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Image of the Month—Diagnosis
Arch Surg. 2007;142(5):486.
Answer: Internal Hernia
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In the left iliac fossa, a Meckel diverticulum was identified. Its tip was adherent to the retroperitoneum. A segment of terminal ileum had herniated through the loop formed by the diverticulum, retroperitoneum, and adjacent bowel. Subsequently, it had become incarcerated and obstructed, resulting in gross dilation of the proximal small bowel. The Meckel diverticulum itself had perforated at its base. The affected segment of ileum was resected with the perforated Meckel diverticulum. Histological analysis confirmed the diagnosis of Meckel diverticulum containing ectopic gastric mucosa. The peritoneal cavity was thoroughly irrigated. Finally, a temporary double-barrel ileostomy was made. The patient had a good and uneventful recovery.
Meckel diverticulum is the most common congenital gastrointestinal malformation; it is found in up to 2% of the population.1 It is the remnant of the vitellointestinal tract, which disappears in the fifth to sixth week of gestation. The diverticulum is classically located 2 ft (60 cm) from the ileocecal junction along the antimesenteric border and is 2 inches (5 cm)2 long. One large retrospective study3 found that 84% of diverticula were asymptomatic. Of the 16% that were symptomatic, the commonest presentations were diverticulitis, bleeding, and perforation.3 It has also been reported that the Meckel diverticulum may present as a focus for intussusception or a volvulus, thus causing obstruction.3 This particular case in which a Meckel diverticulum has caused obstruction and perforation as a result of internal herniation of the bowel through a loop formed by the diverticulum and the retroperitoneum is most unusual. To our knowledge, there are very few cases of this in the literature. We believe it to be only the second documented case of its kind in the adult population.4 In this case, the pathological abnormality arose predominantly as a result of the adhesions created following this patient's appendicitis 4 years previously. It is important to remember that adhesive disease of the peritoneal cavity, following surgery, or inflammation may complicate the presentation of Meckel diverticula.
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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.
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AUTHOR INFORMATION
Correspondence: Chika Edward Uzoigwe, MRCS, Department of Surgery, Bradford Royal Infirmary, Bradford, Yorkshire, BD9 6RJ, England (chika{at}doctors.org.uk).
Accepted for Publication: April 19, 2006.
Author Contributions: Study concept and design: Uzoigwe, Bitra, Munot, Griffith, and Davies. Acquisition of data: Uzoigwe, Bitra, Munot, Griffith, and Davies. Analysis and interpretation of data: Uzoigwe, Bitra, Munot, Griffith, and Davies. Drafting of the manuscript: Uzoigwe, Bitra, and Munot. Critical revision of the manuscript for important intellectual content: Munot, Griffith, and Davies. Administrative, technical, and material support: Uzoigwe, Bitra, Munot, Griffith, and Davies. Study supervision: Munot, Griffith, and Davies.
Financial Disclosure: None reported.
REFERENCES
1. Peoples JB, Lichtenberger EJ, Dunn MM. Incidental Meckel's diverticulectomy in adults. Surgery. 1995;118:649-652.
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2. Jay GD III, Margulis RR, McGraw AB, Northrip RR. Meckel's diverticulum: a survey of 103 cases. Arch Surg. 1950;61:158-169.
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3. Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002). Ann Surg. 2005;241:529-533.
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4. Dalinka MK, Wunder JF, Wolfe RD. Internal hernia through the mesentery of a Meckel's diverticulum. Radiology. 1970;95:39-40.
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SECTION EDITOR: GRACE S. ROZYCKI, MD
RELATED ARTICLE
Image of the Month—Quiz Case
Chika Edward Uzoigwe, Krishna Bitra, Kailas Munot, John P. Griffith, and Justin B. Davies
Arch Surg. 2007;142(5):485.
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