LAUSR

A 42-year-old man presented to the emergency department of Gold Coast University Hospital with a 1-day history of migratory periumbilical to the right iliac fossa pain, associated with nausea and decreased appetite. Physical examination revealed a tender, locally peritonitic right iliac fossa. Laboratory results revealed a raised C-reactive protein and white cell count. The preliminary diagnosis of acute appendicitis was made. A contrast computed tomography (CT) abdomen was ordered to exclude an underlying malignancy; however, this revealed a prominent, inflamed terminal ileum, with a mildly dilated tip of appendix and periappendiceal inflammation. The patient was transferred to the medical admission unit with the diagnosis of terminal ileitis for further investigation. The differentials of inflammatory bowel disease, gastroenteritis and appendicitis with adjacent terminal ileal inflammation were further investigated by the gastroenterology unit. Despite 4 days of intravenous antibiotics, oral steroids and bed rest, the patient’s pain persisted, with progressive signs of localized peritonism. The decision was made to perform a diagnostic laparoscopy. On laparoscopy, the distal ileum and appendix were adherent to the anterior abdominal wall, surrounded by oedematous omentum, all of which appeared inflamed, with abundant fibrin. Further exploration revealed a perforated distal ileal diverticulum with surrounding fibrin and pus about 5 cm from the ileocaecal junction (Fig. 1). The diverticulum had been perforated by a sharp, needle-like foreign body (Fig. 2). The foreign body was retrieved and a laparoscopic appendicectomy and segmental bowel resection with side to side anastomosis was performed. The foreign body appeared to be a fish bone (Fig. 3). Following histological examination, the diagnosis of Meckel’s diverticulitis (as opposed to a pulsion diverticulum) was confirmed. The foreign body had histological features consistent with bone; the patient admitted that he often swallowed fish bones. The patient recovered without complication, being discharged 4 days post-operatively. Merkel’s diverticulum is the most common congenital anomaly affecting the gastrointestinal tract with an overall incidence of approximately 2.2%. Hildanus was the first to describe the presence of Merkel’s diverticulum in 1598; however, Meckel was the first to identify the anatomic abnormality necessary for its development in 1809. It is a true enteric diverticulum encompassing all layers of the bowel wall. It is caused by failure of regression of the omphalomesenteric duct following physiological herniation of the midgut through the umbilicus during the fourth week of fetal development. It is usually an incidental finding during a laparotomy for management of other abdominal pathology. Complications are rare, present usually in childhood and include haemorrhage, bowel obstruction, diverticulitis, intussusception and rarely perforation. Haemorrhage is most common in children whereas obstruction and inflammation occur mostly in adults. The rule of twos is the classic description of the essential features of Merkel’s diverticulum. It occurs 2 feet from the ileocecal valve, is