O B S T R U C T I O N F R O M K N O T I N M E C K E L ’ S D I V E R T I C U L U M 475

KNOT IN MECKEL’S DIVERTICULUM CAUSING ACUTE INTESTINAL OBSTRUCTION

BY ANTHONY WALSH SENIOR SURGICAL REGISTRAR, ROYAL SOUTHERN HOSPITAL, LIVERPOOL

MECKEL’S diverticulum has been well known as a cause of intestinal obstruction since Sandifort (1793) described Van Doeveren’s case. Of 1134 cases of intestinal obstruction analysed by Leichtenstern 67 (6 per cent) were due to the diverticulum. Halstead (1902) found the same percentage in 991 cases collected from the literature.

One of the least known ways in which obstruc- tion may occur is strangulation of a loop of gut by a knot tied in a free Meckel’s diverticulum. I have been able to find only 6 such cases, including the example recorded here, in the literature of the present

a tapering, conical extremity, resembling closely a finger-stall. If, as sometimes happens, the muscle- coat is deficient at the apex the intraluminal pressure causes a bulging at this point, so that the free end of the process presents an ampulla of globular shape.

Treves described three varieties of knot forma- tion :-

a. The diverticulum forms a ring into which its own free end projects (Fig. 605). A loop of intestine enters as shown by the arrow, pushes the clubbed end of the diverticulum before it, and so ties the knot by which the coil becomes obstructed.

FIG. 606.

b. The diverticulum surrounds the pedicle of an intestinal loop so as to encircle it with a simple knot (Fig. 606). This type was described originally

FIGS. 605-607.-Varieties of knot formation. (Trewes.)

century, although the condition would appear to have been much better known to earlier writers. (Of Leichtenstern’s 67 cases, 12 were due to diverti- cular knots, and Treves, in his Jacksonian Prize Essay of 1884, remarked that the condition was not uncommon and described many examtdes from the London museums.)

These remarkable knots and the methods of their formation were very exhaustively studied nearly a hundred years ago by Parise and later by Nothnagel (1898). Before such a knot can be tied the diverticulum must have three peculiarities :-

I. It must be unusually long. 2. It must be quite mobile and unattached, save

for its origin from the ileum. 3. It should possess an ampulla at its distal end.

The ampulla is of paramount importance, and by the French writers was called “ la clef de I’e’tranglement ”. Meckel’s diverticulum is composed of all the layers of the small intestine and usually is cylindrical with

A B

FIG. 608.--Stages in the commonest method of knot formation.

by Regnault in about 1840 and recently by Dorling (1941).

c. In this form two loops of bowel are involved, one above and one below the origin of the diverti- culum (Fig. 607). One loop enters the knot by a preliminary rotation, the other is caught as in the simple knot. Only one case of this type has been recorded (Levy, 1845).

Study of 19 cases from the literature reveals that the commonest mechanism differs in one important

476 T H E B R I T I S H J O U R N A L O F S U R G E R Y

detail from the varieties enumerated by Treves. Here the first step is a partial volvulus, through 180°, of a loop close to the base of the diverticulum. T h e narrow base of the volvulus is then encircled by the diverticulum (Fig. 608). This was the mechanism in the author’s case and Fig. 609 is a sketch of the specimen as seen at operation.

FIG. 609.-A sketch of the specimen in the author’s case Note the partial volvulus and the ampulla as seen at operation.

on the diverticulum.

Many of the collected cases have had a history of several years of abdominal pain before the onset of the acute strangulation, suggesting that the partial volvulus may have been of long standing before the tying of the knot precipitated a crisis. Four out of six personal cases of simple volvulus of the small gut had a history of many years’ dyspepsia, and in all four the patient was symptom-free from the time of resection of the volvulus. Little emphasis has been laid in previous writings on the occurrence of dys- pepsia in chronic volvulus of the small intestine, but I hope to record and discuss these observations in a separate communication.

CASE REPORT W. H. R., an engineer’s fitter, aged 63, was admitted

to the Royal Southern Hospital, Jan. 25, 1949, complain- ing of severe abdominal pain and backache.

HISTORY.-In I940 his ship was torpedoed and he was the only survivor of six hours’ immersion in very cold water. Since that time he had never been well and was able to work only intermittently, his chief com- plaint being abdominal pain about 20 minutes after almost every meal. On Jan. 22 he awoke at 2 a.m. with very severe pain in both loins. When seen by his doctor a few hours later he was shocked and collapsed, but had as yet no symptoms other than the acute backache. During the next 24 hours the pain shifted gradually to the abdomen, and on admission was centred chiefly at the umbilicus. He first vomited 36 hours after the onset of pain and thereafter whenever he took anything to drink. described the vomitus as bile and coffee- grounds and said that it was never more than half a cupful at a time. The bowels had not been opened for four days and there had been absolute constipation for 24 hours before admission. For two days he had noticed some discomfort on micturition.

ON EXAMINATION.-A pale, cachectic man of slight build, he looked ill and anxious and had severe hiccup. The tongue was moist, with a central white fur. T. 98.0” ; P. 88 ; R. 28. The abdomen presented a considerable generalized distension, most marked centrally and below the umbilicus. Generalized tenderness and guarding were maximal in the epigastrium. Auscultation revealed a total absence of any peristaltic sounds, but the occa- sional tinkles typical of very distended small gut could be heard. On rectal examination a very tender cystic swelling was palpable in the rectovesical pouch. A plain radiograph of the abdomen showed grossly dilated coils of small intestine and many fluid levels, but no sub- diaphragmatic gas.

A tentative diagnosis was made of paralytic ileus following perforation of a gastric ulcer and after insti- tuting gastric suction and intravenous saline drip operation was begun.

AT OPERATION.-Anzesthetic (Dr. Rhind) : Sodium thiopentone and d-tubo-curarine chloride supplemented by endotracheal nitrous oxide.

Upper midline incision. Very distended coils of small gut presented. The peritoneal cavity contained only a small amount of blood-stained fluid. The stomach was small and contracted, and it was quickly obvious that there was no peptic ulcer. On passing a hand into the pelvis an impacted cystic mass was felt. This was easily delivered and proved to be a partial volvulus of some 30 cm. of the lower ileum. Around its base was tied, in a tight and complex knot, a Meckel’s diverticulum about 15 cm. long. This truly Gordian knot was impossible to untie and was so tight as almost to sever the involved loop, which was frankly gangrenous. The affected segment was rapidly resected. As soon as the resection was completed there was a marked improvement in the patient’s general condition and an end-to-end anastomosis was made.

Post-operatively gastric suction was continued and intravenous fluids were given, controlled by blood-volume estimations and repeated blood analyses. Penicillin, IOO,OOO units 2-hourly, and sulphathiazole, 2 g. 4-hourly, were given into the drip. An attempt to pass a Miller- Abbott tube failed. The paralytic ileus persisted and the patient died on the ninth post-operative day.

A notable feature was the initial pain in the back. Back pain has occasionally been observed in acute abdo- minal catastrophes in which there is extensive involve- ment of the mesentery (Halligan and Halligan, 1937).

In conclusion, i t is a privilege to record my thanks to Mr. Cosbie Ross for permission to treat and to record this case, and for his very helpful advice and criticism at every stage.

BIBLIOGRAPHY CAZIN (1893), SOC. Anat. Paris. CULLEN, T. S. (1916), The Umbilicus and its Diseases, 159.

~ _ _ DAVISON, C., quoted by HALSTEAD. DORLING, G. C. (1941), Brit. J . Surg., 29, 277. FOX (1897), Trans. Path. SOC. Lond. HABER, J. J. (1947), Amer.J. Surg., 73, 468. HALLIGAN, E. J., and HALLIGAN, H. J. (1937), Amer. J .

HALSTEAD, A. E. (1902), Ann. Surg., 35, 471. HOHLBECK (I~oo) , Arch. klin. Chir., 61. LEICHTENSTERN : Ziemsen’s Handbuch der specielle

LEVY, M. (1845), Gaz. m6d. Fr., 129. NOTHNAGEL (1898), Die Erkrankungen des Darms und des

PARISE, Bull. Acad. Mid., 16, 373. SANDIFORT, (1793), Museum Anatomicurn, s. 3, I, 121. TREVES, F. (1884, Intestinal Obstruction. London :

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Pathologie und Therapie.

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