Meckel’s diverticulum usually appear as a pouch that originates from the antimesentric border of distal ileum at variable lengths from the ileocecal junction [9]. Its length ranged from 1 to 6 cm. It results from the persistence of omphalomesentric duct which usually fails to obliterate by the 5th week of gestation [10]. It is considered as a true diverticulum comprising all intestinal layers, and it usually possesses ectopic gastric, duodenal, colonic, pancreatic, and endometrial tissues in 30–50% of cases. The diverticulum has its blood supply from the omphalomesenteric artery which is derived from the ileal branch of the superior mesenteric artery [11]. MD has different presentations, and about 60% of symptomatic MD occurs in children. The most common presentation in children is gastrointestinal bleeding (40%) followed by different types of small intestinal obstruction (30%) and finally acute diverticulitis (20%) [12]. The remaining 10% of symptomatic MD occurs in infants younger than 1 year, and it presents with intestinal perforation [12].The reported symptomatic MD in neonates is 20% of all pediatric cases and usually due to bowel obstruction. A perforated MD in neonates is very rare, and there are only seven reported cases in the English literature till 2008 [13,14,15,16,17,18,19]. The most common cause of neonatal MD perforation is necrotizing enterocolitis [20]. The less common causes include Hirschprung’s disease, meconium ileus with cystic fibrosis, intestinal atresia, and volvulus neonatorum. In this study, we reported one case with perforated MD in neonate due to its incarceration in the hernia of umbilical cord.
Diagnosis of complications of Meckel’s diverticulum is challenging. Although different imaging modalities like abdominal ultrasonography, abdominal CT scan, gastrointestinal contrast studies, and angiography can rarely diagnose this condition, Tc-99 m pertechnetate scan has a well-established high sensitivity in its diagnosis [21].
Prophylactic resection of asymptomatic MD is not recommended in children. Many reports advocate that normal looking MD that is discovered during surgery should not be resected unless if there is gross pathology suggestive the existence of ectopic tissue, giant diverticulum > 4 cm length, and narrow base < 2 cm wide. There are several approaches for dealing with complicated MD; a wedge or V-shaped resection was done for narrow-base diverticulum and resection anastomosis of a limited segment of small intestine in an inflamed or ulcerated diverticulum [22]. In the current study, both techniques were used according to these criteria.
Diverticulitis represents 20% of the symptomatic MD, and it is more common in adults than children [23]. The clinical manifestation is similar to the manifestation of acute appendicitis and should be considered in patients complaining of right lower abdominal pain. If the appendix is normally looking during operation and the manifestation was not explained, the distal ileum should be delivered and explored for MD. The acute inflammation may be due to stasis and bacterial overgrowth which occurs due to obstruction of the lumen by fecolith, foreign body, or parasites [24]. Acute diverticulitis may be due to peptic ulceration of ileal ectopic gastric mucosa. It may be also due to torsion of the diverticulum and ischemia [25]. Untreated acute diverticulitis may lead to perforation and acute peritonitis. This condition should be managed surgically either by open or laparoscopic approach with resection of the inflamed MD at its base and closure perpendicular to the axis of the intestine. In the current study, the patient was presented by acute abdominal pain and repeated vomiting, but the preoperative investigation was not conclusive for the diagnosis. Exploration was done through infraumbilical midline incision and resection of the inflamed diverticulum was done.
Intestinal obstruction is the second common presentation in children. Intestinal obstruction due to MD can be presented by different mechanisms like (a) volvulus of the distal ileum due to fibrous band; (b) intussusception in which the diverticulum is a nidus to allow the invagination of the loop of the intestine into another one leading to ileoileal and ileocolic intussusception; (c) Littre’s hernia in which the diverticulum incarcerate into inguinal or femoral hernia; (d) mesodiverticular band in which the distal ileum is entrapped beneath the blood supply of the diverticulum; (e) band extending between the diverticulum and the base of the mesentery of the ileum and cecum, forming a loop in which a part of ileum entrapped causing obstruction; (f) other causes include Meckel’s diverticulum lithiasis, stricture secondary to chronic diverticulitis, carcinoid tumors, and gall stone ileus [8, 26,27,28,29,30]. Whatever the cause of obstruction, the patient presents with clinical picture of small intestinal obstruction like acute abdominal pain, repeated bilious vomiting, abdominal distention, and constipation. Plain x-ray on the abdomen, abdominal ultrasonography, and may be abdominal CT are needed for the accurate diagnosis. Hence, intestinal obstruction should be treated as an emergency warranting immediate abdominal exploration either open or laparoscopic after good preoperative resuscitation [31, 32]. In this study, we presented three cases with different mechanisms of intestinal obstruction. The first case was a male child presented with volvulus of the ileal loop over a fibrous band extended from MD to the umbilicus. The second case was a male infant presented with incarcerated inguinal hernia entrapped a MD with ischemia. The third case was male child presented with Gordian knot due to entrapment of proximal ileal loop into another loop formed by adhesion of the tip of giant MD to the cecum. Exploration was done in all patients with limited resection of the MD or small intestinal resection.
