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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 89-91

Internal herniation of Meckel's diverticulum through meso-appendix in infant: An extremely rare occurrence


Department of Pediatric Surgery, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication22-Dec-2015

Correspondence Address:
Md. Hadiuzzaman
Department of Pediatric Surgery, Nil Ratan Sircar Medical College and Hospital, 138 AJC Bose Road, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.172404

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  Abstract 

Intestinal obstruction due to internal herniation is rare. There is only 0.5–5.8% of incidence described in the available literature. In infancy, it is rarer. Internal herniation of Meckel's diverticulum through meso-appendix in an infant is an extremely rare emergency situation, and probably the first case to be reported in the literature.

Keywords: Infant, internal herniation, Meckel's diverticulum, meso-appendix


How to cite this article:
Barman S, Md. Hadiuzzaman, Ray S, Sarkar R. Internal herniation of Meckel's diverticulum through meso-appendix in infant: An extremely rare occurrence. CHRISMED J Health Res 2016;3:89-91

How to cite this URL:
Barman S, Md. Hadiuzzaman, Ray S, Sarkar R. Internal herniation of Meckel's diverticulum through meso-appendix in infant: An extremely rare occurrence. CHRISMED J Health Res [serial online] 2016 [cited 2019 Oct 19];3:89-91. Available from: http://www.cjhr.org/text.asp?2016/3/1/89/172404


  Introduction Top


Intestinal obstruction in pediatric age group is a common emergency situation. It has a wide spectrum of pathology. Obstruction due to internal herniation is rare, and only 0.5–5.8% in an adult is reported in the literature.[1] In pediatric age, it is sparse. Internal herniation through meso-appendix is uncommon, and only one case is reported in an adult until now.[2] Internal herniation of Meckel's diverticulum through meso-appendix in infant is an extremely rare emergency situation. The uniqueness of this case hence prompts us to report in the literature.


  Case Report Top


A 5-month-old male infant presented at emergency with an abdominal distention and constipation for 3 days. On examination, the patient was tachypoenic with a feeble pulse, dehydrated, and febrile. His urine output was scanty. Abdominal examination revealed the features of small bowel obstruction with visible bowel loops. The rectum was empty on digital rectal examination. Straight X-ray abdomen in erect posture showed the classical multiple air-fluid levels suggestive of small bowel obstruction [Figure 1]. Complete hemogram and serum electrolytes were normal except mild pallor. Immediately, after admission the patient was resuscitated with intravenous (IV) fluid, IV antibiotics. The patient was shifted to the operation theater for emergency exploration after initial stabilization. On exploration, it was found that Meckel's diverticulum herniated through a gap in the meso-appendix and adhered to the ascending colon, against which small bowel was twisted and obstructed [Figure 1]. The reduction of internal hernia was done after adhesiolysis [Figure 2]. Excision of Meckel's diverticulum along with adjacent ileum with end-to-end anastomoses along with the closure of the defect in the meso-appendix was done with absorbable polyglactin suture. Gut viability was checked, and the abdomen was closed. Postoperative period was uneventful, and the patient was discharged home on the 5th postoperative day. In a follow-up, the patient was doing well without any complications.
Figure 1: Intra-operative photograph showing tip of the Meckel's diverticulum herniated through meso-appendix (directed with hemostat forceps) (TI: Terminal ileum, IC J: Ileo-caecal junction, and C: Caecum)

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Figure 2: Intra-operative photograph showing the Meckel's diverticulum after reduction

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  Discussion Top


Internal herniation (IH) is a rare cause of acute intestinal obstruction; approximately 0.5–5.8% is reported in the literature.[1] It is defined as herniation of viscera through a normal or abnormal aperture within the peritoneal cavity. It usually presented with nonspecific symptoms such as pain abdomen, vomiting, etc., However, occasionally gangrenous changes may lead to the fatal outcome with very high mortality nearly 50%.[1] The autopsy incidence of IH is 0.2–2%.[3]

Congenital IH are classified according to their locations; (a) foramen of Winslow, (b) paraduodenal, (c) pericecal, (d) transmesenteric, (e) transomental, and (f) intersigmoid hernias. Paraduodenal and transmesenteric hernias are most commonly seen in children.[4] Tang et al., suggested that transmesenteric hernia was the most common type in older children as well as in neonates, whereas paraduodenal hernia was commonly found in adults.

The first case of transmesenteric hernia was reported by Marsh. IH through meso-appendixin children has not been reported in the available literature until now. James et al. reported only a single-case of IH through meso-appendix in an 80-year-old female patient. Defects in the mesentery are commonly found near the ligament of Treitz or the ileocecal valve.[2] They may be single or multiple and vary in size. Severity of the symptoms and progression of the disease depends on the size of the defect. A high index of suspicion is necessary to diagnose preoperatively. The diagnosis is usually established at the time of exploration.

Meckel's diverticulum (MD), the most common congenital anomaly of the gastrointestinal (GI) tract (2–3%), is an embryonic remnant of the vitelline duct and normally disappears by the 7th week of gestation. It is usually asymptomatic and often an incidental finding at laparotomy. Symptoms arise when there are associated complications such as GI bleeding, bowel obstruction, etc. IH of MD causing the bowel obstruction is a rare phenomenon and sparsely reported, but IH of MD through a congenital defect in meso-appendix in children is extremely rare.

Straight X-ray abdomen usually identifies the dilated bowel loops with air-fluid levels. Ultrasonography may suggest MD but often fails to detect IH. Computed tomography (CT) is usually the gold standard imaging modality for intestinal obstruction; however, identifying MD as the cause can be extremely difficult.

Multidetector CT (MDCT) with high spatial resolution and isotropic multiplanar reconstruction images have demonstrated MD included in hernias. The technetium-99 m pertechnetate scan in children has a sensitivity of 80–90%, a specificity of 95%, and an accuracy of 90%. If there is a complicated MD from the clinical or radiological suggestion, the Meckel's scan is the most accurate noninvasive investigation to perform.[5]


  Conclusion Top


Internal herniation of Meckel's diverticulum is a rare finding but should always be kept in mind during the treatment of small bowel obstruction in children. CT scan can be done preoperatively in a stable patient, but laparotomy often establishes the diagnosis. Early exploration after initial stabilization will help avoid potential life threatening complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cazejust J, Lafont C, Raynal M, Azizi L, Tourabi AC, Menu Y. Internal hernia through the omental foramen. Answer to the e-quid “Epigastric pain with sudden onset”. DiagnInterv Imaging 2013;94:663-6.  Back to cited text no. 1
    
2.
Rooney JA, Carroll JP, Keeley JL. Internal hernias due to defects in the meso-appendix and mesentery of srnall bowel and probableIvemark syndrome: Report of two cases. Ann Surg 1963;157:254-8.  Back to cited text no. 2
    
3.
Zissin R, Hertz M, Gayer G, Paran H, Osadchy A. Congenital internal hernia as a cause of small bowel obstruction: CT findings in 11 adult patients. Br J Radiol 2005;78:796-802.  Back to cited text no. 3
    
4.
Jain SK, Kaza RC, Garg PK. Incidental congenital transmesenteric hernia in an adult. Eur Rev Med PharmacolSci 2011;15:461-2.  Back to cited text no. 4
    
5.
Jain V, Sahi S. A rare fatal case of internal hernia caused by Meckel's diverticulum in a paediatric patient. Open J Pediatr 2011;1:17-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
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