C

MA

S

*†

Pocailuln2S

Ke

I

Tacwcpndnaiagp

wcla

CH(

2

ASE REPORTS

eckel’s Diverticulitis: A Rare Etiology of ancute Abdomen During Pregnancy

ergio Huerta, MD*, Andrew Barleben, MD†, Michael A. Peck, MD†, and Ian L. Gordon, MD†

University of Texas Southwestern Medical Center/VA North Texas Health Care System, Dallas, Texas; and

Department of Surgery, University of California, Irvine, California

td

nagntpw(dpcf

C

Awfhaccrpcmapwpf

coch

erforated Meckel’s diverticulum (MD) is a rare complicationf pregnancy. Its diagnosis, however, must be considered in allases of intra-abdominal disease, as its presentation is similar toppendicitis. Prompt diagnosis and appropriate treatment ismperative in these cases due to the high rate of perforationeading to fetal and maternal morbidity and mortality. Thesual lesion affecting a patient with MD and a review of the

iterature on other unusual causes of an acute abdomen in preg-ancy is presented in the following report. (Curr Surg 63:90-293. © 2006 by the Association of Program Directors inurgery.)

EYWORDS: small bowel obstruction, peritonitis, surgicalmergencies, rule of two’s, appendicitis in pregnancy

NTRODUCTION

he diagnosis of an acute abdomen in a pregnant woman can bedifficult challenge. Physiologic nausea, vomiting, and leuko-

ytosis, which are often diagnostically helpful in a nonpregnantoman, may be misleading in the pregnant patient. The most

ommon cause of an acute abdomen during pregnancy is ap-endicitis, which occurs with a frequency of 0.07% of all preg-ancies.1 Prompt surgical intervention is essential as fetal lossrastically decreases from 36% to 1.5% in perforated versusonperforated appendicitis, respectively.1,2 Diagnosis of ancute abdomen as a result of pathology other than appendicitiss rare; however, progressive abdominal pain and tendernessccompanied by hemodynamic instability should prompt sur-ical intervention for definitive diagnosis and treatment in theregnant patient to prevent fetal loss.Atypical pathologies of the acute abdomen in a pregnant

oman prove to be even more diagnostically challenging. In-luded among these atypical pathologies is Meckel’s diverticu-um (MD), which even in the nonpregnant patient is known as“great mimic” as it clinically presents with signs and symp-

orrespondence: Inquiries to Sergio Huerta, MD, Assistant Professor, VA North Texas

mealth Care System, Surgical Services, 4500 S. Lancaster Road, Dallas, TX 75216; fax:

214) 857-1891; e-mail: Sergio.Huerta@utsouthwestern.edu

CURRENT SURGERY • © 2006 by the Association of Program DirPublished by Elsevier Inc.

90

oms consistent with appendicitis. Thus, as a result of delay iniagnosis, symptomatic MD can complicate pregnancy.Symptomatic MD remains an unusual complication of preg-

ancy. However, MD should be suspected in cases of an acutebdomen when the diagnostic radiographic studies do not sug-est a common cause of intra-abdominal disease. Early recog-ition and management of MD may prevent complication tohe patient and her fetus. In this case, the authors discuss aatient who had an unusual etiology of an acute abdomen at 30eeks gestation. Despite undergoing 2 computed tomography

CT) examinations within a week, the diagnosis remained ailemma until the time of laparotomy. The lesion affecting aatient with MD and a review of the literature on other unusualauses of an acute abdomen in pregnancy is presented in theollowing discussion.

ASE REPORT

30-year-old Asian woman, gravida 2, para 1, at 29 and 3/7eeks of gestation, was transferred to the authors’ institution

or the management of abdominal pain and hypotension. Shead initially presented to an outside hospital 7 days before withbdominal pain, malaise, nausea, vomiting, and diarrhea. Herondition was diagnosed as gastroenteritis, and she was dis-harged with pain medications and outpatient follow-up. Sheeturned to the hospital 3 days later with worsening abdominalain, low-grade fever, and leukocytosis. Appendicitis was ex-luded by CT, and she was discharged on oral antibiotics andedications to prevent preterm labor. Despite 4 days of oral

ntibiotic therapy, her abdominal pain worsened and her tem-erature increased to 38°C. The patient returned to the hospitalhere abdominal tenderness and hypotension (systolic bloodressure � 90 mm Hg) were noted. This result prompted trans-er to the authors’ facility.

Upon arrival, the patient complained of abdominal pain fo-used mainly in the periumbilical area. There was no evidencef uterine contractions or fetal distress. Her medical and surgi-al histories were unremarkable. Vital signs were notable for aeart rate of 105 beats per minute and blood pressure of 90/60

m Hg. Physical examination revealed tachycardia. Abdomi-

ectors in Surgery 0149-7944/06/$30.00doi:10.1016/j.cursur.2006.02.009

nfdasmfttlsn1

n2urtoinM

amfrpma

au

whwmmModn

D

Acto

Fflp

Fflt

C

al examination demonstrated a gravid abdomen appropriateor gestational age, hypoactive bowel sounds, and diffuse ten-erness to palpation, most marked in the supra-umbilical areand right lower quadrant. Laboratory examination demon-trated leukocytosis to 18,100/MCL, 97% neutrophils, and he-oglobin of 12.5 g/dl. Serum electrolytes were normal except

or a decreased bicarbonate level of 21 mEq/l. Blood urea ni-rogen and creatinine were 2.0 mg/dl and 0.6 mg/dl, respec-ively. Liver function tests and amylase were within normalimits. The patient underwent an amniocentesis that demon-trated clear amniotic fluid with a negative gram stain test,ormal glucose level at 54 mg/dl, 132 nucleated cells/mm3, and2 red blood cells/mm3.

Repeat CT imaging of the abdomen and pelvis with intrave-ous and oral contrast revealed a rim-enhancing 4.2- � 3.5- �.5-cm midline tubular fluid collection located posterior to thembilicus (Fig. 1) containing a 1.3-cm enterolith (Fig. 2, ar-ow). There were surrounding inflammatory changes andhickening of adjacent bowel loops but no evidence of bowelbstruction. A normal, contrast-filled appendix was identifiedn the right lower abdomen in addition to an intrauterine preg-ancy. The radiographic differential diagnosis included anD, infected urachal cyst, and mesenteric duplication.The patient was started on broad-spectrum antibiotics and

ggressive intravenous fluid hydration with resultant improve-ent in her blood pressure. She remained afebrile. However,

ailure of her abdominal examination to improve promptede-examination of the CT scan, which resulted in a strong sus-icion for a surgical abdomen with symptomatic MD as theost likely diagnosis. Thus, the patient was taken to the oper-

ting room for an exploratory laparotomy.During surgical intervention, a perforated MD was found via

n upper midline incision. Figure 3 shows a wide-base divertic-

IGURE 1. Computed tomography of the abdomen demonstrates auid-filled collection under the umbilicus in addition to an intrauterineregnancy.

lum containing an enterolith (arrow). A small bowel resectionFu

URRENT SURGERY • Volume 63/Number 4 • July/August 2006

as performed, and copious irrigation was undertaken. Eightours postoperatively, the patient went into preterm labor,hich resulted in a vaginal delivery of a 1484-g, premature,ale infant with Apgar scores of 0, 2, and 8 at 1, 5, and 8inutes, respectively. Pathological examination revealed anD with severe inflammation and perforation but no evidence

f heterotopic mucosa. The patient was doing well and wasischarged on postoperative day 6. Her baby remained in theeonatal intensive care unit at time of discharge.

ISCUSSION

nonobstetric surgical abdomen occurs in 1 of 500 pregnan-ies.3 The most common causes of an acute abdomen includehe following: appendicitis (1/1500 pregnancies1); intestinalbstruction (1/1500 to 1/3000 pregnancies4) with adhesions,

IGURE 2. Computed tomography of the abdomen demonstrates auid-filled collection under the umbilicus containing an enterolith in addi-ion to an intrauterine pregnancy.

IGURE 3. Exploratory laparotomy demonstrated a wide-base divertic-lum containing an enterolith.

291

ptnasimdc

wumlompmatfica

afiacatebiogM

On

iavlleidmtrrla

otsfsMtPtp

Ohmtsgom

pomicafi

MbwMc3

a

Fnc

2

elvic inflammatory disease, volvulus, and intussusception ashe most common causes of intestinal obstruction in the preg-ant patient; biliary disease (1/1500 to 1/3000 pregnancies3);nd pancreatitis (1/1000 to 1/50005) (Fig. 4). Other nonob-tetric conditions presenting as an acute abdomen in pregnancynclude pyelonephritis, urinary calculi, gastroenteritis, acute

esentertic adenitis, ischemic mesenteric necrosis, peptic ulcerisease, and symptomatic MD.2 These unusual conditionsomplicate the diagnosis of an acute abdomen in pregnancy.

A bowel diverticulum is a sac opening or pouch in the bowelall. True diverticula involve all layers of the bowel and aresually congenital, whereas false diverticula do not involve theuscular layer and are typically acquired. Meckel’s diverticu-

um is a true diverticulum. It results from failure of obliterationf the vitelline duct, which before the eighth week of develop-ent, establishes communication between the yolk sac and the

rimitive midgut for nutrition. Meckel’s diverticulum is theost common congenital abnormality, and it is typically char-

cterized by the rule of 2s: It affects 2% of the general popula-ion, its average size is roughly 2 to 3 cm long, complicationsrom MD occur in 2% of the cases, the average length from theleocecal valve is 2 feet in patients less than 2 years old, compli-ations most commonly occur in patients less than 2 years old,nd complications occur twice more commonly in men.6-9

The most common complication in patients with symptom-tic Meckel’s is small bowel obstruction, which occurs with arequency of 37%. It is followed by intussusception (14%),nflammation (13%), hemorrhage (12%), perforation (7.0%),nd others (17%). Bleeding is most commonly observed inhildren, whereas small bowel obstruction typically affects thedult population.10 The presence of heterotopic mucosa (gas-ric 62%, pancreatic 16%, gastric and pancreatic 5%, and oth-rs 17%) results in ulceration of the adjacent ileum leading toleeding and, in severe cases, hemorrhage. Heterotopic mucosas found in 90% of bleeding Meckel’s.11 Inflammation of MDccurs with a frequency of 13%, and it is clinically indistin-uishable from acute appendicitis. Thus, inflammation of an

IGURE 4. Common causes of an acute abdomen during pregnancy. Aonobstetric surgical abdomen occurs with a frequency of 0.2%. The mostommon cause is acute appendicitis occurring in 1 of 1500 pregnancies.

D has been described as the condition of the “great mimic.”8 n

92 C

nce inflamed, delayed diagnosis may result in perforation orecrosis, just as in complicated appendicitis.As a great mimic, the clinical diagnosis of symptomatic MD

s rare, with less than 10% of cases of MD diagnosed preoper-tively.8 Computed tomography and sonography are of littlealue as MD is difficult to distinguish from adjacent boweloops. Radionuclide scans (Tc-99m Pertechnetate) are useful toocalize ectopic mucosa and, therefore, a bleeding MD. How-ver, its usefulness is limited in the adult population because ofts high rate of false-positive and false-negative results.12 A highegree of clinical suspicion and surgical intervention thus re-ains the mainstay of treatment. At laparotomy, diverticulec-

omy or small bowel resection can be performed; however, ilealesection should be undertaken in cases of a bleeding MD. Ilealesection is preferred in all cases of bleeding Meckel’s diveticu-um to obliterate the bleeding ulcer and the culprit adjacentcid-producing heterotopic gastric mucosa.10

Although some surgeons perform elective diverticulectomyn patients with incidentally found MD (ie, diverticula with ahick, narrow base13 or greater than 2 cm in length7), a recenttudy from the Mayo clinic14 demonstrates that the benefitsrom removal of an incidental Meckel’s diveticulum are faruperior than the risk of developing complications. Thus, an

D discovered incidentally should be removed regardless ofhe characteristics of the diverticulum or the age of the patient.rophylactic removal of Meckel’s diveticulum found inciden-ally at laparotomy should also be performed in the pregnantatient.15

Symptomatic MD during pregnancy is exceptionally rare.nly 23 cases of Meckel’s diveticulum complicating pregnancy

ave been reported in the literature.15 The first report docu-enting Meckel’s diverticulitis in a pregnant woman dates back

o a manuscript by Walser et al16 in 1962. Subsequently, fewimilar cases have been reported.15,17-19 In each situation, sur-ical intervention was undertaken for a preoperative diagnosisf acute appendicitis, with MD discovered instead, and treat-ent with small bowel resection and copious irrigation.In the pregnant patient, the average maternal age of all re-

orted cases of symptomatic MD was 24 years old (14-31 yearsld). The most common complication was perforation (57%),aternal mortality was 16%, fetal mortality was 13%, and the

ncidence of preterm deliveries was 25%.15 Given the high in-idence of perforation resulting in an enormous rate of maternalnd fetal mortality, removal of incidentally found MD is justi-ed in the pregnant patient.15

Usual presentations of perforated MD include a case bycLean20 of a perforated peptic ulcer within an MD. Hilde-

rand21 reported a perforated diverticulum in a 16-year-oldoman at 4 months of gestation. At laparotomy, a perforatedD containing a tapeworm was found. In another report, in-

arceration of the ileum was found in a 14-year-old woman at2 weeks of gestation.15

The current case demonstrates the diagnostic challenge of ancute abdomen in the pregnant woman. Similar to the nonpreg-

ant patient, the differential diagnosis of an acute abdomen in

URRENT SURGERY • Volume 63/Number 4 • July/August 2006

tapdaiallc

idwdti

R

1

1

1

1

1

1

1

1

1

1

2

2

C

he pregnant patient must primarily include pathology of theppendix. Given the history and clinical examination of thisatient, the most likely diagnosis included a perforated appen-icitis; however, 2 CT studies did not demonstrate evidence ofppendicitis. Even with excellent diagnostic preoperative exam-nations, and with a strong suspicion for symptomatic MD, theuthors did not have a conclusive preoperative diagnosis. Ataparotomy, the diagnosis of perforated MD was readily estab-ished by immediate recognition of the ruptured diverticulumontaining an enterolith.

Symptomatic MD is a rare complication of pregnancy, butts diagnosis must be considered in all cases of intra-abdominalisease in which the cause is not readily apparent, particularlyhen the diagnostic radiographic studies do not suggest appen-icitis. Prompt diagnosis and appropriate treatment is impera-ive in these cases because of the high rates of perforation lead-ng to fetal and maternal morbidity and mortality.

EFERENCES

1. Babaknia A, Parsa H, Woodruff JD. Appendicitis duringpregnancy. Obstet Gynecol. 1977;50:40-44.

2. Sharp HT. The acute abdomen during pregnancy. ClinObstet Gynecol. 2002;45:405-413.

3. Coleman MT, Trianfo VA, Rund DA. Nonobstetricemergencies in pregnancy: trauma and surgical condi-tions. Am J Obstet Gynecol. 1997;177:497-502.

4. Beck WW Jr. Intestinal obstruction in pregnancy. ObstetGynecol. 1974;43:374-378.

5. Jouppila P, Mokka R, Larmi TK. Acute pancreatitis inpregnancy. Surg Gynecol Obstet. 1974;139:879-882.

6. Brown CK, Olshaker JS. Meckel’s diverticulum. Am JEmerg Med. 1988;6:157-164.

7. Mackey WC, Dineen P. A fifty year experience withMeckel’s diverticulum. Surg Gynecol Obstet. 1983;156:56-64.

8. Turgeon DK, Barnett JL. Meckel’s diverticulum. Am J

Gastroenterol. 1990;85:777-781.

URRENT SURGERY • Volume 63/Number 4 • July/August 2006

9. Ymaguchi M, Takeuchi S, Awazu S. Meckel’s diverticu-lum. Investigation of 600 patients in Japanese literature.Am J Surg. 1978;136:247-249.

0. Yahchouchy EK, Marano AF, Etienne JC, et al. Meckel’sdiverticulum. J Am Coll Surg 2001;192:658-662.

1. Berman EJ, Schneider A, Potts WJ. Importance of gastricmucosa in Meckel’s diverticulum. J Am Med Assoc. 1954;156:6-7.

2. Schwartz MJ, Lewis JH. Meckel’s diverticulum: pitfalls inscintigraphic detection in the adult. Am J Gastroenterol.1984;79:611-618.

3. Williams RS. Management of Meckel’s diverticulum. Br JSurg. 1981;68:477-480.

4. Cullen JJ, Kelly KA, Moir CR, et al. Surgical managementof Meckel’s diverticulum. An epidemiologic, population-based study. Ann Surg. 1994;220:564-568.

5. Rudloff U, Jobanputra S, Smith-Levitin M, et al. Meckel’sdiverticulum complicating pregnancy. Case report and re-view of the literature. Arch Gynecol Obstet. 2005;271:89-93.

6. Walser HC, Margulis RR, Ladd JE. Meckel’s diverticuli-tis, a complication of pregnancy. Obstet Gynecol. 1962;20:651-654.

7. Chanrachakul B, Tangtrakul S, Herabutya Y, et al. Meck-el’s diverticulitis: an uncommon complication duringpregnancy. BJOG. 2001;108:1199-1200.

8. Clark KH, Lawson EA. Meckel’s diverticulum and preg-nancy. J Tenn Med Assoc. 1992;85:367-368.

9. Morino GF, Ansaloni L, Galvagno S, et al. Meckel’s di-verticulum in pregnancy: difficult differential diagnosis.Trop Doct. 1998;28:242.

0. McLean JG. Perforation of a peptic ulcer in a Meckel’sdiverticulum during pregnancy. J Obstet Gynaecol Br Com-monw. 1969;76:81-82.

1. Hildebrand HD. Generalized peritonitis. CMAJ. 2002;

166:632.

293