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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 8  |  Issue : 3  |  Page : 143-146

Rare presentation of patent vitellointestinal duct-Meckel's diverticulum and vitelline cyst-A case report


1 Department of Anatomy, D.Y.Patil Medical College, DY Patil Education Society, Deemed to be University, Kasaba Bawada, Kolhapur, Maharashtra, India
2 Department of Surgery, Islampur Multispeciality Hospital, Islampur, Sangli, Maharashtra, India
3 Senior Resident, Department of General Surgery, Seth G S Medical College, KEM Hospital, Mumbai, Maharashtra, India

Date of Web Publication27-Sep-2019

Correspondence Address:
Dr. Vasudha R Nikam
Department of Anatomy, D.Y. Patil Medical College, Dr. D.Y. Patil Education Society, Deemed to be University, D.Y. Patil Medical College, Kasaba Bawada, Kolhapur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_24_18

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  Abstract 


Meckel's diverticulum is one of the most common anomalies of the gastrointestinal tract. Many of them remain unexpressed and are discovered accidentally. Vitello-intestinal duct anomalies are rare and occur in 1–2% of the population. These anomalies may present in adult life like appendicitis; hence, proper investigations will reveal the correct diagnosis. Meckel's diverticulum requires surgical correction. Here, we present a rare case report of Meckel's diverticulum with Vitelline cyst in a 21-year-old male patient, which was successfully resected surgically.

Keywords: Adult patient, Meckel's diverticulum, patent vitello-intestinal duct, vitelline cyst


How to cite this article:
Nikam VR, Garud AS, Patil PD. Rare presentation of patent vitellointestinal duct-Meckel's diverticulum and vitelline cyst-A case report. Arch Int Surg 2018;8:143-6

How to cite this URL:
Nikam VR, Garud AS, Patil PD. Rare presentation of patent vitellointestinal duct-Meckel's diverticulum and vitelline cyst-A case report. Arch Int Surg [serial online] 2018 [cited 2019 Oct 19];8:143-6. Available from: http://www.archintsurg.org/text.asp?2018/8/3/143/268125




  Introduction Top


Meckel's diverticulum is a common congenital anomaly of the gastrointestinal tract affecting 2% of the population.[1] The usual location is on the antimesenteric border of the ileum, usually within about 60–100 cm of the ileocecal valve.[2] Meckel's diverticulum is the result of the variety of omphalomesenteric duct anomalies.[3] It possesses all three coats of the intestine. It presents a ratio of three male to one female. It remains silent but may present with life alarming complications such as the intestinal obstruction, perforation, hemorrhage, and peptic ulceration. Complications imitate gastrointestinal disorders like appendicitis making diagnostic difficulty.[4] Intestinal obstruction due to patent vitello-intestinal duct stipulates early prompt diagnosis as well as successful operative management.[5]

Vitello-intestinal duct connects the developing midgut to the primitive yolk sac, provides nutrition, and remains patent and connected to the intestines until 5th to 9th week of the gestational period. Anomalies develop because of its patency.[6]

Such anomalies present in adulthood with a variety of umbilical disorders that require surgical correction. We present a rare case of Meckel's diverticulum along with vitelline cyst at its terminal end.


  Case Report Top


A 21-year-old male patient came with abdominal colicky pain, with a history of vomiting since last 2 days. There was no history of previous abdominal surgery and no discharge from the umbilicus.

On examination, all vitals were within normal limits. P/A examination revealed soft, non-tender but slight distension of the abdomen. On palpation, there was shifting of pain, tenderness, and guarding was present in right iliac fossa. There was no lump palpable. Ultrasonography (USG) and computerized tomography (CT) abdomen were advised.

The USG examination of the abdomen revealed a well-defined cystic lesion measuring (6.8 × 4.3 × 3.5 cm) in infraumbilical region. It showed the connection with anterosuperior part of urinary bladder by a fibrous band. There were no signs of appendicitis.

A CT revealed a medium-sized cystic lesion laden with air within the central abdomen and was shifted toward the right side; paramedian in position [Figure 1]. It was interconnected with umbilicus on one side and to the loop of small intestine on the other side. There was subacute torsion of the pedicle, and the diagnosis of Meckel's diverticulum was confirmed.
Figure 1: CT abdominal image showing the view of vitelline cyst (Yellow arrow) and its connection with Meckel's diverticulum (Red arrow)

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In view of symptomatic omphalomesenteric duct, elective surgery was planned. The patient was taken for laparotomy; during the surgery, a patent vitello-intestinal duct extending from antimesenteric border of the distal part of the ileum to the posterior wall of the umbilicus and anterior abdominal wall was noted [Figure 2].
Figure 2: Operative image showing the patent vitello-intestinal duct showing the attachment with the small intestine on one side and to the posterior aspect of the umbilicus on the other side

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The Meckel's diverticulum was situated 60 cm proximal to the ileocecal valve, and at its terminal end, the duct showed an inflamed vitelline cyst attached to the umbilicus and by a thin fibrous band with urinary bladder. The length of the diverticulum was approximately (7.2 × 3.5 × 3 cm) with mild subacute torsion near the ileal end [Figure 3].
Figure 3: Operative image showing the torsion of Meckel's diverticulum that was resected from the ileum; the terminal end shows the vitelline cyst

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The patient underwent surgical resection of Meckel's diverticulum with sparing of small bowel; the resection of vitelline cyst at its terminal end was done by separating it from umbilicus and antero-superior surface of the urinary bladder. A drain was kept in the right paracolic space. There were no complications seen postoperatively. The patient was discharged on 7th postoperative day.

Histopathology reports confirmed the diagnosis of persistent vitello-intestinal duct and vitelline cyst [Figure 4].
Figure 4: Operative image showing the intestinal columnar epithelium with goblet cells and lymphoid follicles in lamina propria

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Embryology

Vitello-intestinal duct anomalies have been reported to be congenital anomalies associated with the primitive yolk sac. It is the embryonic structure connecting the primary yolk sac to the embryonic midgut that normally becomes a thin fibrous band, which eventually disintegrates and is absorbed at 5th-10th week of gestation. The duct will continue to grow if it fails to completely atrophy and disintegrate; the failure of such closure may result in various lesions such as; Meckel's diverticulum, patent vitellointestinal duct, vitelline cyst or a fibrous cord connecting ileum to the umbilicus. Meckel's diverticulum remains the most common vitellointestinal duct anomaly.[6]


  Discussion Top


Meckel's diverticulum was first described by Fabricus Hiladanus in 1590; but it derives its name from Johann Friedrich Meckel who well explained its anatomy and embryologic origin in 1809.[3]

The position of Meckel's diverticulum typically arises from antimesenteric surface of ileum within 90–100 cm distance from the ileocecal valve.[3] In our case, it was 60 cm from the ileocecal valve.

According to well-known a statement of Charles Mayo, “Meckel's Diverticulum” is frequently thought of, often anticipated for, and not often found. Preoperative diagnosis of Meckel's diverticulum is still an exceptional challenge. However, USG and CT are common, accurate, non-invasive investigation performed in these cases.[4] In our study also, USG and CT confirmed the diagnosis. It was diagnosed with vitelline cyst, which is very rarely seen.

Preoperative diagnosis is rare, and the diverticulum is usually observed accidentally. “Rule of two” is characteristic for Meckel's diverticulum that includes the frequency in 2% population; it is usually diagnosed under the age of 2; it is 2 inches in size, 2 cm in diameter, 2 feet proximal to ileocecal valve, twice repeated in men, and symptomatic in 2% patient.[4],[7] In our case, the patient was male, and the Meckel's diverticulum was situated 60 cm from the ileocecal valve.

Many studies have revealed different perspectives for symptomatic persistent vitello-intestinal duct such as open laparotomy of laparoscopic excision. Laparoscopic surgery is spreading as an appreciative and successful management for uncomplicated cases. However, open laparotomy is also well-known treatment.[8],[9]

In our case, patient underwent exploratory laparotomy and resection of persistent vitello-intestinal duct and vitelline cyst followed by ileal anastomosis was done. Postoperative no complications were noticed.


  Conclusion Top


Meckel's diverticulum is most common anomaly of gastrointestinal tract and present as appendicitis, intestinal obstruction, perforated peritonitis, and diverticulitis. Urgent surgical intervention is needed to prevent the mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

This work was supported by Islampur Multispeciality Hospital, Islampur; District: Sangli and DY Patil Education Society; Deemed to be University; D.Y. Patil Medical College; Kolhapur.

Thanks to Chancellor, Vice Chancellor, ProVice Chancellor, Registrar and Dean of DY Patil Education Society's Deemed to be University and D.Y. Patil Medical College, Kolhapur. Thanks to Dr. Amit Garud and my colleagues of Department of Anatomy for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mohanty PK, Panda SS, Das RR, Mallick S. Mesenteric location of Meckel'sdiverticulum: Is it really uncommon. Saudi J Health Sci 2014;3:166-7.  Back to cited text no. 1
  [Full text]  
2.
Ahmad Z, Sharma A, Vatti V, Ahmed M, Ashraf Ali M. Rare presentation on Meckel's diverticulum on the mesenteric border forming a mass. Int Surg J 2014;1:188-90.  Back to cited text no. 2
    
3.
Hatipoglu S, Abdullayev R, Benlioglu C, Goksu M, Hqatipoglu F, Bayramoglu E. Enterocutaneous Fistula formation of meckel's diverticulum via the urachal cyst in an adult patient: A case report and literature review. Int J Case Rep Med 2014 (2014):1-9  Back to cited text no. 3
    
4.
Kalaskar N, Thalasta P. Meckel'sdiverticulum, presentation and its management at Basaveshwarateaching and general hospital. Scholars J Appl Med Sci 2016;4:4224-30.  Back to cited text no. 4
    
5.
Bhandari TR, Shahi S, Gautam M, Pandey S. A rare case report of patent vitellointestinal duct causing bowel obstruction in an adult. Int J Case Rep 2017;39:231-4.  Back to cited text no. 5
    
6.
Goyal S, Goyal R, Sharma PK, Rashid A, Sandhu SS, Utaal MS. Persistent vitellointestinalduct causing small bowel obstruction-A rare entity. Indian Med Gaz 2014;147:393-6.  Back to cited text no. 6
    
7.
Altaf A, Aref H.A case report: Cecalvolvulus caused by Meckel's diverticulum. Int J Surg Case Rep 2014;5:1200-2.  Back to cited text no. 7
    
8.
Lassen PM, Harris MJ, Kearse WS Jr, Argueso LR. Laparoscopic management of incidentally noted omphalomesenteric duct remnant. J Endourol 1994;8:49-51.  Back to cited text no. 8
    
9.
Annaberdyev S, Capizzani T, Plesec T, Moorman M. A rare case presentation of a symptomatic omphalomesenteric cyst in an adult, 24 year old patient treated with laparoscopic resection. J Gastrointest Surg 2013;17:1503-6.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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