P2665 - The Complicated Rule of Two’s in an Adult: Meckel’s Diverticulum Incarcerated in a Volvulus Internal Hernia

Shivaan Oomrigar, MD, Elvis Caraballo Antonio, MD, Jennifer Lara, DO, Yailier Gomez Torres, MD, Enny Cancio, MD
HCA Florida Kendall Hospital, Miami, FL

Introduction: Meckel’s diverticulum (MD) is one of the most common congenital gastrointestinal anomalies, with symptoms typically manifesting in young patients. However, this anomaly is rarely diagnosed in adults.

Case Description/Methods: A 47-year-old male presented with lower abdominal pain associated with nausea, bilious emesis and mild leukocytosis. Abdominal CT revealed dilated loops of small bowel with a transition point, significant vascular engorgement, inflammatory changes in the suprapubic mesentery, concerning for a small bowel obstruction. Small bowel series demonstrated no colonic transit of contrast, concerning for a high-grade obstruction. Despite conservative therapy, the patient continued to deteriorate with large volume emesis and bilious nasogastric output. An emergent mini-laparotomy demonstrated hyperemic, dusky and dilated small bowel. Careful dissection revealed a diverticulum band 15 cm from the ileocecal valve causing a volvulized internal hernia of the distal ileum. Surgical intervention included a diverticulectomy with a short segment small bowel enterectomy with primary anastomosis. Post-operatively, the patient developed severe ileus resulting in continued bilious nasogastric output, eventually requiring total parental nutrition for seven days. The patient began to improve, resulting in discharge on post-operative day ten. Histopathology confirmed the anatomical anomaly of MD.

Discussion: MD is a true diverticulum involving all layers of the intestinal wall that develops in the embryonic stage. The common ‘rule of two’ denotes that MD occur in 2% of the population, within 2 feet of the ileocecal valve and are approximately 2 inches long². Up to 36.5% of symptomatic adults develop intestinal obstruction as a complication, including small intestinal volvulus around the diverticula band, as demonstrated in this case¹. This case demonstrates a small bowel obstruction that failed conservative therapy and progressed to an acute abdomen leading to surgical intervention. Due to the rare presentation, MD should be promptly managed intra-operatively to avoid the challenging complications.
Blouhos K, et al. Meckel's Diverticulum in Adults: Surgical Concerns. Front Surg. 2018 Sep 3;5:55. doi: 10.3389/fsurg.2018.00055. PMID: 30234126; PMCID: PMC6129587.
Higginson AP, Hall RI. Meckel's diverticulitis due to an obstructing enterolith: ultrasound and CT appearances. Clin Radiol. 2001 Jul;56(7):593-5. doi: 10.1053/crad.2000.0702. PMID: 11446760.


Disclosures:


Shivaan Oomrigar, MD, Elvis Caraballo Antonio, MD, Jennifer Lara, DO, Yailier Gomez Torres, MD, Enny Cancio, MD. P2665 - The Complicated Rule of Two’s in an Adult: Meckel’s Diverticulum Incarcerated in a Volvulus Internal Hernia, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.