An Uncommon Presentation of Axial Torsion with Ischemic Perforation of Meckel’s Diverticulum

Introduction: Meckel’s diverticulum (MD) is the commonest congenital anomaly of the gastrointestinal tract due to incomplete obliteration of the vitellointestinal duct. Most of the patients were asymptomatic with only 4% of them presented with complications. Axial torsion leading to ischemic perforation of MD is a rare presentation with only few cases reported in the literature.
Case Summary: A 25 year old man presented with two days acute severe abdominal pain with evidence of peritonism over the lower abdomen. He was posted for an urgent laparotomy with a preoperative diagnosis of perforated appendicitis. An emergency laparotomy was performed and the intraoperative diagnosis was axial torsion of the MD with purulent peritonitis. The MD had a narrow base with a length of 6cm and was attached anteriorly via a mesodiverticular band. A wedge resection with primary repair was performed with peritoneal lavage. Patient recovered well and was discharged home seven days after the surgery. The histopathological report of the specimen was consistent with ischemic perforation without evidence of malignancy.

Discussion: Axial torsion is a rare complication of MD with clinical presentation mimicking other common intra-abdominal pathology. The diagnosis is usually made intraoperatively, even with the modern diagnostic methods currently available. Factors associated with higher risk of complications include patient at extremes of age or immunosuppressed, presence of anatomic risk factors such as length of more than two cm, palpable abnormality and presence of fibrous band. Current recommendation suggests excision for all symptomatic MD and asymptomatic MD found during abdominal exploration with risk factors of developing complications. It is important to include complicated MD in our differential diagnosis for patient with such presentation in order to identify and manage accordingly.