Gangrenous Meckel’s diverticulum causing acute intestinal obstruction in an adult

We present a rare case of acute intestinal obstruction by Meckel’s diverticulum. The peculiarities were first, its unusual age of presentation, second, its unusual way of causing obstruction and third, the gangrenous nature of Meckel’s diverticulum. A 24-year-old man presented with features of acute intestinal obstruction. Supine abdominal radiograph showed distended bowel loops. In absence of any evident cause of obstruction, urgent exploratory laparotomy was planned after resuscitating the patient. On exploration, a gangrenous Meckel’s diverticulum 0.6096m proximal to ileocaecal junction was found, the tip of which continued as a band, being attached with its mesentery forming a loop. That loop was encircling a portion of terminal ileum, thus causing obstruction and proximal bowel dilatation (Fig. 1). Band was released and a segment of ileum containing gangrenous Meckel’s diverticulum was resected, followed by end-to-end ileo-ileal anastomosis. Meckel’s diverticulum results from incomplete obliteration of the vitelline duct. Generally asymptomatic, various complications may occur like haemorrhage, intussusception, diverticulitis, perforation and intestinal obstruction. Average age of presentation is 2 years and presentation in adulthood is unusual. Haemorrhage and obstruction are the most common presentations in children and adult, respectively.1,2 There are varied causes of obstruction, the most common being intussusception. Others being volvulus around fibrous bands adherent to the umbilicus, inflammatory adhesions, Littre’s hernias and diverticular strictures. In our case, an unusual mechanism was found wherein a Meckel’s diverticulum loop acted as a band with the tip of the diverticulum being adhered to adjacent mesentery in which a segment of ileum got encircled and stuck. Our case also presented with gangrenous changes of the Meckel’s diverticulum, which is a very rare reported phenomenon.3 Coexistence of gangrenous Meckel’s diverticulum and its loop-forming mechanism of obstruction is a very rare co-occurrence and has not been reported earlier. Two possible pathophysiologies behind the gangrenous changes could have been (i) ischaemia due to mechanical reasons; and (ii) postinflammation.4 During the event of herniation of the portion of terminal ileum in the loop of Meckel’s diverticulum, it might have caused axial rotation of Meckel’s diverticulum and thus gangrene. However, the distended ileal loop (secondary to pressure of band of Meckel’s diverticulum) could also have been responsible for opposite pressure and compression effects on Meckel’s diverticulum, resulting in ischaemic changes and gangrene of the Meckel’s diverticulum. Thus, a unique vicious cycle, arising from obstruction by the Meckel’s diverticulum and culminating into gangrene of the causative agent itself (Meckel’s diverticulum) by distended loop of ileum appears to be another pathophysiological event. Either of these mechanisms might have played the offending role in our case. Inflammation as a cause of gangrene was unlikely, as it usually occurs very late and usually diagnosed because of intense diverticulitis.