Abstracts: CLINICAL VIGNETTES/CASE REPORTS - SMALL INTESTINE/UNCLASSIFIED
An Unusual Cause of a Small Bowel Obstruction in a 55-Year-Old Male
Purpose: A 55-year-old white male presented with a four day history of nausea, vomiting, diarrhea and abdominal pain. The patient denied fever, chills, night sweats or unexplained weight loss. There was no history of melena or hematochezia. He denied recent travel or contact with individuals with similar symptoms. No previous surgeries. No family history of colon cancer or IBD. Vital signs: T102.2F, P117bpm, RR20br/min, and BP127/78. Abdominal exam revealed prominent distention, normoactive bowel sounds, and diffuse minor tenderness on deep palpation. No rebound or guarding. A tubularshaped mass was palpated in the RLQ. Lab data: WBCs 1.5 x 103/μL with 35% bands. H/H, Plt, CMP, amylase, CEA, UA normal. Stool was Hemoccult positive. C. difficile toxin, fecal leukocytes, blood cultures, and toxicology were negative. Flat plate of the abdomen showed a mild high grade small bowel obstruction (SBO) without free air. CT revealed moderate to high-grade partial SBO with a transition point in the distal ileum. No evidence of free air or abscess. Exploratory laparotomy divulged small bowel largely dilated proximally with a large 6 x 5-cm Meckel's diverticulum two feet from the ileocecal valve with no ischemia or necrosis. Adhesions from the Meckel's tip to small bowel created a SBO that was resected. Pathology confirmed diagnosis. Meckel's diverticulum is the most common congenital anomaly of the GI tract. It is usually clinically silent. If symptomatic in adults it generally presents as painless GI bleeding. Isolated cases have been reported in adults with SBO caused by adhesions from a Meckel's diverticulum. Predisposition to develop symptoms is age less than 50, male sex, histologically abnormal tissue within the diverticulum and a diverticulum greater than two cm in length. As concluded in other case reports on SBO, there should be a high level of suspicion of Meckel's preoperatively if there are no other obvious causes. Had we suspected this we could have ordered a Meckel's scan, with a sensitivity of approximately 50%. Laparotomy can diagnose causation and lead to resection of Meckel's diverticulum causing small bowel obstruction.© The American College of Gastroenterology 2013. All Rights Reserved.