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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 130-132

Incidental finding of meckel's diverticulum in a patient with ascaris-induced intestinal obstruction


Department of Pediatric Surgery, Safdarjung and VMMC Hospital, NewDelhi, India

Date of Web Publication30-Nov-2016

Correspondence Address:
Mohit Bhatia
1, Bank Colony, Opposite Old Sessions Courts, Ambala City - 134003, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.194990

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  Abstract 

Ascaris lumbricoides is a large parasite that infests the human bowel, especially in regions with poor environmental sanitation in the tropics. Meckel's diverticulum is mainly an asymptomatic congenital intestinal anomaly. Rarely, it becomes symptomatic when it is associated with complications such as diverticulitis, perforation, and bleeding. It may be associated with a heavy worm load. We report a case of 7-year-old female child with intestinal obstruction and incidental finding of Meckel's diverticulum with gangrenous bowel.

Keywords: Ascariasis, intestinal obstruction, Meckel's diverticulum


How to cite this article:
Bhatia M, Tomar V, Shankar R. Incidental finding of meckel's diverticulum in a patient with ascaris-induced intestinal obstruction. Arch Int Surg 2016;6:130-2

How to cite this URL:
Bhatia M, Tomar V, Shankar R. Incidental finding of meckel's diverticulum in a patient with ascaris-induced intestinal obstruction. Arch Int Surg [serial online] 2016 [cited 2021 Jan 20];6:130-2. Available from: https://www.archintsurg.org/text.asp?2016/6/2/130/194990


  Introduction Top


Intestinal obstruction and infestation by Ascaris is mostly seen in developing countries.[1] In most of the cases, it remains asymptomatic, however, in cases with heavy worm load, it can result in complications such as obstruction, perforation involving appendix or Meckel's diverticulum, or biliary ascariasis.[2]

Incidence and severity of complications depends on factors such as a high burden of worm and worm size.[3] Radiological modalities often helps in detecting worm in bowel with sonographic images depicting intestinal worm bolus, floating worms with free fluid, and sluggish peristalsis. Preoperative diagnosis of Meckel's diverticulum associated with worm infestation is rarely made, and hence in most of the cases, it is an incidental finding.[4]

Here, we present a case of 7-year-old female child with massive worm infestation along with an incidental finding of Meckel's diverticulum.


  Case Report Top


A 7-year-old female child presented with a history of abdominal pain/distension with recurrent vomiting (with worms in the vomitus), and high grade fever since 4 days. On examination, the child had a toxic look. Abdominal findings revealed abdominal distension [Figure 1], with generalized tenderness and rebound tenderness in lower abdomen. Total leucocyte count was 18700, and her hemoglobin was 8 gm/dl. Plain X-ray of the abdomen revealed multiple air fluid levels. Ultrasound of the abdomen showed sluggish peristalsis with worms entangled with free fluid. Ryles tube was inserted to decompress the upper gastrointestinal tract. The patient was subjected to emergency exploratory laparotomy. Intraoperative findings comprised Meckel's diverticulum with gangrenous segment of terminal ileum because of volvulus with worm bolus in the terminal ileum and proximal segment [Figure 2]. Resection of the gangrenous bowel segment, diverticulectomy, and appendectomy with proximal ileostomy was done [Figure 3] and [Figure 4]. Thorough lavage was given and the patient had an uneventful postoperative period and was discharged on postoperative day 6.
Figure 1: Image showing abdominal distension

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Figure 2: Worm being extracted from the bowel

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Figure 3: Worms and gangrenous bowel

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Figure 4: Specimen showing Meckel's diverticulum and appendix with resected bowel segment

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  Discussion Top


Although ascariasis remains mostly asymptomatic, it can lead to abdominal complications, varying from intestinal obstruction, perforation, volvulus, and rarely Meckel's diverticulitis.[5] The most common complication caused by ascariasis is intestinal obstruction. However, in some cases, association of Meckel's with ascariasis has been found, which is probably due to worm incarceration resulting from the blockage of the base of diverticulum by interlocking of the roundworms.[6] Because of worm bolus obstruction (due to compromise in vascularity caused by worm bolus), ileal perforation and gangrene occurs secondary to pressure necrosis.[7] Volvulus of the ileal segment because of impacted worm bolus can further lead to gangrene of Meckel's diverticulum.[8]

Meckel's diverticulum is a commonly seen anomaly of gastrointestinal tract. Due to a heavy load of worms, possibility of getting entangled at the narrow base of the diverticulum are high, therefore resulting in perforation of diverticulum.[9] Perforation of Meckel's diverticulum is rarely caused by the roundworms.[10] Perforation at the tip of the diverticulum is due to the pressure necrosis caused by the impacted worms.[11]

Studies have justified the removal of silent Meckel's diverticulum in an emergency surgery for ascariasis intestinal obstruction, and have also mentioned the use of diverticulectomy site as an enterotomy site for the complete removal of worms.[12]


  Conclusion Top


A surgeon treating a case of ascaris-induced intestinal obstruction should always be vigilant for the possible complications associated with ascariasis. Meckel's diverticulum may remain asymptomatic but if found during the surgery should be removed prophylactically in view of its anticipated complications. Early surgical intervention in patients with features of peritonitis will help in reducing mortality and may salvage the bowel.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mishra PK, Agrawal A, Joshi M, Sanghvi B, Shah H, Parelkar SV. Intestinal obstruction in children due to Ascariasis: A tertiary health centre experience. Afr J Paediatr Surg 2008;5:65-70.  Back to cited text no. 1
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2.
Wani I, Snábel V, Naikoo G, Wani S, Wani M, Amin A, et al. Encountering Meckel's diverticulum in emergency surgery for ascaridial intestinal obstruction. World J Emerg Surg 2010;5:15.  Back to cited text no. 2
    
3.
Cullen J, Kelly A. Current management of Meckel's Diverticulum. Adv Surg 1996,29:207-14.  Back to cited text no. 3
    
4.
Cullen J, Kelly A, Moir R, Hodge D, Zinsmeister A, Melton L 3rd. Surgical management of Meckel's diverticulum. An epidemiologic population based study. Ann Surg 1994,220:564-8.  Back to cited text no. 4
    
5.
Chawla A, Patwardhan V, Maheshwari M, Wasnik A. Primary ascaridial perforation of the small intestine: Sonographic diagnosis. J Clin Ultrasound 2003;31:211-3.  Back to cited text no. 5
    
6.
Sreevathsa M, Humberto J, Jaffer M. Meckel's diverticulitis caused by roundworm incarceration. Paediatr Surg Int 1996;11:179.  Back to cited text no. 6
    
7.
Bhattacharjee PK, Biswas PC, Ray D. Perforation of Meckel's diverticulum by roundworm. Indian J Gastroenterol 2005;24:25-6.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Pujari BD, Deodhare SG. Ascarideal penetration of Meckel's diverticulum. Int Surg 1978;63:113-4.  Back to cited text no. 8
    
9.
Sharma R, Jain V. Emergency surgery for Meckel's diverticulum. World J Emerg Surg 2008;3:27.  Back to cited text no. 9
    
10.
Layer T, Jupp R, Maitra T. Slow-release potassium and perforation of Meckel's diverticulum. Postgrad Med J 1987,63:211-2.  Back to cited text no. 10
    
11.
Tai H, Chu L. Successful treatment of case of panperitonitis caused by perforation of meckel's diverticulum by ascaris. Tsa Chih Gaoxiong Yi Xue Yuan Tong Xue Hui 1963,28:89-91.  Back to cited text no. 11
    
12.
Bani-Hani E, Shatnawi J. Meckel's diverticulum: Comparison of incidental and symptomatic cases. World J Surg 2004,28:17-20.  Back to cited text no. 12
    


    Figures

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



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
References
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