsequently underwent a laparoscopic right hemicolectomy with regional lymphadenectomy. She had an uneventful postoperative course and was discharged free of symptoms.
Meckel's diverticula are remnants of the omphalomesenteric duct. They have 2% incidence in the general population, are usually asymptomatic, and tend to be diagnosed incidentally. The generally held principle had been that asymptomatic cases do not require resection, as exemplified by a 2008 systematic review of over 200 studies.1 However, a recent series reported an increased risk of malignancies, and recommended mandatory resection.2
The diagnosis and management of symptomatic MD (encountered in 2 to 4% of patients3) is relatively straightforward. Acute massive (and less frequently indolent) gastrointestinal bleeding is the most common presenting complaint in patients under 2 years of age.4 Intestinal obstruction is the primary presentation in adults, usually associated with small bowel volvulus around the diverticulum. Local inflammation is less common, but still reported in up to 25% of patients.5 Many times these cases can be clinically indistinguishable from appendicitis.6 Differential diagnosis includes Crohn disease, colonic diverticulitis, perforated neoplasms, pelvic inflammatory disease (in female patients), and urachal remnants (when localized to the periumbilical region).7,8 Our patient's clinical presentation was not typical of symptomatic MD. Diagnosis can be facilitated by the presence of small bowel obstruction and visualization of a normal appendix.9 In this case, where neither was present, diagnostic laparoscopy was undertaken. The MD was found at its expected location (approximately 2ft from the ileocecal valve) and resected. Full examination of the peritoneal cavity yielded a mass in the setting of an otherwise unremarkable appendix. While there have reports of carcinoid tumors within MD10 and appendiceal carcinoids mimicking MD,11 we believe this is the first report of an incidental appendiceal carcinoid in the setting of Meckel diverticulitis. Some have hypothesized that an interaction between neural crest cells and endoderm during embryogenesis could account for the increased incidence of ileal carcinoids and MD.12 Our case further confirms that all patients undergoing exploratory laparoscopy for unexplained right lower quadrant abdominal pain should have a thorough evaluation of the entire peritoneal cavity in search of concomitant intra-abdominal pathologies.
• Study concept and design: Deutsch and Anantha Sathyanarayana.
• Acquisition of data: Anantha Sathyanarayana.
• Analysis and interpretation of data: Deutsch, Anantha Sathyanarayana, Rubach, and Friedman.
• Drafting of the article: Deutsch.
• Critical revision of the article for important intellectual content: Anantha Sathyanarayana, Nicastro, Molmenti, Coppa, Rubach, and Friedman.
• Study supervision: Molmenti, Rubach, and Friedman.
Disclosures The authors have no financial disclosures.