Revisiting the forgotten remnant: Imaging spectrum of Meckel's diverticulum

SA Journal of Radiology ISSN: (Online) 2078-6778, (Print) 1027-202X Page 1 of 6 Case Series Revisiting the forgotten remnant: Imaging spectrum of Meckel’s diverticulum Authors: Manish Kumar1 Priya Singh1 Priti Kumari2 Rohit Kaushik3 Affiliations: 1 Department of Radiodiagnosis, Mayo Institute of Medical Science, Barabanki, India Department of Radiodiagnosis, BPS Government Medical College for Women, Sonepat, India 2 Department of Radiodiagnosis, House of Diagnostics, New Delhi, India Meckel’s diverticulum is a true diverticulum of the alimentary tract occurring resulting from the persistence of remnants of the vitello-intestinal duct. They are often asymptomatic and incidentally diagnosed during surgery. Complications such as intestinal obstruction, diverticulitis, intestinal haemorrhage and perforation may occur with Meckel’s diverticulum, which renders them symptomatic. The clinical and imaging diagnosis of Meckel’s diverticulum is very challenging. As a result of the rare occurrence of complicated Meckel’s diverticulum and the difficult preoperative diagnosis, knowledge of its imaging features is limited. The presented case series describes a spectrum of complications caused by Meckel’s diverticulum and its CT imaging features. It highlights the importance of a high clinical suspicion by carefully searching for a Meckel’s diverticulum on CT in its characteristic location to avoid missing it preoperatively. Keywords: Meckel’s diverticulum; computed tomography; imaging; complications; Meckel’s acute abdomen. 3 Corresponding author: Priya Singh, singhpriya2861990@gmail. com Dates: Received: 05 Mar. 2022 Accepted: 11 Apr. 2022 Published: 19 July 2022 How to cite this article: Kumar M, Singh P, Kumari P, Kaushik R. Revisiting the forgotten remnant: Imaging spectrum of Meckel’s diverticulum. S Afr J Rad. 2022;26(1), a2431. https://doi.org/10.4102/sajr. v26i1.2431 Copyright: © 2022. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. Introduction Meckel’s diverticulum (MD) is the commonest structural congenital anomaly of the gastrointestinal tract. It is part of the spectrum of abnormalities that occur because of the persistence of remnants of the vitellointestinal duct. It is a true diverticulum of the alimentary tract consisting of all layers of the intestinal wall and lined by normal intestinal mucosa, which frequently contains heterotopic gastric or pancreatic mucosa.1 The incidence of MD is about 2% – 3% in the population with a similar occurrence in both sexes; however, it often becomes symptomatic in males. Although it is mainly asymptomatic, a myriad of complications may develop with a lifetime risk of about 4.2% – 6.4%.2 The common complications include intestinal obstruction, diverticulitis, intestinal haemorrhage and perforation. Thus, knowledge of the embryology, anatomy, clinical presentation and diverse complications is of paramount importance. The diagnosis of MD and its related complications is often challenging to establish preoperatively. However, identification of MD and its various complications can be reliably achieved with improved CT scan techniques. Case presentations Case 1 A 25-year-old man presented with complaints of left lower abdominal pain radiating to the back. On ultrasound, multiple renal calculi were present in the left kidney with mild hydronephrosis. A contrast enhanced CT (CECT) and urography were performed for further evaluation, confirming left lower ureteric and left renal calculi with mild left hydronephrosis. In addition, a tubular diverticulum was seen arising from the antimesenteric border of the distal ileum, just proximal to the ileocecal junction (Figure 1). A diagnosis of incidentally diagnosed MD was made. The patient was treated for ureteric calculi and as the MD was asymptomatic, no surgical treatment was performed and follow-up was advised. Case 2 Read online: Scan this QR code with your smart phone or mobile device to read online. A 30-year-old man presented with abdominal distension, vomiting and obstipation for three days. On ultrasound, the small bowel loops were dilated and fluid-filled, with to and fro movements. An erect abdominal X-ray demonstrated dilated central bowel loops with multiple air-fluid levels suggestive of small bowel obstruction. The CECT abdomen revealed small bowel http://www.sajr.org.za Open Access Page 2 of 6 Case Series a b FIGURE 1: Contrast enhanced computed tomography in the coronal (a) and sagittal (b) planes demonstrating a tubular, blind-ending structure arising from antimesenteric border of the distal ileum with enhancing walls, suggestive of Meckel’s diverticulum (white arrows). No abnormal wall thickening or surrounding fat inflammation was present. a c b d FIGURE 2: X-ray abdomen (a) erect anteroposterior view shows dilated gas-filled bowel loops with multiple air-fluid levels. Contrast enhanced computed tomography in the axial (b) and coronal (c, d) planes shows dilated small bowel loops with an inflamed Meckel’s diverticulum (white arrows) arising at the level of the transition point. Case 3 A 36-year-old male presented with right lower quadrant and periumbilical abdominal pain for 1 month. Ultrasound of abdomen was within normal limits. Contrast enhanced CT abdomen revealed the presence of a MD with thickened, enhancing walls associated with inflammatory changes in the adjacent fat (Figure 4). The normal appendix was identified separately on CT, resulting in a diagnosis of Meckel’s diverticulitis. The patient underwent laparoscopically assisted trans-umbilical Meckel’s diverticulectomy. Histopathology confirmed the imaging diagnosis. FIGURE 3: Intraoperative image demonstrated the inflamed Meckel’s diverticulum (white arrow) causing a stricture of the distal ileum resulting in intestinal obstruction. dilatation with multiple fluid levels and a transition point at the level of the distal ileum. A tubular blind-ended structure arising from the antimesenteric border was seen at the transition point (Figure 2). The diagnosis of a MD causing small bowel obstruction was made on imaging. The patient immediately proceeded to laparotomy, where an inflamed MD was found, causing a stricture in the adjoining distal ileum (Figure 3). Surgical resection of the MD and small bowel was performed. http://www.sajr.org.za Case 4 A 40-year-old male patient presented with complaints of acute severe abdominal pain and swelling predominately towards the right side, associated with fever and obstipation. His general examination revealed marked tenderness of the abdomen, guarding and rigidity, raising the suspicion of perforation with peritonitis. An erect plain X-ray abdomen revealed free air under the diaphragm. An urgent CECT abdomen was performed, which indicated an inflamed perforated MD arising from the distal ileum with free extraluminal air (Figure 5). Surrounding Open Access Page 3 of 6 Case Series a b c FIGURE 4 (...truncated)