European Journal of Radiology, 12 (1991) 45-46 45
Elsevier
EJR 00107
Sonographic manifestation
of an inflamed Meckel’s diverticulum: a case report
J.G. Poelman, Department
and G.H. Ritsema
of Radiology, St. Clara Hospital, Rotterdam, The Netherlands
(Received
Key words: Ultrasound,
D.N. Htipscher
18 April 1990; accepted
Meckel’s diverticulum;
after revision 16 July 1990)
Meckel’s diverticulum,
diagnosis;
Meckel’s diverticulum,
ultrasound
study
Introduction Inflammation of Meckel’s diverticulum is a rare surgical finding. However, if the surgeon finds a normal appendix during operation, he should examine the ileum to see whether a Meckel’s diverticulum is present. Recently, sonography has been included in the preoperative work-up of patients suspected of acute appendicitis [ 11. In this case report a patient in whom an inflamed Meckel’s diverticulum was found sonographically is presented. Case report A 68-year-old man was referred to our clinic for pre-operative sonographic evaluation as clinical signs suggested acute appendicitis. The graded compression method [l] was used to examine the right side of the lower abdomen. Just lateral to the median line there was a bull’+eye lesion, i.e., a tubular structure with a diameter of 21 mm and concentric layers (Fig. la). This structure was not compressible, there were no visible signs of peristalsis, and the tube seemed to have a blind end on one side. These findings were reproducible. Local pain while pressing was present. The structure could not be adequately visualized in its length (Fig. lb), and the coecum was difficult to visualize. No intra-abdominal fluid could be seen. Although the sonographic picture was not entirely typical, the diagnosis was thought to be appendicitis. At Address for reprints: J.G. Poelman M.D., Department ofRadiology, St. Clara Hospital, Olympiaweg 350, 3078 HT Rotterdam, The Netherlands. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
b
a
Fig. 1. (a) Transverse sonogram showing a non-compressible eye lesion. (b)The same structure shown longitudinally. seems to be a blind end (arrow).
bull’sThere
operation, however, a normal appendix was found. Inspection of the terminal ileum showed an inflamed Meckel’s diverticulum measuring 2-3 cm. Both the appendix and the diverticulum were removed. The histological findings confirmed the diagnosis. The post-operative course was uneventful. Discussion For the diagnosis of an acute appendicitis, sonography is reported to have high sensitivity (7589%) and specificity (96-100%) [ 1,2]. An inflamed appendix
B.V. (Biomedical
Division)
46
presents as a non-compressible tubular, concentrically layered, and aperistaltic structure with a blind ending, the other end being attached to the pole of the coecum. Intraluminal air is usually absent. The diameter ranges between 6 and 20 mm. These findings should be reproducible [ I]. In the case presented here there were some doubts about the diagnosis. The structure was large (21 mm) and its localization atypical. It could not be adequately visualized in the longitudinal view, and the pole of the coecum was not clearly visible. Although inflammation of the terminal ileum was considered, the absence of intraluminal air and of peristalsis, the incompressibility, and the impression that one end of the structure was blind, pleaded against that diagnosis. Meckel’s diverticulum is the most common congenital anomaly of the digestive tract, the incidence amounting to l-4% [3], and in these cases the possibility of local complications is about 4% [4]. In the series by Diamond et al. [ 31, over a period of 15 years, a Meckel’s diverticulum was removed in 49 adult patients. In 12 out of 24 patients in whom an inflamed Meckel’s diverticulum was found, the preoperative diagnosis had been acute appendicitis. It has been estimated that the combination of acute appendicitis and an inflamed Meckel’s diverticulum of all appendectomies occurs in 0.15 to 0.47 % [ 51. In the
literature, we have been able to find only one report of a case in which the diagnosis appendicitis was based on the sonographic findings, but a Meckel’s diverticulum which had undergone torsion was found at operation [6]. The case presented here shows that in patients suspected of acute appendicitis a sonogram showing a tubular structure is not always pathognomonic to appendicitis. The differential diagnosis should also include inflamed Meckel’s diverticulum. References Puylaert JBCM. The use of ultrasound in patients with clinical signs of appendicitis. Ph.D. Thesis, Leiden, The Netherlands, 1988. Jeffrey, Jr RB, Laing FC, Townsend RR. Acute appendicitis: sonographic criteria based on 250 cases. Radiology 1988; 167: 327-329. Diamond T, Russel CFJ. Meckel’s diverticulum in the adult. Br J Surg 1985; 72: 480-482. Soltero MJ, Bill AJ. The natural history of Meckel’s diverticulum and its relation to incidental removal. Am J Surg 1976; 132: 168-173. Colina Alonso A, Gbmez Iglesias S, Dominguez Hinarejos C, Baquero Valdelomar R. Coexistencia de diverticulo de Meckel pathologico y appendicitis agunda en el adulto. Aportaci6n de seis cases. Rev Esp Enferm Apar Dig 1987; 71: 437-439. Larson J, Ellinger D. Sonographic findings in torsion of a Meckel’s diverticulum. AJR 1989; 152: 1130.
Elsevier
EJR 00107
Sonographic manifestation
of an inflamed Meckel’s diverticulum: a case report
J.G. Poelman, Department
and G.H. Ritsema
of Radiology, St. Clara Hospital, Rotterdam, The Netherlands
(Received
Key words: Ultrasound,
D.N. Htipscher
18 April 1990; accepted
Meckel’s diverticulum;
after revision 16 July 1990)
Meckel’s diverticulum,
diagnosis;
Meckel’s diverticulum,
ultrasound
study
Introduction Inflammation of Meckel’s diverticulum is a rare surgical finding. However, if the surgeon finds a normal appendix during operation, he should examine the ileum to see whether a Meckel’s diverticulum is present. Recently, sonography has been included in the preoperative work-up of patients suspected of acute appendicitis [ 11. In this case report a patient in whom an inflamed Meckel’s diverticulum was found sonographically is presented. Case report A 68-year-old man was referred to our clinic for pre-operative sonographic evaluation as clinical signs suggested acute appendicitis. The graded compression method [l] was used to examine the right side of the lower abdomen. Just lateral to the median line there was a bull’+eye lesion, i.e., a tubular structure with a diameter of 21 mm and concentric layers (Fig. la). This structure was not compressible, there were no visible signs of peristalsis, and the tube seemed to have a blind end on one side. These findings were reproducible. Local pain while pressing was present. The structure could not be adequately visualized in its length (Fig. lb), and the coecum was difficult to visualize. No intra-abdominal fluid could be seen. Although the sonographic picture was not entirely typical, the diagnosis was thought to be appendicitis. At Address for reprints: J.G. Poelman M.D., Department ofRadiology, St. Clara Hospital, Olympiaweg 350, 3078 HT Rotterdam, The Netherlands. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
b
a
Fig. 1. (a) Transverse sonogram showing a non-compressible eye lesion. (b)The same structure shown longitudinally. seems to be a blind end (arrow).
bull’sThere
operation, however, a normal appendix was found. Inspection of the terminal ileum showed an inflamed Meckel’s diverticulum measuring 2-3 cm. Both the appendix and the diverticulum were removed. The histological findings confirmed the diagnosis. The post-operative course was uneventful. Discussion For the diagnosis of an acute appendicitis, sonography is reported to have high sensitivity (7589%) and specificity (96-100%) [ 1,2]. An inflamed appendix
B.V. (Biomedical
Division)
46
presents as a non-compressible tubular, concentrically layered, and aperistaltic structure with a blind ending, the other end being attached to the pole of the coecum. Intraluminal air is usually absent. The diameter ranges between 6 and 20 mm. These findings should be reproducible [ I]. In the case presented here there were some doubts about the diagnosis. The structure was large (21 mm) and its localization atypical. It could not be adequately visualized in the longitudinal view, and the pole of the coecum was not clearly visible. Although inflammation of the terminal ileum was considered, the absence of intraluminal air and of peristalsis, the incompressibility, and the impression that one end of the structure was blind, pleaded against that diagnosis. Meckel’s diverticulum is the most common congenital anomaly of the digestive tract, the incidence amounting to l-4% [3], and in these cases the possibility of local complications is about 4% [4]. In the series by Diamond et al. [ 31, over a period of 15 years, a Meckel’s diverticulum was removed in 49 adult patients. In 12 out of 24 patients in whom an inflamed Meckel’s diverticulum was found, the preoperative diagnosis had been acute appendicitis. It has been estimated that the combination of acute appendicitis and an inflamed Meckel’s diverticulum of all appendectomies occurs in 0.15 to 0.47 % [ 51. In the
literature, we have been able to find only one report of a case in which the diagnosis appendicitis was based on the sonographic findings, but a Meckel’s diverticulum which had undergone torsion was found at operation [6]. The case presented here shows that in patients suspected of acute appendicitis a sonogram showing a tubular structure is not always pathognomonic to appendicitis. The differential diagnosis should also include inflamed Meckel’s diverticulum. References Puylaert JBCM. The use of ultrasound in patients with clinical signs of appendicitis. Ph.D. Thesis, Leiden, The Netherlands, 1988. Jeffrey, Jr RB, Laing FC, Townsend RR. Acute appendicitis: sonographic criteria based on 250 cases. Radiology 1988; 167: 327-329. Diamond T, Russel CFJ. Meckel’s diverticulum in the adult. Br J Surg 1985; 72: 480-482. Soltero MJ, Bill AJ. The natural history of Meckel’s diverticulum and its relation to incidental removal. Am J Surg 1976; 132: 168-173. Colina Alonso A, Gbmez Iglesias S, Dominguez Hinarejos C, Baquero Valdelomar R. Coexistencia de diverticulo de Meckel pathologico y appendicitis agunda en el adulto. Aportaci6n de seis cases. Rev Esp Enferm Apar Dig 1987; 71: 437-439. Larson J, Ellinger D. Sonographic findings in torsion of a Meckel’s diverticulum. AJR 1989; 152: 1130.
