Giant Meckel’s diverticulum with inflammation, ischemia, and adhesive obstruction: A case report

Abstract

BACKGROUND

Adult Meckel diverticulum (MD) is an uncommon cause of acute abdomen, and preoperative diagnosis remains difficult because the presentation overlaps with more familiar right lower quadrant pathology. Giant lesions are particularly rare, with the literature using varying size thresholds. We report a 14-cm MD complicated by inflammation, ischemia, and adhesive small-bowel obstruction in an elderly man.

CASE SUMMARY

A 67-year-old man presented with 3 days of nausea, vomiting, abdominal distension, and obstipation. Laboratory testing showed leukocytosis, elevated inflammatory markers, and dehydration-related renal dysfunction. Contrast-enhanced computed tomography demonstrated diffuse small-bowel dilatation and a blind-ending, inflamed tubular lesion in the right lower quadrant, separate from the cecum. Emergency laparotomy revealed a 14-cm MD arising 50 cm proximal to the ileocecal valve. The diverticulum was distended, ischemic, and densely adherent to adjacent bowel and mesentery, creating a fixed transition point. Adhesiolysis and stapled diverticulectomy were performed. Recovery was uneventful, and the patient was discharged on postoperative day 4. Histopathology showed transmural necrosis, vascular congestion, and acute inflammation without ectopic gastric or pancreatic mucosa.

CONCLUSION

A giant MD should be considered in unexplained adult small-bowel obstruction.

Key Words: Meckel diverticulum; Diverticulitis; Small bowel obstruction; Intestinal ischemia; Diagnostic imaging; Adhesive obstruction; Laparotomy; Case report

Core Tip: Giant Meckel diverticulum is an unusual but important diagnostic pitfall in adults with small-bowel obstruction. In this case, computed tomography showed a blind-ending, inflamed tubular structure separate from the cecum, and surgery confirmed a 14-cm ischemic diverticulum, with inflammatory adhesions creating the transition point. The case is notable not only for its size but also because severe symptoms developed in the absence of ectopic mucosa, underscoring the role of stasis, ischemia, and adhesion formation in giant lesions.

INTRODUCTION

Meckel diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract, with an estimated prevalence of about 2%[1,2]. Most lesions remain clinically silent, but when symptoms do occur, they may be caused by bleeding, inflammation, obstruction, perforation, or, more rarely, neoplasia[2-5]. In adults, obstruction is among the leading complicated presentations, yet preoperative diagnosis remains difficult because the clinical picture often resembles appendicitis, terminal ileitis, or other causes of mechanical small-bowel obstruction[3-6].

The term giant MD is not used uniformly. Some recent reports apply it to lesions longer than 5 cm, whereas others reserve it for diverticula exceeding 10 cm[7,8]. Whatever threshold is used, giant lesions are distinctly uncommon and appear more likely to present with torsion, obstruction, diverticulitis, perforation, or ischemia than diverticula of usual size[5,7-14].

We describe a 14-cm giant MD in a 67-year-old man who presented with inflammation, ischemia, and adhesive small-bowel obstruction. Because the lesion was recognised preoperatively as a blind-ending, inflamed tubular structure separate from the cecum, the case also offers an opportunity to discuss the radiologic differential diagnosis and the current surgical questions raised by giant MD in adults.

CASE PRESENTATION

Chief complaints

A 67-year-old man presented with nausea, vomiting, abdominal distension, and failure to pass stool or flatus for 3 days.

History of present illness

The symptoms began 3 days before admission and progressed despite conservative measures at home.

History of past illness

His medical history included type 2 diabetes mellitus, hypertension, heart failure, and chronic obstructive pulmonary disease. He had no prior abdominal surgery. His regular medications were ivabradine 7.5 mg, eplerenone 25 mg, clopidogrel 75 mg, carvedilol 25 mg, linagliptin 5 mg, and metformin 1000 mg.

Personal and family history

No relevant family history was reported.

Physical examination

Vital signs were stable. The abdomen was distended, with diffuse tenderness but no peritoneal irritation. Bowel sounds were hypoactive.

Laboratory examinations

Laboratory testing showed leukocytosis (17 × 10⁹/L) with neutrophilia (85%), C-reactive protein 175 mg/L, urea 11.3 mmol/L (68 mg/dL), and creatinine 203 μmol/L (2.3 mg/dL), consistent with an inflammatory process and dehydration-related renal dysfunction. Liver function tests and serum electrolytes were within normal limits.

Imaging examinations

Contrast-enhanced computed tomography (CT) of the abdomen and pelvis showed diffuse small-bowel dilatation, with loops measuring up to 50 mm, and a blind-ending tubular structure measuring approximately 92 mm × 39 mm in the right lower quadrant. The lesion was separate from the cecum and associated with surrounding fat stranding and free fluid in the perihepatic, perisplenic, paracolic, and pelvic recesses (Figure 1). Its blind-ending tubular configuration and apparent continuity with the distal ileum made a complicated MD more likely than appendiceal or cecal pathology.

Figure 1  Contrast-enhanced computed tomography showing diffuse small-bowel dilatation and a blind-ending, inflamed tubular lesion in the right lower quadrant.

FINAL DIAGNOSIS

Giant, inflamed, and ischemic MD with adhesive small-bowel obstruction.

TREATMENT

After fluid resuscitation and broad-spectrum antibiotics, the patient underwent emergency exploratory laparotomy through a midline incision. The small bowel was diffusely dilated. Approximately 50 cm proximal to the ileocecal valve, a giant diverticulum was identified on the antimesenteric border of the ileum. It measured about 14 cm × 4 cm, was markedly distended and ischemic, and was densely adherent to adjacent bowel loops and mesentery, thereby creating the transition point of the obstruction (Figure 2). Adhesiolysis was performed, and the diverticulum was resected flush with the ileal wall using a 60-mm linear stapler. Bowel patency and hemostasis were confirmed before layered abdominal closure.

Figure 2 Emergency exploratory laparotomy through a midline incision. A: Intraoperative view showing diffusely dilated small-bowel loops; B: Severe inflammation and adhesions involving the terminal ileum and adjacent loops; after adhesiolysis, an ischemic, markedly dilated Meckel diverticulum was exposed; C: Giant Meckel diverticulum before resection, showing marked distension with inflammation and ischemia.

OUTCOME AND FOLLOW-UP

Recovery was uneventful. Oral intake was resumed on postoperative day 2, and the patient was discharged on postoperative day 4 with stable vital signs and restored bowel function. Histopathological examination showed transmural necrosis, vascular congestion, and intense neutrophilic inflammation without ectopic gastric or pancreatic mucosa (Table 1).

Table 1 Timeline of clinical events.

Time	Event
Day-3	Onset of nausea, vomiting, and obstipation
Day 0 (ED)	Evaluation, laboratory testing, and contrast-enhanced CT suggesting complicated MD
Day 0	Emergency exploratory laparotomy; adhesiolysis and stapled diverticulectomy
Postoperative day 2	Oral intake resumed
Postoperative day 4	Discharged with uneventful recovery

ED: Emergency department; CT: Computed tomography; MD: Meckel diverticulum.

DISCUSSION

Although MD is common as a congenital anomaly, symptomatic disease in adults remains uncommon[1,2]. When adult patients do become symptomatic, the clinical picture is often nonspecific, and diagnosis is frequently delayed until surgery[3-6]. In the classic series by Ymaguchi et al[6], obstruction was among the most frequent complicated presentations. Our patient illustrates this diagnostic problem well: He was elderly, had no prior abdominal surgery, and presented with obstruction and right lower quadrant inflammation, a combination that initially raises more common possibilities than MD.

The question of size also deserves clarification. The literature does not apply a single definition of giant MD. Some recent reports use the term for diverticula longer than 5 cm, whereas others reserve it for lesions exceeding 10 cm[7,8]. The present lesion measured 14 cm and therefore qualifies as giant by either definition. This matters clinically because the longer and more mobile the diverticulum, the greater the opportunity for stasis, torsion, adhesion formation, and other mechanical complications.

From a radiologic standpoint, the most relevant preoperative alternatives in an older patient with right lower quadrant inflammation are appendiceal mucocele, duplication cyst, and cecal neoplasm. In our case, CT favoured MD because the lesion appeared as a blind-ending tubular structure separate from the cecal base, with upstream small-bowel dilatation and surrounding inflammatory change[3,4]. Appendiceal mucocele is usually contiguous with the cecum, whereas duplication cysts are more commonly rounded cystic lesions that share the bowel wall rather than a tubular outpouching from the distal ileum. Cecal neoplasms, in contrast, tend to be centred in the cecal wall rather than presenting as an isolated, inflamed ileal blind pouch.

Several mechanisms have been described for obstruction caused by MD, including volvulus around a fibrous or mesodiverticular band, internal hernia, intussusception, enterolith formation, and inflammatory adhesions[2,5,6,9-14]. The operative findings in our patient strongly supported an adhesive mechanism. The diverticulum was inflamed, ischemic, and densely tethered to adjacent bowel and mesentery, creating a fixed transition point. The resulting picture was not simply diverticulitis plus ileus; it was true mechanical obstruction driven by local inflammatory fixation. Figure 3 illustrates the likely mechanism by which a giant inflamed diverticulum can tether surrounding structures and produce obstruction.

Figure 3  Box diagram of the proposed stepwise mechanism in the present case: A giant Meckel diverticulum became distended, inflamed, and ischemic; inflammatory adhesions tethered it to adjacent ileal loops and mesentery; a fixed transition point then produced mechanical small-bowel obstruction.

A hallmark of symptomatic MD is the presence of ectopic gastric or pancreatic mucosa, especially in bleeding presentations. Even so, ectopic tissue is not necessary for symptoms to develop[2,5]. Histopathology in the present case showed transmural necrosis, vascular congestion, and intense neutrophilic inflammation, but no ectopic tissue. In giant lesions, luminal stasis, progressive distension, torsion of a long, mobile diverticulum, or impaired venous outflow may be sufficient to trigger diverticulitis and ischemia, with secondary adhesion formation leading to obstruction[5,10,12,13]. The absence of ectopic mucosa, therefore, does not weaken the diagnosis; rather, it helps explain that the dominant mechanism here was mechanical and ischemic rather than acid-mediated ulceration.

To place the case in context, Table 2 summarises adult giant MD cases reported over the last decade. Two patterns are especially striking. The first is obstruction related to torsion, internal hernia, or band formation[9,12,13]. The second is diverticulitis, with or without perforation[10,11,14]. Most patients required emergency laparotomy, and segmental bowel resection was favoured when the base or adjacent ileum was inflamed, perforated, or of uncertain viability. Our case fits the obstructive end of this spectrum, but it is distinctive because dense inflammatory adhesions rather than a congenital band or axial torsion were the dominant intraoperative finding.

Table 2 Adult giant Meckel diverticulum cases reported during the last decade.

Ref.	Age/sex	Size (cm)	Main presentation	Operative approach
Capelão et al[9], 2017	51/male	15	SBO due to internal hernia and mesodiverticular band	Laparotomy; segmental small-bowel resection
Malcom et al[10], 2018	71/female	29	Diverticulitis with perforation	Laparotomy; small-bowel resection
García-Quijada García et al[11], 2019	44/male	17	Diverticulitis	Ileal resection with primary anastomosis
Dirim and Ozyazici[12], 2021	Adult/female	7 cm × 4.5 cm	Diverticulitis with perforation due to necrosis	Segmental ileal resection with end-to-end anastomosis
Munasinghe et al[13], 2022	20/male	25	Axial torsion, gangrene, and SBO	Diverticulectomy plus segmental ileal resection
Nasir et al[14], 2023	25/male	35	Post-traumatic hemoperitoneum	Diverticulectomy with repair of small-bowel defect
Anis et al[7], 2023	45/NR	25	SBO caused by the fibrous-band internal ring	Laparotomy; segmental small-bowel resection
Alkhlaifat et al[8], 2024	44/male	> 5	Perforation with fecalith obstruction	Adhesiolysis, bowel resection, and anastomosis

SBO: Small-bowel obstruction; NR: Not reported.

The management of incidentally discovered MD remains unsettled. Zani et al[15] argued against routine resection of every incidental diverticulum, whereas later reviews have emphasised individualised decision-making based on age, sex, diverticular length, macroscopic appearance, and the presence of fibrous bands or ectopic tissue[5,16-18]. The question becomes more pressing in the case of giant diverticula. Large size increases the theoretical risk of stasis, torsion, obstruction, and delayed technical difficulty if complications develop later. In addition, MD can harbour neoplasms, particularly neuroendocrine tumours, and malignancy may be clinically silent[17,18]. For that reason, although a 10-cm incidental diverticulum in an older asymptomatic patient would not necessarily mandate resection in every circumstance, many surgeons would reasonably favour resection if the operative field is favourable and the patient's physiologic reserve permits.

Laparoscopy also deserves comment. Diagnostic laparoscopy can be extremely helpful in stable patients with equivocal imaging findings and may allow either laparoscopic-assisted or targeted extracorporeal resection once the diverticulum is identified[4,16]. In our patient, however, open surgery was the more appropriate option. The bowel was markedly distended, the lesion was severely inflamed and ischemic, and dense adhesions were already producing mechanical obstruction. Under those circumstances, rapid exposure and safe adhesiolysis took precedence over a minimally invasive approach.

Taken together, the present case shows that a giant MD can present late in life, can mimic more common right lower quadrant pathology on imaging, and can become symptomatic even in the absence of ectopic mucosa. Careful CT interpretation, early operative judgment, and definitive resection remain central to good outcomes.

CONCLUSION

Giant MD should remain in the differential diagnosis of unexplained small-bowel obstruction, particularly when CT shows a blind-ending, inflamed tubular lesion that is separate from the cecum. In adults, giant diverticula may become symptomatic through inflammation, ischemia, and adhesion formation even without ectopic mucosa. Prompt resection is both diagnostic and therapeutic.