Perforated Meckel diverticulum

Case contributed by Chris Witkowski
Diagnosis certain


Patient presented to the Emergency Department with severe lower abdominal pain which radiated to the groin, on a background of two days of generalized abdominal pain. Associated nausea and anorexia. Nil urinary or gynecologic symptoms. On examination, the patient was tachycardic with generalized severe abdominal tenderness with 'voluntary' guarding.

Patient Data

Age: 25 years
Gender: Female

Initial ultrasound to investigate for gynecological pathology failed to yield such findings, however, did demonstrate large volume free fluid throughout the pelvis and abdomen, presumed to be hemorrhage given its echogenicity. No source for the hemorrhage was identified.

CT angiogram of the abdomen was then undertaken to investigate the source of the presumed hemorrhage.

  • widespread free fluid and gas consistent with perforation of hollow viscus
  • site of perforation not definitively identifiable
  • likely site of perforation within multiple loops of thickened small bowel with adjacent gas locules, located in the left flank
  • non-specific mucosal enhancement of a small bowel loop within the pelvis in the midline

Case Discussion

The patient presentation was somewhat non-specific, with suspicion for a gynecologic or obstetric source for the patient's presentation. As such, when the patient's pain did not settle pelvic ultrasound was performed which demonstrated widespread free fluid, likely hemorrhage. It is important to note that blood tests were unremarkable at this time, in particular the B-hCG <1, strongly suggestive that the etiology was not obstetric in nature, such as ruptured ectopic pregnancy - a key differential in a patient of this demographic.

CT angiogram of the abdomen was then utilized which further demonstrated widespread free fluid and gas, with the source of the free fluid not definitely identified, however suspicion was raised by multiple loops of thickened small bowel.

The patient was then taken for urgent exploratory laparoscopy, subsequently converted to laparotomy on discovery of perforated Meckel diverticulum, with resection and washout.

The presumed perforated Meckel diverticulum was confirmed on histopathological analysis.

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