An Unexpected Case of Intestinal Ischemia (this Is a Case of Bowel Obstruction Due to Meckel's Diverticulum)
Case Presentation A full term previously healthy 5 month old male infant presented with sudden onset non-bloody, non-bilious vomiting associated with feeds, fever, and lethargy. In the emergency department, he was febrile and tachycardic. Physical examination was significant for lethargy, dry mucous membranes, and grunting without increased work of breathing or adventitious lung sounds. His abdomen had normoactive bowel sounds, mild distention, generalized tenderness, and rigidity. Initial laboratory results including CMP, amylase, lipase, lactate, CBC, fibrinogen, and CRP were all within normal limits. Sepsis evaluation only yielded positive rhinovirus/enterovirus on respiratory PCR panel. Abdominal x-rays showed multiple loops of dilated bowel with multiple air-fluid levels. Abdominal CT scan revealed partial small bowel obstruction with transition point in the mid abdomen without a clear etiology, increased bowel wall thickness, and large abdominopelvic ascites. Initial management included fluid resuscitation and broad spectrum antibiotics. Pediatric surgery was consulted, and the patient was taken to the operating room for a diagnostic laparoscopy, which was converted to a laparotomy after visualization of ischemic bowel. A Meckel’s diverticulum was found with strangulated blood supply to the distal ileum resulting in 55cm of necrotic bowel. The small bowel was de-torsed, and the necrotic ileum and cecum were resected with re-anastomosis of the remaining bowel. Discussion This case demonstrates a potential complication of Meckel’s diverticulum, a vitelline duct remnant of which 2% are symptomatic and can present acutely with bowel obstruction, diverticulitis or hemorrhage. Bowel obstruction can lead to acute intestinal ischemia, a medical emergency due to its high rates of mortality and morbidity with delay in diagnosis. However, diagnosis is difficult and relies on non-specific clinical findings (especially challenging in the non-communicative infant), laboratory investigation, and radiologic studies. As a product of anaerobic metabolism, serum lactate has been well recognized as a biomarker of tissue ischemia. However, its utility in diagnosing early intestinal ischemia may be limited. Traditional biomarkers of inflammation, tissue ischemia, and non-specific small bowel enzymes, including CRP, lactate, LDH, and AST are significantly higher in vascular causes of intestinal ischemia compared to non-vascular causes, like strangulated bowel obstruction. Similarly, imaging studies are helpful but reliability varies and is highly subject to the skill of the reader. Contrast CT has a 52-100% sensitivity, 61-93% specificity, 72-88% positive predicted value, and 93-100% negative predicted value in diagnosing strangulated bowel. Typical findings in a closed loop obstruction include a unique C- or U- shaped distended fluid filled loops at the obstructed site, bowel wall thickening indicative of strangulation, and proximal gas distended loops. Conclusion Ultimately, timely assessment by an experienced surgeon remains an important intervention in early diagnosis of a closed loop bowel obstruction, especially in such cases where clinical suspicion is high but imaging is equivocal and laboratory results misleading.
Intestinal Ischemia Figure 1
Multiple air-fluid levels seen on the lateral decubitus abdominal x-ray
Intestinal Ischemia Figure 2
Visualized ischemic bowel delivered for inspection and eventual resection
- Copyright © 2018 by the American Academy of Pediatrics