Abstract:

Intussusception is a common cause of intestinal obstruction in children but far less frequent in pre-adolescent age group. Most common presentation is of ileocolic type in children. Ileoileal intussusception is relatively rare, and when present, often associated with a pathological lead point. We report a case of 12-year-old male, where a routine diagnosis of intussusception took a surprising turn intraoperatively with the discovery of “Inverted Meckel’s diverticulum”. Through this case, we emphasize the need for vigilance and adaptability in surgical practice and highlight the importance of considering rare aetiologies during evaluation.

Introduction

Intussusception is telescoping of the lumen of the adjacent distal segment (intussuscipiens) into the lumen of the proximal segment of the intestine (intussusceptum). Although intussusception is relatively common in children, it occurs infrequent in adults (1).

Meckel’s diverticulum, the most prevalent congenital anomaly of the gastrointestinal tract, affects around 2% of the population (2). It remains largely asymptomatic but can occasionally cause complications like bleeding, obstruction and intussusception. At times, Meckel's diverticulum can invert into the intestinal lumen, serving as a lead point for intussusception. This may lead to bowel obstruction, reduced blood flow, tissue ischemia, and eventually infarction (3). About 4% of intestinal obstructions caused by intussusception are linked to the inversion of Meckel's diverticulum (4). This occurs when a Meckel's diverticulum invaginate into the bowel lumen, acting as a lead point that enables the small intestine to telescope into itself, first involving the distal ileum and then extending into the large intestine, resulting in ileo-ileal and ileocolic types of intussusceptions. The mechanism behind the inversion of a Meckel’s diverticulum remains unclear. According to one theory, abnormal peristaltic activity triggered by ulceration or the presence of ectopic tissue at the base of a Meckel’s diverticulum may lead to its inversion (5,6).

Case Report

A 12-year-old male child was admitted to emergency department with complaints of abdominal pain and recurrent episodes of vomiting since 2 days. On examination, the child was conscious, oriented, afebrile and vitals were stable. On per abdominal examination, there was distention and tenderness was present over Right hypochondrium, epigastrium and umbilical regions. There was no guarding and rigidity with active bowel sounds. Initially child was kept nil per oral and kept under continuous Ryles tube aspiration. Simultaneously child was managed with IV fluids and broad-spectrum antibiotics. All routine blood investigations were done and was within normal limits. Ultrasound abdomen showed: long segment ileocecal and ileoileal intussusception at right lower quadrant region with evidence of alternating hypoechogenic and hyperechogenic regions giving classical “target sign”. Mild dilatation of proximal small bowel loops (3.2cm maxi). Since intussusception is unusual at this age, to find the lead point CECT abdomen was taken;

- ileocolic intussusception with telescoping of distal ileal loops into the colon at the ileocecal junction and proximal small bowel obstruction.

- Linear fat density lesion (-90 HU) within the telescoped segment, likely representing a lipoma, which may serve as a lead point. 

Picture 1,Picture 2

Since the patient presented as an emergency with features of Intestinal Obstruction, an emergency Diagnostic laparoscopy was planned. Under General Anaesthesia, 10mm Umbilical (camera) and two 5mm iliac fossa (right and left) working ports were placed. On bowel walking, distal ileal (40cms from IC junction), ileoileal intussuception was identified and was subsequently reduced (pictures 3, 4, 5). Subsequently, a small 5 cms midline incision was made for thorough inspection of the small bowel and to identify the pathology.

On manually inspecting the bowel, an ileoileal intussuception was identified at 60 cms from IC junction and on further reducing it manually, it was found to be an inverted Meckel’s diverticulum with fatty tissue at the tip of the diverticulum causing a lead point for the same.

Diverticullectomy was performed by stapling the base using 45 linear cutter stapler, and the staple line was inverted with 3-0 prolene.

Patient tolerated the procedure well, was initiated on oral the next day and was discharged on the 3rd post-op day.

INTRA-OPERATIVE PICTURES:

Picture 3

Picture 4: Laparoscopic reduction of the intussusception.

Histopathology report was suggestive of Meckel’s diverticulum with “Gastric heterotopia”.

Focally the lining epithelium was gastric foveolar and shows glands lined by parietal cells and mucinous cells. Areas of ulceration and granulations seen. No evidence of metaplasia.

Picture 8(a): with 40X H and E stanning

Picture 8 (b): with 40X H and E stanning

Picture 8 (c): with 100X H and E stanning

Discussion

Meckel’s diverticulum can lead to intestinal obstruction in both adults and children. Occasionally, an inverted Meckel’s diverticulum can result in intussusception, leading to ischemia and infarction. Reports indicate that 21% of Meckel’s diverticula are inverted, and among these, 72% present with intussusception (7). The overall likelihood of intussusception caused by an inverted Meckel’s diverticulum is just 4% (8). It is more common in adults and rarely seen in children (9, 10). The exact cause of inversion of Meckel’s diverticulum remains unclear. It is believed that abnormal peristaltic activity, triggered by ectopic tissue or ulceration at the base of Meckel’s diverticulum—especially in the presence of ectopic gastric mucosa—may contribute to its inversion (9, 10). The inverted Meckel’s diverticulum acts as a lead point, triggering intussusception.

Histopathological examination can identify ectopic gastric or pancreatic tissue in approximately 73% of cases, with gastric tissue comprising 97% of these ectopic findings. It is also useful to identify benign or malignant lesions. In our case histopathology revealed heterotopia of gastric mucosa. There was no evidence of any malignancy.

In adults, intussusception typically presents with varying symptoms, often including chronic colicky abdominal pain and episodes of partial intestinal obstruction, accompanied by nausea and vomiting (11). Due to its varied symptoms, diagnosis is frequently delayed. As a result, all adult patients with intussusception typically require surgical exploration. Resection is recommended for large bowel intussusception; however, in cases involving the small bowel— where malignancy is less common and no intestinal abnormalities are detected—reduction without resection may be considered a viable option (12). Now a day’s laparoscopic surgery or lap assisted surgery is gaining popularity as it is safe and effective (13, 14).

Child had an uneventful recovery and was doing well on subsequent follow ups.

Conclusion

Intussusception due to inverted Meckel’s diverticulum is rare in pre-adolescent children and can only be detected intra operatively. A definite pre operative clinical or radiological diagnosis is difficult. Nevertheless, inverted Meckel’s diverticulum is a recognized clinical condition and can be a cause of intussusception in children. This case reiterates the importance of considering rare but significant causes in differential diagnosis of bowel obstruction, especially when preoperative imaging may not reveal the full picture.

Funding: No funding sources.

Conflict of Interest: None declared.

Ethical approval: Not required.

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