Title: Gunshot wound to Meckel’s Diverticulum: a one-in-a-million case report
Authors: Elizabeth Kosanke, OMS3; Scott Hadley, MD, FACS
Introduction
Although the Meckel’s diverticulum is the most common gastrointestinal anatomical anomaly, the prevalence is only about two percent. The rarity of this variant makes complications related to the Meckel’s diverticulum medically interesting. While multiple cases have been documented of blunt trauma to the Meckel’s diverticulum, we believe this is one of the first reporting of traumatic injury to the Meckel’s diverticulum from a projectile.
Presentation of Case
23-year-old male presents to the Emergency Room with multiple abdominal and thoracic gunshot wounds. CT showed large bowel injury, suspected small bowel laceration, liver laceration, right renal laceration, and a 12th rib fracture. An emergent laparotomy was performed. The laparotomy demonstrated multiple gunshot-related injuries including thirteen small bowel injuries, one of which hit the distal tip of the Meckel’s diverticulum. A second surgery was needed to put the bowel in continuity, and a posterior rectal injury was closed endoscopically in the ICU. The patient was able to avoid an ostomy. The patient was later discharged after a 9-day hospital stay and is expected to make a full recovery.
Discussion
Due to the low prevalence, small size, and anatomical location of the Meckel’s diverticulum, injury to this structure is rare, with traumatic injury from a penetrating bullet being even more uncommon. This case shows the extreme improbability of receiving penetrating trauma to the Meckel’s diverticulum.
I am one of the judges for your improbable case. You mentioned the anomalies are often not visible on imaging, what/how would you recommend a doctor do to rule out these sorts of anomalies in a trauma case?
Thank you for your question, Dr. Callan. Depending on the cause, trauma cases often warrant a laparotomy. In a hemodynamically, unstable patient is it important to address sources of major bleeding that could lead to patient exsanguination. Once this and other major injuries have been repaired, I would implore surgeons when running the bowel and assessing the rest of the abdomen to keep in mind the possibility of anatomical anomalies. These variants may not be highlighted on traditional imaging but can be with direct examination during a laparotomy. These anomalies, such as a Meckel’s diverticulum, may not necessarily be the source of major hemorrhage in trauma cases but can still contribute to pneumoperitoneum and hemoperitoneum and are critical to not be missed.
Judge: If you had an adult patient with symptoms of nausea and vomiting, abdominal pain and possible bleeding, how would you rule out Meckel’s diverticulum?
Thank you for your question, Dr. Novak. For a patient presenting with the symptoms you mentioned above (nausea, vomiting, abdominal pain, and possible bleeding), it is important to take into consideration the entire clinical picture (patient stability, past medical history, duration of symptoms, etc.). Traditional imagining modalities such as CT are standard for assessing abdominal or pelvic pathology. However, bleeding diverticula are not routinely seen on CT. If the patient is hemodynamically unstable, an exploratory laparoscopy or laparotomy may need to be performed. In a hemodynamically stable patient, with equivocal imaging, a higher clinical suspicion for Meckel’s involvement is warranted, especially in children less than 10 and adults less than 40. Diagnosis of Meckel’s involvement is typically made via a Meckel’s nuclear medicine scan or mesenteric arteriography.
Thank you for your report. How did you calculate the odds of 1 to 1.5 million of hitting the Meckel’s diverticulum?
Thank you for question Dr. Walser. Math (in centimeters) is as follows: Meckel’s prevalence is 0.02, Meckel’s size 3.75cm^2, Body area 1.18×10^5, percent body volume 3.18×10^-5. The equation is (0.02) x (3.18×10^-5) = 0.0000000637 or 1/1,570,790.