Torsion of a meckel diverticulum associated with internal herniation and small bowel obstruction as a cause of right lower quadrant pain in a 12 yr. old girl

BACKGROUND: A number of complications have been described in adolescent girls who have a Meckel diverticulum. Painless rectal bleeding is the most common manifestation during the first two decades of life. Inflammation with diverticulitis may simulate acute appendicitis and lead to perforation with peritonitis. In addition, partial or complete bowel obstruction may occur when the diverticulum serves as the lead point of an intussusception. Intraperitoneal bands may also cause obstruction by internal herniation or volvulus of the small bowel around the band. The purpose of this paper is to heighten awareness among clinicians that torsion of a Meckel diverticulum and internal herniation with small bowel obstruction may present with intermittent right lower quadrant pain in adolescent girls. METHODS: A 12 year old girl was seen in consultation for evaluation of abdominal pain of two weeks duration. The pain was initially intermittent, but then became continuous shortly before she was evaluated at our center. The patient noted a decrease in appetite and she was afraid that the pain would recur whenever she ate. There was mild nausea with one episode of vomiting. There was no history of change in bowel habits or urinary tract symptoms. The patient was premenarchal and had not noted any vaginal discharge. On exam, she was afebrile and the vital signs were normal. The general physical was entirely unremarkable other than mild tenderness in the right lower quadrant. The rectal was also normal. A pelvic examination was not performed. RESULTS: The following studies were performed at the outlying hospital and found to be normal: complete blood count, serum chemistries, pregnancy test, urinalysis, urine culture and stool culture. A stool sample was slightly positive for occult blood. A plain film of the abdomen showed distended small bowel loops. Markedly thickened loops of small bowel in the right lower abdomen were seen on a CAT scan of the abdomen. The patient was felt to have a ruptured appendix and then transferred to our facility. At surgery, she was found to have torsion of a Meckel diverticulum with adhesive bands to the mesentery and an internal hernia with 20 centimeters of twisted, necrotic small bowel. The involved segment was then resected and the patient had an uneventful recovery. CONCLUSIONS: This paper documents that torsion of a Meckel diverticulum associated with internal herniation and small bowel obstruction may present in adolescent girls with unexplained right lower quadrant pain. Practitioners who provide gynecologic care for teenagers should be aware of this entity as it may simulate a number of pelvic conditions. Early recognition and prompt surgical treatment are essential to an optimal outcome so that any serious complications can be avoided.