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\begin{document}

\title{Intussusception Secondary to a Meckel's Diverticulum as Leading Point in
fourth decade of Life, Case Report}



\author[1]{Faisal Albaqami}%
\author[1]{Feras Alsannaa}%
\author[1]{Reem Bin Saleem}%
\author[1]{Nahla Arab}%
\affil[1]{Prince Sultan Military Medical City}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
37-year-old man presented to the emergency department with a three-hour
history of severe, generalized abdominal pain. Computed tomography of
abdomen revealed two distal ileoileal intussusceptions with high
suspicion of 3 cm mass within the intussusception around the ileocecal
region. Laparoscopic right hemicolectomy with extracorporeal ileocolic
anastomosis which showed Meckel%
\end{abstract}%



\sloppy


\textbf{Introduction:}

Meckel's diverticulum (MD) is considered the most common
gastrointestinal tract (GIT) congenital anomaly.\textsuperscript{1} MD
can lead to many complications including bleeding, obstruction,
inflammation and perforation. The bowel obstruction may occur through
volvulus, intussusception or herniation.\textsuperscript{2} During adult
life, intussusception is usually due to malignancy, polyp, stricture or
rarely MD.\textsuperscript{3} Here we report a rare case of small bowel
intussusception secondary to Meckel's diverticulum in his fourth decade
of life.

\textbf{Case Presentation:}

A 37-year-old middle eastern man presented to the emergency department
(ED) with a three-hour history of severe, worsening, generalized
abdominal pain and nausea. Past medical history included inactive
hepatitis B and morbid obesity. Past family history was unremarkable.
Past surgical history included laparoscopic gastric bypass.

On examination, the patient looked unwell, and in pain. His Glasgow coma
scale score was 15, and he had a heart rate of 86 beats per minute,
blood pressure 129/82 mm/Hg, respiratory rate 20 breaths per minute, and
body temperature 36\selectlanguage{ngerman}°C. On examination, his abdomen was lax with
generalized tenderness, and his laparoscopic wounds had healed. Body
mass index is 27.9 (52 pre surgery).

Initial laboratory investigations revealed a white blood cell count
(WBC) of 11,800/uL (4000-11000 uL), and hemoglobin 15 g/dL (10-15 g/dL).
Other blood investigations were unremarkable. Abdominal X-Ray showed
dilated small bowels are noted in the left side of abdomen. Computed
tomography (CT) of the abdomen and pelvis with intravenous contrast
revealed two distal ileoileal intussusceptions with high suspicion of a
3 cm mass within the intussusception around the ileocecal region.
(\textbf{Figure 1} ).

He was admitted under the care of the general surgical team,
resuscitated, and underwent laparoscopic exploration which confirmed the
CT findings and no ischemic bowel identified. Laparoscopic right
hemicolectomy with extracorporeal ileocolic anastomosis was done
(\textbf{Figure 2} ). Upon examining of the specimens Meckel
diverticulum was found (\textbf{Figure 3} ). Specimen was sent for
pathology which revealed Meckel's diverticulum lined by gastric mucosa.
A solid diet was introduced gradually, and the patient was discharged
home on day 8 post operation. He was followed up in the outpatient
clinic for almost two years, with uneventful course.

\textbf{Discussion:}

When there is one segment of the bowel that invaginates into another
portion, this process is named as intussusception. During
intussusception, venous outflow will be obstructed due to edema which
will lead to ischemia, necrosis and perforation.\textsuperscript{4} The
highest incidence of intussusception falls in the first two year of
life. It is considered as the most common cause of bowel obstruction
during infancy.\textsuperscript{5} However, some studies showed that
intussusception can occur at older age and should be considered as
differential diagnosis in all age groups (up to 23\% of all
intussusceptions). \textsuperscript{6} With aging, the intussusception
tends to be due to pathological leading point. Those points including
carcinoid tumors, leiomyoma, small bowel lymphoma, vascular
malformations, inverted appendiceal stumps or
MD.\textsuperscript{7}Furthermore, intussusception's leading point can
be part of systematic disease such as Henoch-Schönlein purpura,cystic
fibrosis , and hemolytic-uremic syndrome.\textsuperscript{8} MD is
considered as the most common gastrointestinal tract (GIT) congenital
anomaly.\textsuperscript{9} It is resulted from incomplete obliteration
of the vitelline duct which leads to formation of diverticulum. The MD
is true diverticulum which containing all layers of small
bowel.\textsuperscript{9} Prevalence of MD is estimated up to 2 percent
in general population.\textsuperscript{10} Out of this percentage, only
approximately 2 to 4 percent of patients develop a complication in their
lifetime, specially before two years old.\textsuperscript{11} The rule
of two in MD are two inches in length, two feet from the ileocecal
valve, two percentage of population and two ectopic
mucosa.\textsuperscript{12} The presentation of MD intussusception
varies between the age groups, in first two year of life, classic triad
of vomiting, abdominal pain, and bloody stools are expected. However, as
patient grows the presenting symptoms becoming
vaguer.\textsuperscript{13} The complications of MD include bleeding,
obstruction, inflammation and perforation. One of the causes of MD bowel
obstruction is intussusception. \textsuperscript{2} Since most MDs are
asymptomatic and most intussusceptions are of unknown cause, MD causing
small bowel intussusception is extremely rare. Despite the rarity of the
condition, this case report is demonstrating the importance of
considering such diagnosis in this age group. Unlike pediatric
intussusception, once the diagnosis of intussusception is made in adult,
surgery is the standard of care. Inspection of involved segment should
be made, and the resection depends on the viability of the bowel
segment.\textsuperscript{14} Back to our case, the diagnosis of MD was
not certain, and the involved segment was not healthy therefore
resection was done.

\textbf{Conclusion:}

Although intussusception secondary to MD is rare during adult life and
the clinical presentation was not typical, only abdominal pain and
isolated nausea, it is important to report such a case and to consider
it as differential. Management of MD varies and mainly depends on age of
presentation.

\textbf{Reference:}

\begin{enumerate}
\tightlist
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\end{enumerate}

\textbf{Figure legends:}

Figure 1; CT of abdomen pelvis revealing evidence of intussusception,
with a target sign.

Figure 2; abdomen, ileoceacum, ileo-ileal intussusception

Figure 3; Resected Specimen ( Ileoceacum),Meckel's diverticulum\selectlanguage{english}
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