Introduction

Meckel’s diverticulum is the most commonly occurring congenital anomaly of small bowel. It occurs due to incomplete obliteration of omphalomesenteric (vitelline) duct, a process which normally occurs during 5th week of embryonic development. It is a true intestinal diverticulum, containing all layers of normal intestine. The incidence of Meckel’s diverticulum ranged from 0.5 to 2% in an autopsy series.1

There are various complications associated with this diverticulum. In majority of studies they have been lower GI bleed, intussusception, simple obstruction, perforation, strangulation due to mesodiverticular band, diverticulitis, hernia, neoplasms and stone.2

Here we report a case of tuberculous perforation of Meckel’s diverticulum, a rare case scenario.

Case Report

Mr. H.P a 40 year old male chronic alcoholic presented to us with complaints of pain in abdomen, fever and vomiting for 3 days. There was history of tuberculosis in childhood for which patient had completed nine months of AKT then. There was no history to suggest diverticulitis in past as inquired postoperatively.

On admission patient was haemodynamically stable. Abdomen was guarded. X-ray chest revealed free gas under both domes of diaphragm. Patient was taken for urgent exploratory laparotomy. There was evidence of tuberculosis of terminal ileum for a length of two feet terminating one feet from ileocaecal junction in form of severe thickening of bowel. A perforation approximately 3 mm in diameter was seen on lateral aspect of Meckel’s diverticulum approximately one cm from its base. The Meckel’s diverticulum was approximately 3 cms long and 3 cms in diameter at its base (Fig. 1). Another perforation was visible in ileum one feet from Meckel’s diverticulum. There was mesenteric lymphadeno-pathy and around one litre of feculent contamination. A resection anastomosis of ileum including Meckel’s diverticulum was done.

Postoperatively patient was uneventfull till post operative day 21.He was on full diet and there was no evidence of leak. However patient succumbed to sudden cardiac arrest in wards. Postmortem examination could not reveal a cause of death. There was no evidence of leak from anastomotic site.

Histopathological examination revealed tuberculosis in Meckel’s diverticulum, ileal perforation and mesenteric lymphnode.

Discussion

Perforation of Meckel’s diverticulum leading to peritonitis is a not so well documented phenomenon.

Fig. 1 :Picture of tuberculous perforation of Meckel’s diverticulum.

It constitutes approximately 11% of all associated complications in one of the studies.2 However majority of studies revealed only a low incidence.3, 4 Majority of these perforations are caused by foreign bodies, followed in frequency by perforations due to ectopic gastric mucosa causing ulceration and subsequent perforation in diverticulum.5

There has been no case reported of tuberculous perforation of Meckel’s diverticulum. Our extensive literature has revealed only two cases of tuberculosis of Meckel’s diverticulum.6,7

75% of reported Meckel’s diverticulum are incidental finding during laparotomies performed for various reasons..9 Whether to perform a diverticulectomy for incidentally detected Meckel’s diverticulum is a question to think about.

In a study by Soltero et al, in a population of 1.4 millions over 15 years they found a complication rate of 4.2 per cent for Meckel’s diverticilum in infancy decreasing to 3% in adulthood and almost zero in old age.9 They reported a 9% complication rate with incidental diverticulectomy. This study opposes incidental diverticulectomy.

In another study by William et al, 16.9% of people were found to be symptomatic for diverticular disease.3 There was 8.8% mortality and 17.6% morbidity rates reported in this study. They also reported a 1.2 % complication rate and no morbidity attributed to diverticulectomy in series of 85 incidental diverticulectomy. They advise a routine incidental diverticulectomy. Patients younger than 40 years, diverticulum 2 cms or more in length and containing heterotopic mucosa were patients advisable for incidental diverticulectomy as inferred by this study. Michas et al also advise for a incidental diverticulectomy.10

References

1. Jay GD, Margulis RR, McGraw AR et al. Meckel’s diverticulum ; A survey of 103 cases. Arch Surg 1950; 61: 158–69.
2. Hiroki Kusumoto, Motofumi Yoshida, Ikuo Takahashi, et al. Complications and diagnosis of Meckel’s diverticulum in 776 patients. Am J Surg 1992; 164: 382-3.
3. William C, Peter MD. A fifty year experience with Meckel’s diverticulum. Surg Gynae and Obst 1983; 156: 56–64.
4. Williams RS. Management of Meckel’s diverticulum. Br J Surg 1981; 68 : 477–80.
5. Rosswick RP. Perforation of Meckel’s diverticulum by foreign bodies. Post Grad Med J 1965; 41 : 105-6.
6. Ian B MacDonald. Tuberculosis of Meckel’s diverticulum. Br J Surg 1947; 34 : 324–25.
7. Levin S. Tuberculosis of Meckel’s diverticulum. S Afr Med J 1950; 496-7.
8. Wienstein EC, Cain JC, Remine WH. Meckel’s diverticulum. JAMA 1962; 182 : 251–3.
9. Soltero MJ, Bill AH. The natural history of Meckels diverticulum and its relation to incidental removal. Am J Surg 1976; 132: 168-73.
10. Michas CA, Cohenn SE, Wolfman EF. Meckel’s diverticulum should it be excised incidentally at operation. Am J Surg 1975; 129 : 682–5.

*Resident; **Lecturer, Dept of General Surgery, Nair hospital, Mumbai.