meckel s diverticulum ( md ) is the most common congenital malformation of gastrointestinal tract [ 14 ] . it is the remanant of omphalomesenteric duct which is normally obliterated by 7th week of gestation . those patients who develops symptoms are due to its complications which could be bowel obstruction , hemorrhage , diverticulitis , perforation or other umbilical lesions . small bowel obstruction is the most common presentation in adults accounting for 1/3rd of all symptomatic cases . a 14 year old male presented to emergency with complaint of pain abdomen with history of constipation with passage of flatus , vomiting ( 56 episodes ) and mild abdominal distension since 3 days . patient also gave history of minor blunt trauma abdomen 4 days back and subsequently , a day later patient developed the symptoms . on abdominal examination , the abdomen was soft , non tender and bowel sounds were present with soft stools on per rectal examination . fluid resuscitation and antibiotics were started and patient was put on conservative management and patient had relief of symptoms with passage of stools and flatus but again after 2 days developed the features of sbo for which exploratory laparotomy was undertaken for the persistent feature of sbo . about 50  cm  s away from ileo - caecal junction , was herniated loops of bowel through unusual mesentery of meckel s extending from base of diverticulum to the band which was running from it s tip to adjacent mesentry encircling the herniated loops of intestine forming a complete hernial sac ( figs . the attachment of the diverticulum along with its adhesive band was rotated over the hernial sac in such a way thus giving the appearance of bilobed sac ( fig . 4 ) and the band was released which revealed meckel s diverticulum with its mesentery forming the hernial sac ( fig . 5a ) . diverticulectomy with its mesentery and adjacent portion of the ileum with ileo - ileal anastomosis was done in single layer . if this regression fails , various anomalies can occur which includes meckel s diverticulum with / without fibrous cord attached to the abdominal wall , an umblical intestinal fistula , enterocystoma or an umblical adenoma . md is present in approximately 13% of the population with equal incidence in males and females   but symptoms are commonly present in males . it is a true diverticulum containing all layers of the ileal wall containing heterotrophic tissue . it arises from the anti - mesenteric border of the ileum , situated between 30 and 150  cm  s from ileo - caecal valve   and receiving its blood supply from a remnant of the vitelline artery . symptoms arises when associated with complications which occurs in 4% of cases   including gastrointestinal bleeding , diverticulitis , and small bowel obstruction [ 25 ] . are frequently non specific and can mimic other pathologic conditions such as appendicitis , crohns disease , cholecystitis and peptic ulcer . various mechanisms by which it can cause intestinal obstruction .volvulus of small intestine around fibrous band extending from meckel s diverticulum to umbilicus.intussusception.littres hernia : incarceration of the diverticulum in inguinal and femoral hernia.entrapment of small bowel beneath mesodiverticular band.adhesions secondary to diverticulitis.enterolithiasis causing impaction inflammation.herniation of gut through loop formed by adhesion band extending between the diverticulum and base of the mesentery.neoplasm obstruction.bezoar lodged in diverticulum in y shaped pantaloons pattern . herniation of gut through loop formed by adhesion band extending between the diverticulum and base of the mesentery . bezoar lodged in diverticulum in y shaped pantaloons pattern . internal hernia caused by entrapment of internal herniation by md leading to sbo is an extremely rare complication   and it should be considered in patients with obstructive symptoms , especially in younger people without previous abdominal surgery . a case of internal hernia through mesentry of meckel s diverticulum has been reported by dalinka et al . . several other cases have been reported of internal herniation due to adhesion of inflamed end of md to corresponding base of mesentry by papaziogas et al .   and lin et al . , through mesodiverticular band by jain and sahi   and srinivas and cullen , fibrous cord extending upto umblical wall by maia et al .   and aggarwal et al . . but in our case patient had both adhesion band extending from tip of diverticulum to adjacent mesentry along with internal herniation of gut into a sac formed by unusual mesentry of the meckel s diverticulum and the adhesion band . abdominal radiographs may be useful if enteroliths are present , which can be seen as peripheral calcification with a radiolucent center ultrasonograms may suggest evidence of a round or tubular cystic lesion , however , this can often mimic a dilated bowel loop . the use of barium studies is limited , due to poor barium filling of the obstructed bowel . computed tomography is usually the gold standard imaging modality however , identifying md as the cause of obstruction can be difficult . though , in internal hernia , clustering of bowel loops and stretched crowded and engorged mesenteric vessels may be suggestive features . however , due to emergency situation and limitations of the imaging modalities in identifying complications of md , typically the diagnosis is made only at laparotomy . its presentation due to herniation of bowel loops into sac formed by mesentery attached to diverticulum and the adhesion is rarest , with non specific signs and symptoms . written informed consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request .
highlightsmeckel s diverticulum ( md ) , a remanant of omphalomesenteric duct , is the most common congenital malformation of git.most patients are asymptomatic . 
 patients develops symptoms due to its complications like bowel obstruction , hemorrhage , diverticulitis , littre s hernia or perforation.case presented with persistent features of subacute intestinal obstruction due to herniation of bowel loops through unusual mesentery of meckel s diverticulum extending from base of diverticulum to the band which was running from it s tip to adjacent mesentry encircling the herniated loops of intestine forming a complete hernial sac ; a rarest way of presentation.limitation of imaging modalities in diagnosis of complications of diverticulum.surgical intervention indicated for patients with intestinal obstruction or high risk of incarceration . the treatment option is surgical resection with diverticulectomy and reduction of internal herniation .