Meckel's

J.R. SAUNDERS, M.P. GRIFFITHS and S.S. KADIRKAMANATHAN
Homerton Hospital, Homerton, London, UK

Dual perforation of the gastrointestinal tract is rare. We present a case of a patient who presented with a simultaneous perforation of a Meckel’s diverticulum and a duodenal ulcer.

Dual perforation of the gastrointestinal tract due to separate pathology is rare. Here we present a case of a perforation of a Meckel’s diverticulum with synchronous perforation of a duodenal ulcer.

A 21-year-old male with Down’s syndrome presented with a two day history of generalised abdominal pain accompanied by vomiting on the second day. There was no haematemesis or melaena or history of non-steroidal anti-inflammatory drug ingestion. On examination, the patient was in extreme pain, febrile and tachycardic. His abdomen was diffusely tender and rigid with loss of liver dullness on percussion and absent bowel sounds. Investigations revealed a normal haemoglobin level and a moderate neutrophil leucocytosis. Blood biochemistry was within normal limits. A chest radiograph revealed free gas under the right hemidiaphragm (Figure 1). A presumptive diagnosis of a perforated duodenal ulcer was made and the patient was resuscitated and taken to theatre for a laparotomy.

At laparotomy, there was free gas and bile stained fluid. An anterior perforated ulcer was present in the first part of the duodenum but there was also an inflamed Meckel’s diverticulum with a perforation at the base (Figure 2). The ulcer was oversewn with an omental patch and the Meckel’s diverticulum was excised in a segmental resection of the ileum using a GIA 60 to fashion an isoperistalic side-to-side anastomosis. Copious peritoneal washout was followed by subhepatic and pelvic drainage. His recovery was uncomplicated apart from a minor wound infection.

Histology revealed the presence of chronically inflamed gastric mucosa in the Meckel’s diverticulum.

A Meckel’s diverticulum is the commonest congenital gastrointestinal anomaly and owes its name and description to Johaan Friedrich Meckel.¹ It is a true diverticulum (consisting of all intestinal layers) and is due to the persistence of the vitellointestinal duct. It is present in approximately two percent of the population with a male: female ratio of 2:1 and approximately 20% may contain ectopic gastric mucosa.² It is thought that four percent of people with this anomaly develop complications, which include obstruction, haemorrhage, inflammation, perforation, neoplasia and Littre’s hernia.³

Ectopic gastric mucosa can cause inflammation and ulceration in the base of the diverticulum or in the adjacent ileal mucosa. This can on occasion cause perforation - as in this case. We believe that a stress ulcer formed and perforated in response to the presence of the inflamed Meckel’s diverticulum.

There are other causes for multiple perforations of the bowel due to a single pathology such as typhoid fever, tuberculosis or non-Hodgkin’s lymphoma.⁴ A rare cause of perforation of two regions of the gastrointestinal tract is Degos’ disease (malignant atrophic papulosis), a rare form of arteritis.⁵ However, we believe that we are the first to report such a combination of conditions causing perforation in the proximal and distal end of the small bowel.

Figure 2: Perforation demonstrated at the base of the Meckel’s diverticulum. Tip held between thumb and forefinger of left hand

1. Meckel JF. Arch Physiol 1809; 9: 439-53
2. Mackey WC, Dineen PA. A 50-year experience with Meckel’s diverticulum. Surg Gynecol Obstet 1983; 156: 56-64
3. Leijonmarck CE, Bonman-Sandelin K, Frisell J, Raf L. Meckel’s diverticulum in the adult. Br J Surg 1986; 73: 146-9
4. Mechat F, Zerouali ON. Non-traumatic perforation of the small intestine. Journal de Chirugie 1993; 130: 292-6
5. Kanai M, Kandoh S, Kuruki H, Mukaiyama H, Mori K, Tanno T. A report of an atypical case of Degos’ disease with multiple perforations of the stomach and small intestine. Nippon Geka Gakkai Zasshi 1998; 89: 1127-31

Copyright date: 17th July 2001
Correspondence: J.R. Saunders, Academic Department of Surgery, St Bartholomew’s and the Royal London School of Medicine and Dentistry, London E1 1BB, UK E-mail: j.r.saunders@mds.qmw.ac.uk

Synchronous perforation of a Meckel’s diverticulum and a duodenal ulcer