Presentation
3 days of diffuse abdominal pain and vomiting. BNO for 3 days.
Patient Data
Multiple distal fluid filled small bowel loops with no obvious transition point. Submucosal edema within the distal bowel loops within the right lower quadrant. Focal blind-ending outpouching at the anti-mesenteric side of a distal small bowel loop is concerning for a Meckel's diverticulum. Adjacent mesenteric free fluid and fat stranding within the right iliac fossa region. No free gas. Foreign body in the lumen of the distal small bowel has the form of a tooth. Multiple small local regional mesenteric lymph nodes likely reactive.
Collapsed large bowel. Uncomplicated diverticular disease of the large bowel with no evidence of acute diverticulitis. Normal appearance of the appendix.
Normal enhancement of the liver parenchyma with no solid liver lesions. Hepatic and portal veins opacify normally. Normal appearance of the gallbladder with no biliary tree dilation. Normal appearance of the pancreas, adrenal glands, spleen and kidneys. No hydronephrosis. Small renal cyst within the right kidney.
Normal opacification of the intra abdominal vessels with mild calcified atheromatous disease of the abdominal aorta. Normal appearance of the pelvic structures.
No destructive bony changes. Features of bilateral sacroiliitis. Lung bases are clear.
Impression
Meckel's diverticulitis, no evidence of free gas
foreign body (molar) tooth in the terminal ileum approximately 5 cm from the ileocecal valve with surrounding granulation tissue and focal luminal narrowing of the terminal ileum. Possible distal SBO due to the luminal foreign body
The patient underwent laparoscopy with the following surgical report:
Indication: SBO, pre-op CT scan demonstrated ? foreign body and Meckel's diverticulum
Findings: Meckel's diverticulum with local ? perforation approximately 30cm from IC valve. A segment of small bowel 10cm distal to the Meckel's diverticulum was inflamed with fat wrapping consistent with Crohn disease. The distal small bowel was thickened and difficult to palpate any foreign body. The remainder of the bowel was normal.
Procedure: Final check, supine, GA, ABs, TEDS/ SCDs 1cm infraumbilical hassan's 5mm ports x 2
Findings as above
Decision to proceed with Meckel's resection and limited ileocolic resection. A linear stapler was used to resect the Meckel's from the anti-mesenteric border of the small bowel. The staple line was oversewn and the lumen was widely patent. An ileocolic resection was performed incorporating the distal diseased 20cm of terminal ileum (no diseased small bowel remained). The right colon was mobilized from the retroperitoneum with diathermy. The duodenum was visualized and preseved. The ligasure impact was used for non-oncological division of the mesentery. The ileocolic vessels were ligated with sutures close to the bowel. Only the distal 10cm of cecum was resected (most of ascending colon left in situ). A stapled, side-to-side ileocolic anastomosis was fashioned. Crotch stitch and staple line were oversewn with 3-0 PDS. Wash. Rectus catheters.
Case Discussion
Interesting case for several reasons:
Meckel's diverticulitis with no free gas on CT but possible perforation found in surgery
distal ileal obstruction due to luminal FB (that looks like a tooth)
no FB identified in surgery
first diagnosis of active Crohn disease
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