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| CASE REPORT |
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| Year : 2023 | Volume
: 12
| Issue : 1 | Page : 64-66 |
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Tubercular Meckel diverticulitis mimicking acute appendicitis
Mangesh Hivre1, Pravinkumar Ghongade2, Bharat Umakant Patil2, Anupama Gupta2, Dilip Gupta1
1 Department of General Surgery, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
2 Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
| Date of Submission | 02-Jan-2023 |
| Date of Acceptance | 02-Feb-2023 |
| Date of Web Publication | 15-Mar-2023 |
Correspondence Address:
Bharat Umakant Patil
Department of Pathology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha - 442 102, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjhs.sjhs_2_23
Meckel's diverticulum (MD) is usually silent and asymptomatic. Acute diverticulitis, perforation, intestinal obstruction, hemorrhage, and other complications are seen in <4% of cases of MD. 27 year old female, presented with complaints of pain in her abdomen, clinically suspected of acute appendicitis, and finally diagnosed with tubercular Meckel diverticulitis. A clinical and laboratory diagnosis of Meckel's diverticulitis is challenging as it mimics appendicitis and is generally observed during surgical procedures. Meckel's diverticulitis should be suspected and explored, especially when the appendix appears normal in an acute abdomen. The presence of intestinal tuberculosis (TB) in unusual locations should be closely monitored, particularly in countries where TB is endemic.
Keywords: Appendicitis, Meckel's diverticulitis, tuberculosis
How to cite this article:
Hivre M, Ghongade P, Patil BU, Gupta A, Gupta D. Tubercular Meckel diverticulitis mimicking acute appendicitis. Saudi J Health Sci 2023;12:64-6 |
| Introduction | |  |
Meckel's diverticulum (MD) represents the most common congenital gastrointestinal (GI) anomaly.[1] It is common among children but entirely surprising in adults. Most cases (53%) are diagnosed within the first 2 years of life.[2] MD is found 45–90 cm proximal to the ileocecal valve and measures 1–12 cm in length.[1] It is susceptible to infection and obstruction because it has its blood supply. About 50% of patients with MD have ectopic gastric or pancreatic mucosa. Ulceration within the gastric mucosa or the adjacent ileal mucosa can cause GI bleeding.[3]
It is usually silent, but in 4% of cases, it can cause life-threatening complications such as intestinal obstruction, perforation, and hemorrhage.[4] Lower GI bleeding intussusception, simple obstruction, perforation, strangulation due to mesodiverticular band, diverticulitis, hernia, inflammation, neoplasms, and stone are the most common symptoms. The most severe complication of MD in adults is intestinal obstruction.[1]
Only less than 10 cases of tuberculosis (TB) of MD were found in our extensive literature. 75% of reported MD are discovered during laparotomies for various reasons.[5] There have been a few reports of tubercular involvement of MD and small intestine.[4] However, isolated TB involvement of the MD presenting as acute appendicitis is rare.
| Case Report | | |
A 27-year-old female presented with complaints of generalized weakness, abdominal pain, vomiting, and loss of appetite for the previous 2 days. She had been treated conservatively at a local hospital before being referred to a tertiary hospital, where she received no specific diagnosis or treatment and showed no improvement. There was rebound tenderness at McBurney's point on abdominal examination. An empty rectum was discovered during a digital per-rectal examination. In the erect position, a plain X-ray abdomen revealed a crescentic shadow in the right iliac region. Blood tests revealed elevated total leukocyte count and erythrocyte sedimentation rate.
There was no specific diagnosis reported on ultrasound. However, based on clinical findings, an acute appendicitis diagnosis was made. The patient was admitted to the hospital for a laparoscopic procedure for diagnostic and therapeutic purposes (appendectomy). Laparoscopy revealed dense adhesions. A tubular structure was discovered to adhere to the anterior abdominal wall from its tip. Adhesiolysis was performed, and the tubular structure was confirmed to be an MD located about 50 cm from the ileocaecal junction [Figure 1]a. The appendix was located retrocecally, and an appendectomy was performed. The decision was made to perform a minilaparotomy for Meckel's diverticulectomy. On examination, whitish tubercules were found at the base of MD. The organs in the abdomen, including the large and small intestines and the omentum, were perfectly normal. There was no free fluid in the pelvis or mesenteric lymphadenopathy. As a result, the decision to resect the MD was made to evaluate and confirm the diagnosis. In addition, a 2 cm free border with the ileum was taken, and an end-to-end ileoileal anastomosis was performed. For histopathological diagnosis, sectioning was performed on resected specimens. | Figure 1: (a) On laparoscopy, MD shows tubercules on the base and mesentery, (b) Sections from MD show granuloma composed of epithelioid cells with Langerhans giant cells (×400). MD: Meckel's Diverticulum
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A gross section revealed numerous areas of caseation necrosis at the base of the MD. Histopathological examination revealed the presence of Langerhans giant cells, histiocytes, and multiple granulomas composed of epithelioid cells, all of which were suggestive of TB. [Figure 1]b The appendix was unremarkable. Hence, MD, with tubercular involvement, was eventually reported. The patient was then started on an anti-tubercular regimen (ATT) and had regular checkups. The postoperative period was uneventful, and the patient was discharged on the 7th day of surgery. The patient gained weight and improved their appetite and overall condition after starting ATT within 2 months.
| Discussion | | |
TB is a potentially fatal disease affecting every body's organs.[6] The ileum and ileocecal region are the most common sites of GI involvement, accounting for 64% of all cases of GI TB. Because of factors such as stasis, abundant lymphoid tissue, the increased rate of absorption at this site, and closer contact of the bacilli with the mucosa, the terminal ileum is more commonly involved.[7]
Despite having the world's most prominent TB cases, accounting for approximately 26% of all TB cases,[7] only a few cases of TB of MD have been reported in the literature. These TB cases in MD had a male predominance and were between the ages of 20 and 45 years. Identifying the signs of MD TB is problematic because these findings frequently resemble other diseases and can be difficult to distinguish.[8] Another reason is that MD is not difficult to identify clinically because the majority of cases of MD remain asymptomatic throughout life; only 2%–4% of people become symptomatic.[4]
MD lesions, including TB, frequently emulate clinically acute appendicitis and Crohn's disease in the diverticulum.[3] Only clinical characteristics could indeed tell them off from each other. The laparoscopic examination is required for diagnostic and therapeutic purposes to differentiate from its mimicker, particularly acute appendicitis. It is frequently not diagnosed before laparotomy for another condition or one of its complications. Because the condition is rarely diagnosed, it often goes unnoticed until it worsens. Crohn's ileitis was also considered as a possible diagnosis. However, TB was confirmed by histopathology in this case.[4]
Diverticulectomy or ileal resection are surgical treatments for MD. For an asymptomatic diverticulum, a simple diverticulectomy is sufficient; however, if there is induration of the base extending into the adjacent ileum, ileal resection is required. Hemorrhage, intestinal obstruction, diverticulitis, and umbilical-ileal fistulas are absolute indications for resection.[4]
The best way to manage an incidentally discovered MD is debatable. In their study, Soltero and Bill[5] argued that the possibility of an MD becoming symptomatic in an adult patient is <2%. In contrast, morbidity rates of incidentally removed MD were as high as 12%. However, many researchers reported that removing an asymptomatic MD resulted in minimal (2%) postoperative complications such as morbidity and mortality.[4] Because it is challenging to diagnose MD pathology preoperatively, many surgeons recommend prophylactic diverticulectomy to confirm the diagnosis on histopathology if it is discovered incidentally.
| Conclusion | | |
The presence of intestinal TB in unusual locations should be closely monitored, particularly in countries where TB is endemic. This case demonstrates the critical importance of suspecting a complicated MD when diagnosing appendicitis. Thus, the importance of considering MD as one of the possible diagnoses in a patient presenting with the acute abdomen is emphasized.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 5. | Soltero MJ, Bill AH. The natural history of Meckel's diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel's diverticulum found in King County, Washington, over a fifteen year period. Am J Surg 1976;132:168-73. |
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| 8. | Dharmesh J, Mahna A, Khanpara PM, Sheth M, Munjal V. Tuberculous perforation of Meckel's diverticulum. J Clin Diagn Res 2021;15:12-4. doi: 10.7860/JCDR/2021/48369.15195. |
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