Meckel's diverticulum: misdiagnosis and delayed presentation with ureterohydronephrosis

Abstract

MD occurs in 2% of the population and is the most common congenital malformation of the gastrointestinal tract. Most patients are asymptomatic and complications are found in about 5%. This study reports an exceptional case where a longstanding Meckel's diverticulum (MD) was initially misdiagnosed as inflammatory bowel disease and further complicated with ureterohydronephrosis. A 14-year-old male presented with abdominal pain and fever, minor elevation of inflammatory markers, the ultrasound showed a liquid collection and suggested complicated acute appendicitis. Laparoscopy showed a thickened small bowel segment, low grade inflammation of the appendix and no collection; appendectomy was performed. Follow-up ultrasound showed bowel wall thickening and collections, which further suggested inflammatory bowel disease. One month after discharge, the patient returned with abdominal pain and subfebrile temperature. Imaging studies showed pelvic plastron, purulent fluid, collections and right ureterohydronephrosis. Treatment for complicated inflammatory bowel disease was ineffective, there was worsening of the ureterohydronephrosis, however, the collections were small and persisted roughly unchanged, which suggested a different etiology. Scintigraphy with technetium-99m pertechnetate was positive and surgery was proposed. A MD was found intimately adherent to the posterior abdominal wall, involving the ureter. En bloc enterectomy and primary anastomosis were completed successfully. Follow-up ultrasound 11-days after surgery was normal. After 6-months, the patient was asymptomatic. This case represents a diagnostic challenge since ureterohydronephrosis was never described as a complication of MD and it was an important element in the diagnosis.