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Journal of Medical Case Reports
ISSN 1752-1947 · DOI: 10.1186/s13256-024-04821-3
Received 3 September 2024
Accepted 18 November 2024
Published 5 December 2024
Arjun Mehta¹, Sunita Patel¹, Vikram Shekhawat², Rohit Agrawal³
¹ Department of General Surgery, Grant Medical College & Sir J.J. Hospital, Mumbai 400008, India
² Department of Pathology, Grant Medical College, Mumbai 400008, India
³ Department of Radiology, Sir J.J. Hospital, Mumbai 400008, India
Correspondence: Dr. Arjun Mehta, Department of General Surgery, Grant Medical College, Mumbai. Email: arjunmehta@gmc.edu.in
Background: Meckel's diverticulitis is the most common complication of Meckel's diverticulum, affecting approximately 4–6% of individuals. It can mimic acute appendicitis clinically and radiologically, and diagnosis is rarely established preoperatively. The coexistence of ectopic pancreatic tissue within a Meckel's diverticulum is an exceptionally rare pathological finding with fewer than 50 cases reported in world literature.
Case presentation: A 24-year-old male presented with right iliac fossa pain, fever and raised inflammatory markers, clinically diagnosed as acute appendicitis. Intraoperatively, a normal appendix was found with an inflamed Meckel's diverticulum 60 cm from the ileocaecal junction. Diverticulectomy was performed. Histopathology revealed acute diverticulitis with ectopic pancreatic tissue (Heinrich type III) within the diverticular wall — an extremely rare concurrent finding.
Conclusions: Meckel's diverticulitis should be considered in the differential diagnosis of right iliac fossa pain, particularly when the appendix appears normal at surgery. Surgeons should systematically inspect the terminal ileum. Ectopic pancreatic tissue in Meckel's diverticulum is a rare incidental finding that requires no additional intervention when asymptomatic.
Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract, occurring in approximately 2% of the population as a remnant of the omphalomesenteric duct. Though most remain asymptomatic throughout life, complications — including diverticulitis, bleeding, obstruction, and perforation — occur in 4–6% of cases and represent important surgical emergencies.
Clinically, Meckel's diverticulitis can closely mimic acute appendicitis, with identical presenting symptoms including right lower quadrant pain, fever, and leucocytosis. Preoperative diagnosis is established in fewer than 5% of cases. Consequently, Meckel's diverticulitis is most often diagnosed intraoperatively when a normal appendix is found and systematic bowel inspection follows.
Ectopic pancreatic tissue (heterotopic pancreas) within a Meckel's diverticulum is an exceptionally rare phenomenon. To our knowledge, fewer than 50 cases have been documented in world literature, predominantly in Asian populations. We report this unusual combination discovered intraoperatively in a young Indian male with acute right iliac fossa pain.
A 24-year-old male construction worker presented to the surgical emergency of Sir J.J. Hospital, Mumbai with a 36-hour history of progressively worsening right iliac fossa pain, anorexia, nausea, and one episode of vomiting. He had no prior abdominal surgeries, no significant medical history, and no family history of abdominal pathology. He denied diarrhoea or rectal bleeding.
On examination: temperature 38.4°C, pulse 102/min, BP 118/76 mmHg. Abdomen revealed localised tenderness at McBurney's point with guarding and positive Rovsing's sign. Rebound tenderness was present in the right iliac fossa. Bowel sounds were present. Rectal examination was unremarkable. Clinical diagnosis of acute appendicitis (Alvarado score 8) was established.
Laboratory: Total WBC count 15,800/mm³ (neutrophilia 84%). CRP 86 mg/L. Other parameters were normal. Urine examination was unremarkable.
Ultrasonography of the abdomen: Non-compressible tubular structure in the right iliac fossa measuring 8 mm in diameter consistent with appendicitis. Free fluid in the pelvis. No bowel obstruction.
CT abdomen and pelvis (plain and contrast): Inflamed appendix-like structure with periappendiceal fat stranding. Normal appendix not separately identified. Radiological impression: Acute appendicitis.
The patient was taken for emergency laparoscopic appendectomy under general anaesthesia. Intraoperatively, the appendix was found to be entirely normal in appearance and histologically confirmed later. However, a 4 cm, inflamed, congested diverticulum was found on the antimesenteric border of the ileum, approximately 60 cm proximal to the ileocaecal junction, with surrounding inflammatory fibrinous exudate.
Conversion to open surgery was performed through a lower midline extension. Diverticulectomy with primary ileal closure was performed. The specimen was sent for histopathological examination. The abdomen was irrigated with warm saline and closed in layers. The normal appendix was also removed (incidental appendectomy).
The postoperative course was uneventful. The patient was commenced on clear fluids on day 1, a soft diet on day 2, and discharged on day 5 on oral antibiotics. Sutures were removed at day 10 with excellent wound healing.
Histopathology report: Acute suppurative diverticulitis with transmural inflammation. Within the muscularis propria of the diverticular wall, a 6 mm nest of mature pancreatic acini, ductal elements, and islets of Langerhans were identified — consistent with ectopic pancreatic tissue, Heinrich classification Type III. No malignant transformation was seen. At 3-month follow-up, the patient was asymptomatic with no recurrence.
The 'rule of 2s' describes Meckel's diverticulum: 2% prevalence, 2 feet proximal to the ileocaecal valve, 2 cm average length, 2:1 male predominance, and most symptomatic presentations within the first 2 years of life. However, complications can present at any age. Diverticulitis, the most common complication in adults, is indistinguishable from acute appendicitis in most cases.
The CT finding of a right iliac fossa inflammatory process without a separately identified normal appendix should raise suspicion for Meckel's pathology, though this is diagnostically challenging. Several case series from India (Bhandarkar et al., Indian J Gastroenterol 2020) have reported MD as an incidental or emergency finding in 0.3–0.8% of emergency laparotomies/laparoscopies.
Ectopic pancreas is defined as pancreatic tissue lacking anatomical and vascular connection to the main pancreas. It most commonly occurs in the stomach (25–38%), duodenum (17–36%), and jejunum (15–21%). Occurrence within a Meckel's diverticulum represents an embryological curiosity — both derive from the same developmental period (weeks 5–7 of gestation), and simultaneous mislocalisation of pancreatic progenitor cells into the diverticular bud is the proposed mechanism. Heinrich's classification (Types I–III) guides management: Type III (acinar tissue only without ductal elements) as in our case carries minimal risk of malignant transformation.
Concomitant diverticulectomy and incidental appendectomy is the accepted approach. Surveillance is not required for Type III ectopic pancreas identified incidentally.
This case illustrates the importance of systematic bowel inspection when a normal appendix is found intraoperatively in patients with clinical acute appendicitis. Meckel's diverticulitis is the most important alternate diagnosis. The concurrent finding of ectopic pancreatic tissue (Heinrich Type III) within the diverticular wall, while extremely rare, requires no additional surgical or surveillance intervention. Histopathological examination of all resected diverticular specimens is mandatory.
Learning Points / Take-Away Lessons
Patient Consent
Written informed consent was obtained from the patient for publication of this case report and the accompanying intraoperative and pathological images.
Ethics
This case report was approved by the Institutional Ethics Committee of Grant Medical College, Mumbai (IEC Ref: GMC/IEC/2024/CR/087).
Competing Interests
The authors declare no competing interests.
Funding
No funding was received for this study.
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