Open Journal of Pediatrics, 2011, 1, 17-19 OJPed
doi:10.4236/ojped 2011.12005 Published Online June 2011 (
Published Online June 2011 in SciRes. nal/OJPed
A rare fatal case of internal hernia caused by Meckel’s
diverticulum in a paediatric patient
Vandana Jain, Sanjay Sahi
Queen Mary’s Hospital, Department of Paediatrics, Sidcup, UK.
Received 26 April 2011; revised 25 May 2011; accepted 2 June 2011.
We describe a very rare case of an internal hernia
associated with a Meckel’s diverticulum, which lead
to the death of a young 3 year-old boy. The case de-
scribes symptoms of abdominal pain and vomiting,
on a background of previous intermittent abdominal
pain. The possibility of small bowel obstruction was
suspected, and appropriate imaging was performed.
This case illustrates the need for a high index of sus-
picion for small bowel obstruction, with appropriate
investigations and review. It also highlights the limi-
tations of imaging modalities in identifying co mplica-
tions of Meckel’s diverticulum. It is important to
raise awareness of this fatal cause for small bowel
obstruction and to help identify suggestive imaging
features, which may point towards a possible com-
plicated Meckel’s diverticulum. Earlier recognition
and diagnosis could reduce morbidity and mortality.
Keywords: Meckel’s Diverticulum; Internal Hernia;
Small Bowel Obstruction
Meckel’s diverticulum (MD) is an embryonic remnant of
the omphalomesenteric (vitelline) duct, which normally
disappears by the seventh week of gestation [1]. It is the
most common congenital anomaly of the gastrointestinal
tract, occurring in 2% - 3% of the population [2]. MD is a
true diverticulum, containing all layers of the ileal wall,
where heterotrophic tissue is present. Gastric mucosa is
the most common heterotrophic tissue, followed by pan-
creatic tissue, then mixed pancreatic tissue and gastric
mucosa [1]. It occurs in approximately equal frequency in
both sexes, but symptoms more commonly present in
males [3]. The most symptomatic age group is the un-
der-2’s. Most MDs are clinically silent and are often an
incidental finding at laparotomy. Symptoms arise when
there are associated complications, which include, haem-
orrhage, small bowel obstruction (SBO) and di verticuli tis.
We describe a rare case of SBO originating from her-
niation into the orifice formed from a congenital band
from the diverticulum to the root of a mesentery. We
aim to highlight the importance of this condition and its
potential fatal co nsequence, as well as exploring reasons
as to why diagnosis can be difficult.
A 3 year-old boy attended Paediatric Accident and Emer-
gency, with an acute history of vomiting and abdominal
pain. He looked unwell and had generalised abdominal
tenderness, but no abdominal distension and normal
bowel sounds. He was haemo-dynam icall y stable.
He had presented with a similar episode, 10 weeks pre-
viously, with a history of diarrhoea and vomiting, after a
short holida y to Turkey. At this s tage, he was also no ticed
to have abdominal distension. An abdominal x-ray re-
vealed dilated large bowel loops, thought to be secondary
to colitis or ileus. An abdominal computed tomography
scan showed no abdominal obstruction. Blood, stool and
urine tests were normal. The child recovered with intra-
venous fluids, and was discharged home after 48 hours
with outpatient follow up arranged. The most likely diag-
nosis was gastroenteritis. Parents reported that he did have
a past history of intermittent abdominal pain and vomiting,
but no previous m edical consult ation.
During the current admission, an infective cause for
his symptoms seemed most likely, and he was managed
with intravenous fluids. Blood tests were normal, in-
cluding inflammatory markers. A clean catch urine sam-
ple was awaited. With in 12 hours of admissio n, his vom-
iting settling, however the abdominal pain persisted.
Hence, an abdominal ultrasound was performed. Visu-
alization was difficult due to gas and tenderness, but
upper abdominal viscera was normal and there was no
evidence of malrotation or intussusception. He was oth-
erwise well in himself with normal vital signs. A CT
scan had been arranged for the next day for further in-
V. Jain et al. / Open Journal of Pediatrics 1 (2011) 17-19 18
vestigation of the persistent pain.
However, at 24 hours into the admission, the patient
acutely deteriorated. He was showing signs of hypovol-
aemic shock, followed by a large dark brown vomit and
a rigid abdomen, very suggestive of peritonitis. He
quickly became unresponsive, and cardiopulmonary re-
suscitation was commenced, but unsuccess ful .
Post-mortem diagnosis revealed haem orrhagic infarction
of 47 cm of small bowel, which had herniated through a
small gap in the mesentery, formed from a band running
from a Meckel’s diverticulum to the root of a mesentery.
Symptoms of abdominal pain and vomiting are common
presentations to Paediatric Accident and Emergency. The
majority of cases are viral infections, but a high index of
suspicion for possible SBO is required. Any unusual fea-
tures in the presentation, such as bilious vomiting, ab-
dominal distension, abnormal bowel sounds, tympanic
percussion, constipation, previous history of abdominal
pain and vomiting, worsening or non-resolution of sym-
ptoms should ring alarm bells [4]. Although the presence
of diarrhoea is unusual i n small bowel obst ru c t i on, i t does
not exclude it. Our index case demonstrates that despite
the physician’s vigilence and high index of suspicion,
this unusual cau se of SBO is difficult to identify. W e aim
to raise awareness of this rare condition and it’s diagnosis,
to help reduce morbidity and mortality.
Meckel’s Diverticula are usually asymptomatic. The
most common complication to arise is haemorrhage.
Other complications include diverticulitis and SBO. The
mechanisms for SBO can involve a volvulus, intussus-
ception, diverticulitis, foreign body impaction, inversion
of the diverticulum into bowel lumen or hernia, neoplas-
tic obstruction, or, as in our case, formation of an inter-
nal hernia [1]. An internal hernia is a particularly rare
form of MD obstruction, and is caused by the MD at-
taching to the adjacent mesentery, forming an orifice for
ileal loop herniation [2,6-8].
A few other case reports of MD associated internal
hernia have been identified, with diagnosis at laparo-
tomy for clinical and radiological evidence for SBO
[6,7]. In our case, diagnosis of SBO was further compli-
cated by initial resolution of symptoms and inconclusive
imaging result.
We know that radiological signs of SBO are well es-
tablished, but recogn izing MD as the cause is very diffi-
cult pre-operatively. Some radiological features, which
may point towards MD, in the setting of intestinal ob-
struction, have been suggested, but are not without their
limitations [5].
Abdominal radiographs may be useful to identify MD
by the presence of enteroliths [5], which can be seen as
peripheral calcification with a radiolucent centre, often
located in the right lower quadrant of the abdomen.
However, as enteroliths are often absent, this sign will
not always be illicited.
Ultrasonograms may suggest MD if there is evidence
of a round or tubular cystic lesion, however, this can
often mimic a dilated bowel loop or duplication cyst, and
more commonly visualization is difficult due to overly-
ing bowel loops [1,6 ].
The use of barium studies is limited, due to poor bar-
ium filling of the obstructed bowel and their time con-
suming nature [9]. However, they can show MD as a
blind-ended saccular or tubular lesion on the antimes-
enteric site of the ileum or as a triradiate fold pattern at
the junction of the diverticulum and the ileum [4,5].
Computed tomography (CT) is usually the gold stan-
dard imaging modality for intestinal obstruction, however,
identifying MD as the cause can be extremely difficult
[5,9]. It looks like a bowel loop and can be obscured by
co-existant complications, such as intussussecption and
volvulus [5,6]. If seen, it appears as a blind ending, tubu-
lar or sausage shaped structure that communicates with
the small int estine lumen a t the level of the obstruction . It
may contain air, fluid, fecal matter or enteroliths. In par-
ticular, with an internal hernia, such as in our case, clus-
tering of bowel loops and stretched crowded and engor ged
mesenteric vessels may be suggestive features [10].
A technique known as multidetector computed tomo-
graphic scan (MDCT) with high spatial resolution and
isotropic multiplanar reconstruction images have dem-
onstrated MD included in hernias [6,11,12], and is being
used second line after the abdominal x-ray in suspected
cases [6].
The technetium-99 m pertechnetate scan in children has
a sensitivity of 80% - 90%, a specificity of 95% and an
accuracy of 90%. It is specific to ectopic gastric mucosa,
hence may give false positives in gut duplication cysts
with ectopic gastric mucosa [13]. Also false negative
scans may be due to the rapid dilution of radioactive sec-
ondary to impaired vascular supply or insufficient gastric
mucosa. However, if there is a complicated MD from
clinical or radiological suggestion, the Meckel’s scan is
the most accurate non-i nvasive i nvestigati on to perform .
We conclude that in unclear diagnoses of abdominal
pain and vomitin g in young children, the uncommon but
potentially catastrophic complications of MD associated
obstruction should be considered, which may be difficult
to diagnose radiologically. Awareness of the specific
radiological features of the MD is important, although
there are many limitations.
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