Abdominal Pain Caused by a Meckel’s Diverticulum in an Elderly Man
Key words: Abdominal pain, diverticulitis, Meckel’s diverticulum, volvulus.
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The overall mortality in elderly patients who present to the emergency department (ED) with abdominal pain exceeds 10%.1 In this population, small bowel obstruction is one of the most common reasons for surgical intervention.2 Wilhelm Fabricius Hildanus, a German surgeon, first described the diverticulum in 1598, but it was Johann Friedrich Meckel, a German anatomist, who named the entity and described its structure more than 200 years later.3 In 1809, Meckel described the diverticulum of the small bowel as a congenital pouch situated within approximately 60 cm of the ileocecal valve on the antimesenteric border of the bowel.4 It occurs in approximately 2% of the overall population, but tends to be twice as common in men than in women.5 Complications that require emergency treatment include bleeding and obstruction, which are caused by intussusception.6 Other mechanisms for obstruction are volvulus around the fibrous bands adherent to the umbilicus, inflammatory adhesions, Littre’s hernias, and diverticular strictures.7,8
Case Presentation
An 85-year-old man was referred to the ED because of the sudden onset of abdominal pain in his right lower quadrant. This pain had started a few hours earlier and remained localized. The patient reported anorexia and a substantial weight loss of 22 lb over the previous 2 months. He did not have a fever, diarrhea, or dysuria. He reported no melena or bright red blood upon defecation.
His medical history consisted of arterial hypertension and atrial fibrillation, for which he was taking antiarrhythmic therapy (digoxin), a calcium antagonist, a beta-blocker, and aspirin. He had no surgical history.
On clinical examination, abdominal tenderness of the right lower quadrant was noted, and there were sounds of peristalsis on auscultation. The results of a digital rectal examination were normal.
Laboratory tests revealed a normal peripheral blood count, lactate level, and C-reactive protein level, but an elevated D-dimer count of 5419 µg/mL (normal, <0.5 µg/mL). Abdominal ultrasonography showed free fluid in the right iliac fossa and a bowel segment without peristalsis. This segment also had an inflamed and distended wall. A radiograph of the abdomen was normal.
A computed tomography (CT) scan of the abdomen was undertaken, which revealed an inflammatory mass in the right lower quadrant and adjacent dilated small bowel segments, with inflammation of the bowel wall (Figure 1). There was free fluid at the level of the liver and pelvis minor and a discrete pneumoperitoneum.
An urgent median laparotomy was performed, which revealed a small bowel volvulus comprising more than 3 feet of the small bowel. The pivotal point appeared to be an ischemic Meckel’s diverticulum that was incarcerated under an omental adhesion to the right iliac fossa wall (Figure 2). The vascularization of the small bowel was adequately restored after adhesiolysis. A segmental resection of the small bowel with the ischemic Meckel’s diverticulum was performed.
Further inspection of the abdomen revealed a palpable thickened structure at the antric part of the stomach. Because of the now obvious etiology (a small bowel volvulus) of his abdominal symptoms, no biopsy was performed and a gastroscopy was foreseen after the patient recuperated from surgery. The patient recovered well. On the day before he was to be discharged from the hospital, the gastroscopy was performed. The gastric wall was slightly inflamed and a biopsy showed no malignancy. The patient went home on hospital day 13 after an uneventful stay.
A repeat gastroscopy performed 1 month after he was discharged from the hospital showed Helicobacter pylori–positive chronic gastritis. No malignancy was found. Triple therapy consisting of a proton pump inhibitor and eradication therapy with clarithromycin and amoxicillin was initiated.
Case Summary
The patient’s significant weight loss, the clinical signs of obstruction, and his age made a malignant cause of the abdominal symptoms highly likely. The inflamed mass at the level of the right iliac fossa that was seen on the CT image also contributed to the suspicion of a malignancy. The decision to perform an urgent laparotomy was based primarily on the patient’s clinical presentation and supported by the preoperative radiological examination. When the laparotomy was performed, however, the reason for the obstruction was found to be a volvulus caused by Meckel’s diverticulum, rather than a malignancy. After detordation and segmental resection, the abdomen was inspected for other abnormalities, which yielded a solid antral lesion. A gastroscopy that was performed postoperatively showed a chronic inflammation of the gastric wall, with no signs of malignancy. This finding likely explained the patient’s anorexia and weight loss. The patient’s usual aspirin regimen was continued, as it was not thought to play a role in his gastritis. In addition, his symptoms resolved with triple therapy, making the aspirin as the cause of his gastritis even more unlikely.
Discussion
Meckel’s diverticulum is a congenital, intestinal blind pouch that results from an incomplete obliteration of the vitelline duct during the fifth week of gestation.3 Most patients with a Meckel’s diverticulum are asymptomatic, and the condition is often found incidentally during an operation for an unrelated cause.3 In a review of more than 1400 medical records of patients found to have had a Meckel’s diverticulum between 1950 and 2002, Park and colleagues3 discovered that only 16% were symptomatic, with the most common clinical presentation in adults being bleeding, obstruction, and diverticulitis. A report by Menezes and colleagues9 noted that the predominant presentation in children is bleeding; thus, the condition appears to have some consistent symptoms across age groups.
The case patient presented with abdominal pain, a finding that is commonly encountered among elders. Diagnosing the cause of abdominal pain in elders can be challenging, as the signs and symptoms are often not specific and many atypical presentations are observed in this population due to the complexities of advancing age and comorbidities.10 Abdominal pain can have numerous etiologies, including chronic constipation, obstruction, and intussusception, among other conditions.11,12 In elderly patients, the differential diagnosis for abdominal pain is more substantial than for younger patients. This is because older adults have more comorbidities and a much higher prevalence of chronic constipation than their younger counterparts,13 with the latter condition being a significant cause of abdominal discomfort and pain among older adults. A study by Laurell and colleagues14 also found that elderly patients tended to present to the ED after a longer history of abdominal pain compared with younger patients. The reason for this is unclear, but a contributing factor may be that many elders require the assistance of others to seek medical attention.
There are no clear clinical signs of Meckel’s diverticulum; however, there should be a low threshold for performing CT scans in elders with acute or chronic abdominal pain once renal insufficiency has been ruled out via laboratory analysis of serum creatinine levels. When weight loss is present, it could be suggestive of malignancy, particularly in older persons, as the incidence of colon cancer is the highest in patients between 74 and 80 years of age.15 Our patient’s clinical picture was highly suggestive of malignancy; thus, we were surprised to find that a benign condition was causing his abdominal pain. Our case report demonstrates that weight loss is not an absolute parameter of malignancy, but that it does serve as an indicator of disease severity, whether the disease is benign or malignant.
Making the Diagnosis
Because a majority of patients with a Meckel’s diverticulum are asymptomatic, diagnosis is difficult to confirm based on a patient’s history, physical examination, and laboratory testing. Radiographic imaging studies, including laparoscopy and laparotomy, frequently discover asymptomatic Meckel’s diverticulum. When Meckel’s diverticulum is suspected based on clinical observations, blood tests should be performed, including a white blood cell count, an absolute neutrophil count, and a C-reactive protein test. The diagnostic work-up of abdominal pain in elders is more difficult because of a high prevalence of comorbidities, complex histories, and challenges in performing physical examinations. Radiologic imaging remains an important diagnostic modality for elders, as it can often identify the cause of the abdominal pain. For example, abdominal echography can accurately diagnose appendicitis and cholecystitis; CT examination can diagnose diseases of the stomach and small and large bowel; and a technetium-99m pertechnetate scan can show ectopic stomach mucosa, which is present in Meckel’s diverticulum, but this scan is not useful in the acute care setting.
Colonic malignancy is common among elders. Therefore, it is logical to suspect a malignant etiology when encountering an intestinal obstruction in an elder without a history of abdominal surgery, such as the case patient. Physical examination and CT findings do not always reveal whether the surgical team is facing a malignant or benign disease. When an acute abdomen is encountered, surgery should be performed. Surgery can be diagnostic (eg, laparoscopy identifying extensive small bowel ischemia), palliative (eg, gastrojejunal anastomosis for a metastatic distal gastric carcinoma or terminal colostomy for a stage IVb rectal carcinoma), or therapeutic (eg, left hemicolectomy for perforated diverticulitis). Because surgery can have
numerous objectives, it is imperative for clinicians to properly inform their patients and patients’ families on the purpose of the operative procedure.
Conclusion
This case report illustrates that a preliminary diagnosis in the ED can be less reliable in elders than in younger patients.13 Furthermore, older patients may arrive at the ED after a longer history of pain. The diagnostic work-up is more difficult in geriatric patients, and a broad differential diagnosis needs to be considered in such cases.10
Information about Meckel’s diverticulum in the literature is mainly based on case reports.3 Especially in the elderly population, the prevalence of this diagnosis has not yet been reported. Case reports of patients older than 65 years with symptoms from a Meckel’s diverticulum are extremely rare.16 In this context, clinicians should take into account this rare but possible benign cause of an acute abdomen in the elderly patient, even in the context of reported weight loss.
References
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Disclosures:
The authors report no relevant financial relationships.
Address correspondence to:
Thomas Martens, MD
Department of Surgery
Ghent University Hospital 2K12IC
De Pintelaan 185
9000 Gent
Belgium
thom.martens@ugent.be