Spontaneous perforation and intraabdominal abscess due to Meckel's diverticulum revealed on SPECT/CT with 99m-technetium pertechnetate: A case report

Abstract

Rationale: Meckel's diverticulum (MD) is common congenital abnormality of gastrointestinal tract, only about 6.4% of patients become symptomatic. A smaller minority develop potential fatal complications such as hemorrhage, perforation, abscess, and bowel obstruction.

Patient concerns: A 15-year-old boy with history of appendicitis was admitted due to worsening abdominal pain and nausea for 1 day. The physical examination showed the abdomen was soft, with the diffuse tenderness to palpation and voluntary guarding.

Diagnosis: Abdominal computed tomography showed a probable MD in the distal ileum. Single photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging revealed the focal concentration at the right lower quadrant of abdomen region.

Intervention: After the initial management including antibiotic administration and intravenous fluid resuscitation, MD with perforation and localized suppurative peritonitis was confirmed in surgery. The patient underwent a diverticulectomy. Histological examination was confirmed as MD with focal heterotopic gastric tissue.

Outcomes: After surgery, the patient had uneventful recovery during 3 months follow-up.

Lessons: Spontaneous perforation and intraabdominal abscess due to MD is very rare. Accurate diagnosis of MD remains challenging as clinical symptoms from these complications occur nonspecifically. SPECT/CT fusion imaging is critical for prompt recognition and accurate diagnosis in the successful management of this rarely life-threating complication.

Figure 1

Axial contrast-enhanced CT images reveal a thick-mucosa and increased enhancement of segmental ileum loop with air-fluid level (yellow arrows) and intraperitoneal abscess with diffuse infiltration of small bowel mesentery (A). Curved reconstruction shows an enhancing and thickened tubular structure (red arrow) corresponding to suspicious inflamed Meckel diverticulum with an associated phlegmon (B). CT = computed tomography.

Figure 2

99m-technetium pertechnetate scintigraphy show a subtle focus of activity within the right hemiabdomen (arrow) in dynamic images (A 2 min/frame). Delayed imaging (B 30 min, C 60 min) reveal a focal concentration of the right hemiabdomen, which changes simultaneously with the concentration of 99m-technetium pertechnetate in stomach.

Figure 3

SPECT/CT fusion imaging obtained with 99m-technetium pertechnetate (top row: CT, middle row: SPECT, bottom row: fused SPECT/CT). Imaging demonstrate a focal concentration localized anatomically to the tubular structure in the right abdomen, which it is in the front of the right kidney. SPECT/CT = single photon emission computed tomography/computed tomography.

Figure 4

Hematoxylin and eosin analysis (magnification, ×40) of histological specimen revealed ectopic gastric type mucosa in Meckel's diverticulum.