Meckel's Diverticulum Perforation by Foreign Body: A Case Report

Introduction

Meckel’s diverticulum (MD) occurs in 2.2% of the population, representing the most common gastrointestinal congenital anomaly [1, 2]. It is more symptomatic in men, even though the prevalence is similar in male and female patients [1]. MD is a true, short diverticulum with a wide base, composed by the three intestinal layers, it results from a failure in the obliteration and absorption of the omphalomesenteric duct (vitelline), which occurs normally between the sixth and eighth weeks of gestation [1, 2]. It is located in the antimesenteric border of the small intestine at a distance that can vary between 40-100 cm from the ileocecal valve [3]. In its lumen, there is usually the presence of heterotopic mucosa: gastric (60-85%) or pancreatic (5-16%) [1, 3, 4]. 

Less than 2% of patients with MD experience abdominal pain in the right lower quadrant in the first 2 years of life [4] and, afterwards, they become asymptomatic. However, throughout life, complications may arise in 4-40% of cases [5]. The most common complications are inflammation, obstruction and hemorrhage [1]. Perforation cases are rarer and occur secondary to gangrene, inflammation, intestinal obstruction, peptic ulcer or foreign body ingestion (which represents only 5% of these complications) [5, 6].

We present a rare case of MD perforation due to ingestion of chicken bone in a young patient that had an appendicitis-mimicking presentation. Currently only 8 other cases of MD perforation by chicken bone have been described in the current medical literature [1, 4, 7-12].

Case Report

A 24-year-old white man with mild obesity (BMI=33 Kg/m²) presented to the Polydoro Ernani São Thiago University Hospital Emergency Department with periumbilical pain for 2 days, that shifted to the right lower quadrant in the last 24 hours, associated with nausea and 38°C (100.4°F) measured fever. On the first day of the clinical history, he reported having evacuated soft stools on 2 occasions, however, with no signs of blood or mucus. On physical examination, he was in good general condition, hydrated and ruddy, with stable vital signs and with no neurological changes. His abdomen was flat, with global airborne sounds, but painful on palpation in the right flank and lower right quadrant regions, associated with the positive Blumberg sign. Laboratory tests showed leukocytosis (17,470 leukocytes/mm³ without left shift) and elevated C-reactive protein. Abdominal and chest radiographs did not show any noteworthy changes.

Due to strong acute appendicitis clinical suspicion, reinforced by laboratory changes, laparotomy was indicated. McBurney incision was made and the abdominal wall was opened by planes. In the cavity inspection, a retroileal cecal appendix was identified without apparent inflammation signs. However, there was found a small amount of purulent liquid in the peritoneal cavity and a progressive evaluation of the intestinal loops followed 40 cm distant from the appendice, a perforated MD due to a chicken bone (with an approximate length of 5.5 cm) was identified, associated with the presence of fibrin and local phlogosis (Figures 1 and 2).

Fig. 1. MD on the antimesenteric border, 40cm from the ileocecal valve.

Fig. 2. MD wall perforated by chicken bone.

Incidental appendectomy and perforated MD excision with segmental enterectomy (4 cm margin on each side of the diverticulum) (Figure 3) were performed along with posterior end-to-end manual enteroanastomosis, using continuous extramucosal suture with PDS 3.0 thread. Finally, the cavity was cleaned with heated saline and the abdominal wall closed by planes with non-absorbable threads.

Fig. 3. Surgical specimens - enteric segment with resected perforated MD, cecal appendix and 5.5 cm chicken bone.

After surgery, the patient was informed about the intraoperative finding (intestinal perforation by chicken bone) and he reported that he ate roasted chicken 3 days before the onset of his symptoms, without having initially related to his condition. In the postoperative period, at the hospital ward, he was given antibiotic therapy (ciprofloxacin and metronidazole) and analgesics. Despite initially evolving with postoperative ileus, due to lack of ambulation and initial deficit in the amount of analgesics administered, after correction of analgesia, constant stimulation for ambulation and administration of antiphysetic medication (simethicone), he presented with acceptance of oral diet on the 4th postoperative day (PO), being discharged on the 5th PO. Painkillers and antibiotic supplementation (until 7th PO) were prescribed to be taken at home. Afterwards, he returned to an outpatient consult on the 14th PO, not referring any complications, with subsequent outpatient discharge after the result of the anatomopathological examination. It confirmed the presence of Meckel’s diverticulum associated with inflammatory changes of a predominantly acute character, transmural, with abscess formation, acute fibrino-leucocytic serositis, with absence of heterotopic mucosa and free surgical margins, after perforation by foreign body. The cecal appendix showed only reactive lymphoid hyperplasia. 

Discussion

It is known that less than 1% of ingested foreign bodies perforate the gastrointestinal tract and that, of all these, only 1.6% occur in MD [1]. From the complications that can affect MD, foreign body perforation is the rarest [6], and, as in this report, it can mimic acute appendicitis. This might lead to an incorrect diagnosis, considering that patients rarely remember the previous ingestion of a potential foreign body, as it happened in our case [1, 4, 13]. In this case report, the clinical signs strongly suggestive of acute appendicitis (history of periumbilical pain with migration to the right iliac region, associated with low fever and positive Blumberg’s sign) were also found [14]. However, during the intraoperative, no inflammatory process was found in the cecal appendix, and the surgical team correctly proceeded with the expansion of the cavity inspection, that showed a MD perforated by a chicken bone in the small intestine. This is a rare finding, as it is the 9th case described in the medical literature [1, 4, 7, 8-12].

Studies point out the difficulty in diagnosing MD in the preoperative period, due to the absence of symptoms and specific radiological signs [4, 13]. However, a special attention is needed to the differential diagnosis acute abdomen, especially those that suggest acute appendicitis, particularly in men, for the possibility of presence of MD’s complications (perforation, among others), as described in this case report [1, 15].

Besides performing complementary serum, urinary and preoperative imaging tests (ultrasound and abdominal computed tomography), it is necessary to collect a detailed clinical history in cases of acute abdomen with possible surgical approach. In addition, it is also important to always try to expand the cavity inventory in the intraoperative period, especially in the absence of explanations for the previous clinical findings, with mandatory assessment of the small intestine from the ileocecal valve for, at least, the first 100 cm, in order to find a MD and its possible complications [3, 5, 15].

Conflict of Interest: None declared.