We report a case of small bowel obstruction (SBO) caused by internal hernia from persistent attachment of a Meckel's diverticulum (MD) to the umbilicus by the obliterated omphalomesenteric duct that was diagnosed by multidetector CT and confirmed during laparoscopic surgery. Although clinical, pathological and radiological features of MD and its complications are well known, the diagnosis of MD is difficult to establish preoperatively. CT findings that allow the diagnosis of this very unusual cause of SBO are presented here with laparoscopic surgery correlation

BELLINI, DAVIDE

Cavallaro, G

De Santis, D

IORIO, OLGA

LAGHI, ANDREA

MACERONI, MARCO MARIA

Rengo, M

SILECCHIA, Gianfranco

English

Archivio della ricerca- Università di Roma La Sapienza

Received:25 March 2015Revised:05 November 2015Accepted:10 November 2015Cite this article as:Bellini D, Maceroni MM, Cavallaro G, De Santis D, Iorio O, Rengo M, et al. CT diagnosis of small bowel obstruction caused by internal her-nia from persistent attachment of a Meckel's diverticulum to the umbilicus by the obliterated omphalomesenteric duct. BJR Case Rep2016; 2: 20150131.CASE REPORTCT diagnosis of small bowel obstruction caused byinternal hernia from persistent attachment of a Meckel'sdiverticulum to the umbilicus by the obliteratedomphalomesenteric duct1DAVIDE BELLINI, MD, 1MARCO MARIA MACERONI, MD, 2GIUSEPPE CAVALLARO, MD, 1DOMENICO DE SANTIS, MD,2OLGA IORIO, MD, 1MARCO RENGO, MD, PhD, 2GIANFRANCO SILECCHIA, MD and 1ANDREA LAGHI, MD1Department of Radiological Sciences, Oncology and Pathology, Sapienza–University of Rome, Latina, Italy2Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, ItalyAddress correspondence to: Dr Davide BelliniE-mail: bellinidavide29@gmail.comABSTRACTWe report a case of small bowel obstruction (SBO) caused by internal hernia from persistent attachment of a Meckel'sdiverticulum (MD) to the umbilicus by the obliterated omphalomesenteric duct that was diagnosed by multidetector CTand confirmed during laparoscopic surgery. Although clinical, pathological and radiological features of MD and itscomplications are well known, the diagnosis of MD is difficult to establish preoperatively. CT findings that allow thediagnosis of this very unusual cause of SBO are presented here with laparoscopic surgery correlation.SUMMARYWe report a case of small bowel obstruction (SBO) caused byinternal hernia from persistent attachment of a Meckel’sdiverticulum (MD) to the umbilicus by the obliteratedomphalomesenteric duct that was diagnosed by multidetec-tor CT (MDCT) and confirmed during laparoscopic surgery.Although clinical, pathological and radiological features ofMD and its complications are well known, the diagnosis ofMD is difficult to establish preoperatively. CT findings thatallow the diagnosis of this very unusual cause of SBO are pre-sented here with laparoscopic surgery correlation.BACKGROUNDMD is the most common congenital anomaly of the gastro-intestinal tract, occurring in 2–3% of the population.1 It isa true diverticulum composed of all layers of the intestinalwall and resulting from an incomplete atrophy of theomphalomesenteric duct.2 It was first described by Fabri-cus Hildamus in 1598, and was defined embryologically bythe German anatomist Johann Friedrich Meckel in 1809.3About 25% of Meckel’s diverticula become symptomatic.4Symptoms are secondary to complications, with the mostcommon ones being haemorrhage, diverticulitis and intes-tinal obstruction from intussusception, torsion or volvulus.Internal hernia from persistent attachment of the MD tothe umbilicus by the obliterated omphalomesenteric ductis a peculiar cause of bowel obstruction.CASE REPORTA 70-year-old male was admitted to our hospital complain-ing of abdominal pain, nausea and vomiting for 3 days.The pain was accompanied by a loss of appetite, with nogas or faecal discharge within the previous 24 h. His pastmedical history revealed appendectomy. His vital signswere within the normal range and physical examinationrevealed distention of the abdomen with right lower quad-rant tenderness. Laboratory tests were normal with theexception of a mild leukocytosis (11,800 cellsmm3).Abdominal plain film showed findings of mechanicalbowel obstruction and an abdominal CT was requested.The CT scan showed mildly distended ileal loops with fluidlevels, clasped at the level of a fibrous connection betweenthe MD and the abdominal wall. A cluster of collapsedbowel loops, approximately 50 cm, was herniated through-out this orifice, configuring an internal hernia (Figure 1).No signs of infarction were observed on the CTscan (Supplementary Video A).The patient was immediately referred for surgery. Laparo-scopic exploration revealed distension of the small bowel,confirming the presence of an internal hernia throughoutan orifice caused by adhesion of the MD to the abdominalBJR|case reports doi: 10.1259/bjrcr.20150131© 2015 The Authors. Published by the British Institute of Radiology. This is an open access article under the terms of the Creative Commons Attribution4.0 International License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source arecredited.wall. The fibrous band was released, the incarcerated bowel wasnormalized and the MD was sectioned by a laparoscopic linearstapler (Figure 2). The entire small bowel was then carefullyinspected and placed in its correct position. The patient was dis-charged after 5 days without postoperative complications.DISCUSSIONMD is the most common congenital anomaly of the gastrointes-tinal tract. It is located within 100 cm of the ileocecal valve, atthe antimesenteric border of the terminal ileum and accountsfor 90% of all omphalomesenteric duct anomalies.5-7The mnemonic “rule of 2s” is usually used to refer to this condi-tion: it occurs in 2% of the population; it is often about 2 inches(5 cm) in length; it is found within 2 feet (60–100 cm) of theileocecal valve; it is twice more common in males andthe patients are often <2 years old at presentation.8It is generally discovered incidentally during radiological or sur-gical procedures. Morphological features such as length and basediameter are considered as predisposing factors associated withincreased complication rates: long and narrow-base diverticulaare associated with an increased risk of bowel obstruction andinflammation; short and large-base ones are prone to foreignbody entrapment.SBO is the most typical clinical presentation in the adult popula-tion, occurring in almost 36% of patients.7 Rutherford andAkers9 described five principal mechanisms of SBO sustained byMD: volvulus around the vitelloumbilical or mesodiverticularcord; intussusception (free MD as the leading point); bulge ininguinal hernia (Littre’s hernia); inflammation and fibrous bandformation with adhesions; a cord or fibrous band connecting thetip of the diverticulum and the base of the mesentery.In our patient, the abdominal CT scan showed mildly distendeddistal ileal loops with fluid levels, clasped at its base by a loop-like structure, the MD, located 50 cm proximal to the end ofthe ileocecal valve; the suspicion of SBO caused by an internalhernia through a fibrous band formed by adhesion of the tip ofthe MD to the abdominal wall was sustained (Figure 1) and con-firmed during surgery.Internal hernia accounts for 4.1% of SBOs.10 It is a common sur-gical emergency that requires early diagnosis and prompt treat-ment to avoid the high mortality rate associated with thiscondition (approximately 50%).11,12Because clinical diagnosis of internal hernias is difficult (lessthan 10% of symptomatic Meckel’s diverticula are diagnosedpreoperatively7), imaging studies may play an important role ifaccurate and reliable CT findings can be obtained. However,owing to the lack of extensive evaluation of CT findings in theradiological literature, the diagnosis of internal hernia with CTscan is still a challenge for the radiologist. The main CT findingof internal hernias include evidence of SBO; configuration of theobstructed loop, mesenteric changes and enhancement patternsof the bowel wall should be investigated accurately.Figure 1. (a) Coronal reconstruction; (b) sagittal MIP recon-struction; (c) volume rendering parasagittal view; (d) obliqueMIP reconstruction; (e) curved reconstruction; (f) volumerendering paracoronal view. Coronal reconstruction (a) ofcontrast-enhanced CT scan shows diffuse small intestine dila-tation (asterisk) with multiple air–fluid levels. The transitionpoint between the distended and the collapsed bowel loops islocated at the level of a fibrous connection between the MD(arrow) and the anterior abdominal wall. A cluster of collapsedbowel loops (arrowheads; b, c, d and f) herniated throughoutthis orifice (circles in b, c, d and f) and configuring an internalhernia is also clearly visible. Figure (e) represents a curvedreconstruction that shows the origin the MD from the ileal anti-mesenteric border (arrow). MD, Meckel’s diverticulum; MIP,maximum intensity projection.badef cFigure 2. Laparoscopic exploration by 30°, 5-mm laparoscoperevealed distension of the small bowel (a). In (b) laparoscopicview of focus of the bowel obstruction is reported. The ileumwas incarcerated inside the hernia orifice between the MD (M)and the abdominal wall. (c) Serosal surface of a 5.6cm MD (M)located on the antimesenteric side of the ileum was revealed.The fibrous band (arrowhead) is also clearly visible. In (c) and(d) the surgical procedure is reported: the fibrous bandwas released, the incarcerated bowel was normalized and theMD was sectioned by a laparoscopic linear stapler. MD, Meck-el’s diverticulum.badcBJR|case reports Bellini et al2 of 3 birpublications.org/bjrcr BJR Case Rep;2:20150131In conclusion, it is well known that CT is a valuable imag-ing modality for the detection and characterization of SBO.Sometimes is difficult to identify a trigger point and an MDas the trigger point13 is an uncommon cause to be takeninto account.LEARNING POINTSA MD, despite its rarity, can be the leading point of an internalhernia associated with SBO. This condition should be takeninto account and investigated because an early diagnosis andprompt surgery are crucial to prevent the sudden deteriorationof patient’s vital signs. Performing MDCT with the appropriatetechnique and reporting of the results by a radiologist skilledin abdominal imaging is the best way to make the diagnosis.CONSENTWritten informed consent was obtained from the patient forpublication of this case report, including accompanying images.REFERENCES1. Moore TC. Omphalomesenteric ductmalformations. Semin Pediatr Surg 1996; 5:116–23.2. Bauer SB, Retik AB. Urachal anomalies andrelated umbilical disorders. Urol Clin NorthAm 1978; 5: 195–211.3. Meckel JF, . Uber die divertikel amdarmkanal. Arch Physiol 1809;9: 421–53.4. Levy AD, Hobbs CM. Meckel diverticulum:radiologic features with pathologiccorrelation. Radiographics 2004; 24: 565–87.doi: 10.1148/rg.2420351875. Yahchouchy E, Marano AF, Etienne JC,Fingerhut AL. Meckel’s diverticulum. J AmColl Surg 2001; 192: 658–62.6. Mackey WC, Dineen P. A fifty yearexperience with Meckel’s diverticulum. SurgGynecol Obstet 1983; 156: 56–64.7. Ymaguchi M, Takeuchi S, Awazu S. Meckel’sdiverticulum. Investigation of 600 patients inJapanese literature. Am J Surg 1978; 136:247–9.8. Dumper J, Mackenzie S, Mitchell P,Sutherland F, Quan ML, Mew D.Complications of Meckel’s diverticula inadults. Can J Surg 2006; 49: 353–7.9. Rutherford RB, Akers DR. Meckel’sdiverticulum: a review of 148 pediatricpatients, with special reference to the patternof bleeding and to mesodiverticular vascularbands. Surgery 1966; 59: 618–26.10. Takeyama N, Gokan T, Ohgiya Y, Satoh S,Hashizume T, Hataya K, et al. CT of internalHernias. Radiographics 2005; 25: 997–1015.doi: 10.1148/rg.25404503511. Martin LC, Merkle EM, ThompsonWM.Review of internal hernias: radiographic andclinical findings. AJR Am J Roentgenol 2006;186: 703–17. doi: 10.2214/AJR.05.064412. Cheadle WG, Garr EE, Richardson JD. Theimportance of early diagnosis of small bowelobstruction. Am Surg 1988; 54: 565–9.13. Rossi P, Gourtsoyiannis N, Bezzi M,Raptopoulos V, Massa R, Capanna G, et al.Meckel’s diverticulum: imaging diagnosis.AJR Am J Roentgenol 1996; 166: 567–73. doi:10.2214/ajr.166.3.8623629Case report: A Meckel's diverticulum complicated by internal hernia—CT diagnosis BJR|case reports3 of 3 birpublications.org/bjrcr BJR Case Rep;2:20150131

CT diagnosis of small bowel obstruction caused by internal hernia from persistent attachment of a Meckel's diverticulum to the umbilicus by the obliterated omphalomesenteric duct

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CT diagnosis of small bowel obstruction caused by internal hernia from persistent attachment of a Meckel's diverticulum to the umbilicus by the obliterated omphalomesenteric duct

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