- Email: [email protected]
Meckel's diverticulum perforation by a wooden toothpick in a child: A case report
Journal Pre-proof Meckel's diverticulum perforation by a wooden toothpick in a child: A case report Abdulhafidh Kadhi, Stanley Crankson, Saud Al Jadaan PII:
S2213-5766(19)30293-3
DOI:
https://doi.org/10.1016/j.epsc.2019.101322
Reference:
EPSC 101322
To appear in:
Journal of Pediatric Surgery Case Reports
Received Date: 29 September 2019 Accepted Date: 12 October 2019
Please cite this article as: Kadhi A, Crankson S, Al Jadaan S, Meckel's diverticulum perforation by a wooden toothpick in a child: A case report, Journal of Pediatric Surgery Case Reports (2019), doi: https://doi.org/10.1016/j.epsc.2019.101322. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Our reference: EPSC 101322 Article reference: EPSC_2019_285 Article title: Meckel’s diverticulum perforation by a wooden toothpick in a child: a case report To be published in: Journal of Pediatric Surgery Case Reports
The authors group and affiliations: 1- Abdulhafidh Kadhi, Department of Pediatric Surgery – KASCH King Abdulaziz Medical City-Riyadh P.O. Box 22490 – Riyadh 11426 MailCode1446 Kingdom of Saudi Arabia E-mail: [email protected] Phone: +966118011111 /53349 Mobile: +966545345144 2- Stanley Crankson, Department of Pediatric Surgery - king Abdulaziz Medical City-Riyadh-Saudi Arabia, [email protected] 3- Saud Al Jadaan, Department of Pediatric Surgery - KASCH - King Abdulaziz Medical City-Riyadh-Saudi Arabia, [email protected]
Meckel’s diverticulum perforation by a wooden toothpick in a child: a case report
Abstract Perforation of Meckel’s diverticulum (MD) by ingested foreign body (FB) is an extremely uncommon cause of acute abdomen in children. We report on a 13-year-old boy who presented with right iliac fossa pain associated with anorexia, tenderness, guarding and rebound tenderness. Abdominal ultrasound showed findings of acute appendicitis. However, laparoscopy revealed a wooden toothpick perforating MD and a hyperemic appendix. The FB was removed and laparoscopic diverticulectomy and appendectomy performed. Perforation of MD by a FB is a diagnostic challenge and it should be included in the differential diagnosis of acute abdomen in children. Introduction Acute appendicitis is the most common pediatric abdominal emergency. However, because of varied clinical manifestations establishing diagnosis may be challenging for the physician. The differential diagnosis of acute appendicitis includes symptomatic Meckel’s diverticulum (MD). MD is the most common congenital anomaly of the gastrointestinal tract, with an incidence of about 2% (1). Majority of cases of MD are asymptomatic but the modes of presentation include intestinal obstruction, hemorrhage, diverticulitis and perforation (1). Perforation of MD, an extremely rare complication may be caused by ingested foreign bodies (FBs) such as chicken bones, fish bones, melon seeds, peanuts, bay leaf, toothpick, batteries, needles, pins or wood splinters in both children and adults (2-6). Herein, we report a case of perforation of MD by a toothpick in a child. Case Report: A 13- year- old boy presented to the emergency room with complaints of right lower quadrant abdominal pain, anorexia and fever for 1 day. There was no history of FB ingestion and past medical history was unremarkable. On physical examination, he was dehydrated, afebrile with tenderness, guarding and rebound tenderness in the right iliac fossa, Laboratory results revealed leukocytosis with neutrophilia. Abdominal ultrasound (US) showed a hyperemic appendix with about 7mm diameter and preliminary diagnosis of acute appendicitis was made. The patient was admitted and after administration of intravenous (IV) fluids, IV antibiotics (Ceftriaxone and Metronidazole) and analgesia. He was scheduled for laparoscopic appendectomy. Laparoscopy revealed terminal ileum and cecum covered by the greater omentum, which on release showed a wooden toothpick through the tip of a Meckel’s diverticulum (Fig. 1) and fibrinous exudates over the terminal ileum. Also, the appendix was hyperemic (Fig.2). The toothpick was removed and laparoscopic Meckel’s diverticulectomy and appendectomy performed. 1
The patient’s post-operative recovery was uneventful, and was discharged home 5 days after surgery. Histopathology examination of the surgical specimen was consistent with an acutely inflamed and perforated MD and an appendix with serositis. Discussion
MD is a remnant of the omphalomesenteric duct, which usually obliterates by the fifth week of gestation. It is located on the antimesenteric border of ileum at variable distances from the ileocecal valve, with an incidence of about 2 % (1). Although MD is commonly asymptomatic, and presents as an incidental finding at operation or autopsy, it has varied manifestations. There is a 4.2 - 16.9% probability of symptomatic presentations, with 60% of patients being symptomatic before the age of 10 years (6). The modes of presentations of MD include intestinal obstruction, hemorrhage, diverticulitis and perforation (1). Perforation of MD by FBs is extremely uncommon because most ingested FBs pass spontaneously out of the gastrointestinal tract without causing any problems. Reports on FB perforation of MD in both children and adults seem to be on the increase in the medical literature. Most patients do not give a history of ingested FBs which include chicken bones, fish bones, melon seeds, peanuts, bay leaf, toothpick, batteries, needles, pins or wood splinters (2-6). Local inflammation caused by an irritating FB and pressure necrosis at the diverticular wall, combined with secondary attempts by peristalsis to push the FB toward the tip of the diverticulum are possible factors that may lead to the MD perforation (7). The site of the perforation may be covered by fibrin and omentum, as occurred in our patient, or by adjacent bowel loops. Diagnosis of MD perforation by a FB is difficult because the varied clinical presentation may mimic acute appendicitis. Accurate preoperative diagnosis of FB perforation of MD remains challenging despite the availability of radiological imaging. Imaging by abdominal US and computed tomography (CT) are usually inconclusive because of the difficulty in differentiating between bowel loops and MD (6). Abdominal US findings were highly suggestive of acute appendicitis in the present case. A report by Kwon et al of children who had abdominal US for suspected acute appendicitis concluded that increased diameter and hyperemia of the appendix, without periappendiceal fat inflammation may occur in secondary appendicitis, the result of adjacent bowel inflammation (8). The histology report of the appendix in our patient was serositis. Serosal appendicitis is an inflammatory reaction on the surface of the appendix caused by an extra-appendiceal source of inflammation, which in this case, was perforated MD (9). In majority of cases of FB perforation of MD, including ours, the diagnosis is only made intraoperatively. Complicated MD requires surgical resection. In our patient, laparoscopic Meckel’s diverticulectomy was performed with appendectomy. The surgical options for perforated MD are simple diverticulectomy or segmental bowel resection and anastomosis (4). Laparoscopy is a safe, diagnostic and therapeutic tool that can be an important adjunct in the management of acute abdomen in children (10). It helps in visualizing the whole abdominal cavity and establishing diagnosis earlier, allows for faster recovery time, has lower pain scores and significantly reduced hospital length of stay. 2
Conclusion In conclusion, MD perforation by a FB is very rare but the reports in the medical literature are on the increase. Therefore, clinicians should be made aware of perforation of MD by FB in order to consider it in the differential diagnosis of children with suspected acute appendicitis or unexplained abdominal pain. Laparoscopy is good for diagnosis and treatment of perforated MD by a FB...
References 1. Crankson S, Khadi A, AlTawil K, Ahmed IA. Meckel’s diverticulum: a rare cause of intestinal perforation in a preterm newborn. Ann Pediatr Surg 2013; 9:147-149 2. Su CH, Lee JY, Chang YT. Perforation of Meckel’s diverticulum by a peanut presenting as a mesentery abscess. Iran J Pediatr 2013; 23:223-225 3 Okur MH, Arslan MS, Aydogdu B, Uygun I, Goya C, Tokgoz O, Otcu S. Perforation of Meckel’s diverticulum by foreign body. J Pak Med Assoc 2014; 64:826-827 4. Goncalves A, Almeida M, Malheiro L, Costa-Maia J. Meckel’s diverticulum by a fish bone: a case report. Int J Surg Case Rep 2016; 28:28:237-240 5.Aamery A, Al-Shehri R, Malik K, Al-Harthy A. Perforation of Meckel’s diverticulum with a foreign body mimicking acute appendicitis: a rare complication. J Pak Med Assoc 2017; 67: 942944 6. Santos B, Pinto A, Barbosa B, Simoes VC, Silva DS, Davide. Perforation of Meckel’s diverticulum by a swallowed fish bone: case report and literature review. J Surg Case Rep 2019; 1:1-3 7. Bozzi ZT, Brumfitt C, Murphy E. Perforation of a Meckel’s diverticulum by a mussel shell fragment. ANZJ Surg 2017; 9:E104-105 8. Kwon LM, Lee K, Min SK, Ahn SM, Ha HI, Kim MJ. Ultrasound features of secondary appendicitis in pediatric patients. Ultrasonography 2018; 37:233-243 9. Pranesh N, Sathya V, Mainprize KS. Serosal appendicitis: incidence, causes and clinical significance. Postgrad Med J 2006; 82:830-832 10.Nikdopoulos I, Ntakomyti E, El-Gaddal A, Corry D. Extracorporeal laparoscopically assisted resection of a perforated Meckel’s diverticulum due to a chicken bone. BMJ Case Rep 2015; 2015: bcr2014209051 doi: 10.1136/bcr-2014-209051
3
Figure 1: a wooden toothpick through the tip of a Meckel’s diverticulum
Figure 2: appendix
1
Conflict of interest The following authors have no financial disclosures: 1- Stanley Crankson, Department of Pediatric Surgery - king Abdulaziz Medical City-Riyadh-Saudi Arabia, [email protected] 2- Saud Al Jadaan, Department of Pediatric Surgery KASCH - King Abdulaziz Medical City-Riyadh-Saudi Arabia, [email protected]
Declaration of interests ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
Meckel’s diverticulum perforation by a wooden toothpick in a child: a case report
Dr.Abdulhafidh kadhi Department of Pediatric Surgery – KASCH King Abdulaziz Medical City-Riyadh P.O. Box 22490 – Riyadh 11426 MailCode1446 Kingdom of Saudi Arabia E-mail: [email protected] Phone: +966118011111 /53349 Mobile: +966545345144
S2213-5766(19)30293-3
DOI:
https://doi.org/10.1016/j.epsc.2019.101322
Reference:
EPSC 101322
To appear in:
Journal of Pediatric Surgery Case Reports
Received Date: 29 September 2019 Accepted Date: 12 October 2019
Please cite this article as: Kadhi A, Crankson S, Al Jadaan S, Meckel's diverticulum perforation by a wooden toothpick in a child: A case report, Journal of Pediatric Surgery Case Reports (2019), doi: https://doi.org/10.1016/j.epsc.2019.101322. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
Our reference: EPSC 101322 Article reference: EPSC_2019_285 Article title: Meckel’s diverticulum perforation by a wooden toothpick in a child: a case report To be published in: Journal of Pediatric Surgery Case Reports
The authors group and affiliations: 1- Abdulhafidh Kadhi, Department of Pediatric Surgery – KASCH King Abdulaziz Medical City-Riyadh P.O. Box 22490 – Riyadh 11426 MailCode1446 Kingdom of Saudi Arabia E-mail: [email protected] Phone: +966118011111 /53349 Mobile: +966545345144 2- Stanley Crankson, Department of Pediatric Surgery - king Abdulaziz Medical City-Riyadh-Saudi Arabia, [email protected] 3- Saud Al Jadaan, Department of Pediatric Surgery - KASCH - King Abdulaziz Medical City-Riyadh-Saudi Arabia, [email protected]
Meckel’s diverticulum perforation by a wooden toothpick in a child: a case report
Abstract Perforation of Meckel’s diverticulum (MD) by ingested foreign body (FB) is an extremely uncommon cause of acute abdomen in children. We report on a 13-year-old boy who presented with right iliac fossa pain associated with anorexia, tenderness, guarding and rebound tenderness. Abdominal ultrasound showed findings of acute appendicitis. However, laparoscopy revealed a wooden toothpick perforating MD and a hyperemic appendix. The FB was removed and laparoscopic diverticulectomy and appendectomy performed. Perforation of MD by a FB is a diagnostic challenge and it should be included in the differential diagnosis of acute abdomen in children. Introduction Acute appendicitis is the most common pediatric abdominal emergency. However, because of varied clinical manifestations establishing diagnosis may be challenging for the physician. The differential diagnosis of acute appendicitis includes symptomatic Meckel’s diverticulum (MD). MD is the most common congenital anomaly of the gastrointestinal tract, with an incidence of about 2% (1). Majority of cases of MD are asymptomatic but the modes of presentation include intestinal obstruction, hemorrhage, diverticulitis and perforation (1). Perforation of MD, an extremely rare complication may be caused by ingested foreign bodies (FBs) such as chicken bones, fish bones, melon seeds, peanuts, bay leaf, toothpick, batteries, needles, pins or wood splinters in both children and adults (2-6). Herein, we report a case of perforation of MD by a toothpick in a child. Case Report: A 13- year- old boy presented to the emergency room with complaints of right lower quadrant abdominal pain, anorexia and fever for 1 day. There was no history of FB ingestion and past medical history was unremarkable. On physical examination, he was dehydrated, afebrile with tenderness, guarding and rebound tenderness in the right iliac fossa, Laboratory results revealed leukocytosis with neutrophilia. Abdominal ultrasound (US) showed a hyperemic appendix with about 7mm diameter and preliminary diagnosis of acute appendicitis was made. The patient was admitted and after administration of intravenous (IV) fluids, IV antibiotics (Ceftriaxone and Metronidazole) and analgesia. He was scheduled for laparoscopic appendectomy. Laparoscopy revealed terminal ileum and cecum covered by the greater omentum, which on release showed a wooden toothpick through the tip of a Meckel’s diverticulum (Fig. 1) and fibrinous exudates over the terminal ileum. Also, the appendix was hyperemic (Fig.2). The toothpick was removed and laparoscopic Meckel’s diverticulectomy and appendectomy performed. 1
The patient’s post-operative recovery was uneventful, and was discharged home 5 days after surgery. Histopathology examination of the surgical specimen was consistent with an acutely inflamed and perforated MD and an appendix with serositis. Discussion
MD is a remnant of the omphalomesenteric duct, which usually obliterates by the fifth week of gestation. It is located on the antimesenteric border of ileum at variable distances from the ileocecal valve, with an incidence of about 2 % (1). Although MD is commonly asymptomatic, and presents as an incidental finding at operation or autopsy, it has varied manifestations. There is a 4.2 - 16.9% probability of symptomatic presentations, with 60% of patients being symptomatic before the age of 10 years (6). The modes of presentations of MD include intestinal obstruction, hemorrhage, diverticulitis and perforation (1). Perforation of MD by FBs is extremely uncommon because most ingested FBs pass spontaneously out of the gastrointestinal tract without causing any problems. Reports on FB perforation of MD in both children and adults seem to be on the increase in the medical literature. Most patients do not give a history of ingested FBs which include chicken bones, fish bones, melon seeds, peanuts, bay leaf, toothpick, batteries, needles, pins or wood splinters (2-6). Local inflammation caused by an irritating FB and pressure necrosis at the diverticular wall, combined with secondary attempts by peristalsis to push the FB toward the tip of the diverticulum are possible factors that may lead to the MD perforation (7). The site of the perforation may be covered by fibrin and omentum, as occurred in our patient, or by adjacent bowel loops. Diagnosis of MD perforation by a FB is difficult because the varied clinical presentation may mimic acute appendicitis. Accurate preoperative diagnosis of FB perforation of MD remains challenging despite the availability of radiological imaging. Imaging by abdominal US and computed tomography (CT) are usually inconclusive because of the difficulty in differentiating between bowel loops and MD (6). Abdominal US findings were highly suggestive of acute appendicitis in the present case. A report by Kwon et al of children who had abdominal US for suspected acute appendicitis concluded that increased diameter and hyperemia of the appendix, without periappendiceal fat inflammation may occur in secondary appendicitis, the result of adjacent bowel inflammation (8). The histology report of the appendix in our patient was serositis. Serosal appendicitis is an inflammatory reaction on the surface of the appendix caused by an extra-appendiceal source of inflammation, which in this case, was perforated MD (9). In majority of cases of FB perforation of MD, including ours, the diagnosis is only made intraoperatively. Complicated MD requires surgical resection. In our patient, laparoscopic Meckel’s diverticulectomy was performed with appendectomy. The surgical options for perforated MD are simple diverticulectomy or segmental bowel resection and anastomosis (4). Laparoscopy is a safe, diagnostic and therapeutic tool that can be an important adjunct in the management of acute abdomen in children (10). It helps in visualizing the whole abdominal cavity and establishing diagnosis earlier, allows for faster recovery time, has lower pain scores and significantly reduced hospital length of stay. 2
Conclusion In conclusion, MD perforation by a FB is very rare but the reports in the medical literature are on the increase. Therefore, clinicians should be made aware of perforation of MD by FB in order to consider it in the differential diagnosis of children with suspected acute appendicitis or unexplained abdominal pain. Laparoscopy is good for diagnosis and treatment of perforated MD by a FB...
References 1. Crankson S, Khadi A, AlTawil K, Ahmed IA. Meckel’s diverticulum: a rare cause of intestinal perforation in a preterm newborn. Ann Pediatr Surg 2013; 9:147-149 2. Su CH, Lee JY, Chang YT. Perforation of Meckel’s diverticulum by a peanut presenting as a mesentery abscess. Iran J Pediatr 2013; 23:223-225 3 Okur MH, Arslan MS, Aydogdu B, Uygun I, Goya C, Tokgoz O, Otcu S. Perforation of Meckel’s diverticulum by foreign body. J Pak Med Assoc 2014; 64:826-827 4. Goncalves A, Almeida M, Malheiro L, Costa-Maia J. Meckel’s diverticulum by a fish bone: a case report. Int J Surg Case Rep 2016; 28:28:237-240 5.Aamery A, Al-Shehri R, Malik K, Al-Harthy A. Perforation of Meckel’s diverticulum with a foreign body mimicking acute appendicitis: a rare complication. J Pak Med Assoc 2017; 67: 942944 6. Santos B, Pinto A, Barbosa B, Simoes VC, Silva DS, Davide. Perforation of Meckel’s diverticulum by a swallowed fish bone: case report and literature review. J Surg Case Rep 2019; 1:1-3 7. Bozzi ZT, Brumfitt C, Murphy E. Perforation of a Meckel’s diverticulum by a mussel shell fragment. ANZJ Surg 2017; 9:E104-105 8. Kwon LM, Lee K, Min SK, Ahn SM, Ha HI, Kim MJ. Ultrasound features of secondary appendicitis in pediatric patients. Ultrasonography 2018; 37:233-243 9. Pranesh N, Sathya V, Mainprize KS. Serosal appendicitis: incidence, causes and clinical significance. Postgrad Med J 2006; 82:830-832 10.Nikdopoulos I, Ntakomyti E, El-Gaddal A, Corry D. Extracorporeal laparoscopically assisted resection of a perforated Meckel’s diverticulum due to a chicken bone. BMJ Case Rep 2015; 2015: bcr2014209051 doi: 10.1136/bcr-2014-209051
3
Figure 1: a wooden toothpick through the tip of a Meckel’s diverticulum
Figure 2: appendix
1
Conflict of interest The following authors have no financial disclosures: 1- Stanley Crankson, Department of Pediatric Surgery - king Abdulaziz Medical City-Riyadh-Saudi Arabia, [email protected] 2- Saud Al Jadaan, Department of Pediatric Surgery KASCH - King Abdulaziz Medical City-Riyadh-Saudi Arabia, [email protected]
Declaration of interests ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
Meckel’s diverticulum perforation by a wooden toothpick in a child: a case report
Dr.Abdulhafidh kadhi Department of Pediatric Surgery – KASCH King Abdulaziz Medical City-Riyadh P.O. Box 22490 – Riyadh 11426 MailCode1446 Kingdom of Saudi Arabia E-mail: [email protected] Phone: +966118011111 /53349 Mobile: +966545345144