gastrointestinal bleeding is the most common presentation in the paediatric population while intestinal obstruction is the most common complication in adults . we present a first report of an unusual mechanism of small bowel obstruction due to meckel s diverticulitis in a paediatric patient . a 15-year - old girl presented with one day history of colicky central abdominal pain associated with loss of appetite and nausea . she was afebrile with normal hemodynamic parameters . she was mildly dehydrated and abdominal examination revealed tenderness over the periumbilical and suprapubic regions . laboratory tests showed leukocytosis with left shift ( 16,600 white blood cells / mm3 , 92.8% neutrophils ) , raised serum amylase ( 468 u / l ) and raised urinary amylase ( 769 u / l ) . the patient underwent computed tomography ( ct ) scan of her abdomen / pelvis on the first day of admission which showed mild dilatation of the small bowels , particularly in the distal jejunum and proximal ileum with thickening of the bowel wall and submucosal oedema . computed tomography scan showing dilated small bowel loops and mucosal oedema . the bowel wall is well enhancing . however , her abdomen became increasingly distended and she developed vomiting over next three days . a repeat ct scan of the abdomen / pelvis was performed on the fourth day of admission and this showed interval worsening of small bowel dilatation along with a transition point in the distal ileum ( figure 2 ) . intra - operatively , gangrenous 6 cm long meckel s diverticulum was found with omentum adherent at its tip ( figure 3 ) . a short segment of the terminal ileum containing the meckel s diverticulum and adhesion band was resected and stapled anastamosis with linear staples was performed . the histology showed an infracted meckel s diverticulum lined by small intestine - type mucosa . she was discharged on post - operative day 8 and was well at her clinic follow - up visit . figure 2computed tomography scan showing worsening small bowel dilatation and a transition point ( green arrow ) at the ileum . computed tomography scan showing worsening small bowel dilatation and a transition point ( green arrow ) at the ileum . intra - operative photograph showing normal appendix and gangrenous meckel s diverticulum . miniature photograph of resected specimen . meckel s diverticulum was first described by fabricus heldanus in 1650 , then reported by levator in 1671 and by ruysch in 1730 . however , its embryonic origin was established by johann friedrich meckel much later in 1809 and since then bears his name . during the first few weeks of gestation , the midgut loop remains in open connection with the yolk sac by way of the vitelline duct . meckel s diverticulum represents a common vestigial remnant of the omphalomesenteric duct ( also known as the vitelline duct ) . persistence of the duct may also rarely lead to ( i ) fistula between umbilicus and ileum when the entire duct remains patent ; ( ii ) umbilical sinus when the umbilical end of the duct is not obliterated and ( iii ) fibrous cord between the umbilicus and the ileum representing an obliterated duct . it is a true diverticulum containing all layers of the intestinal wall and is usually situated 60100 cm from the ileocecal valve on the anti - mesenteric border of the terminal ileum . the apex of the diverticulum may be free or attached by a fibrous band to the umbilicus or to the mesentery , in which case it can cause intestinal obstruction . as the cells lining the vitelline duct are pluripotent , it is not uncommon to find heterotopic tissue within a meckel s diverticulum . in one study , heterotopic gastric mucosa was found in 62% of cases , pancreatic tissue was found in 6% while pancreatic tissue and gastric mucosa were found in 5% . the raised serum amylase levels in our patient were reflective of intestinal ischaemia rather than ectopic pancreatic tissue . most people with meckel s diverticulum remain asymptomatic with only 416% developing symptoms arising from complications such as intestinal obstruction , gastrointestinal bleeding , and diverticulitis . in a large series of 1476 cases of meckel s diverticulum found intra - operatively in a single institution over a span of 52 years , it was found that 16% were symptomatic with a mean age of 31 years and a male : female ratio of 3:1 . in the paediatric patient population , the commonest complication is gastrointestinal bleeding arising from peptic ulceration due to acid secreted by heterotopic gastric mucosa . on the other hand , intestinal obstruction occurs by various mechanisms : omphalomesenteric band , internal hernia through vitelline duct remnants , volvulus around vitelline duct remnant , intussusceptions , incarceration within a hernia sac ( littre s hernia ) or chronic meckel s diverticulitis . the small bowel obstruction in our patient was not explained by any of the above mechanisms . this is the first report of an omental band adherent to meckel s diverticulum causing intestinal obstruction . charles mayo once remarked meckel s diverticulum is frequently suspected , often looked for and seldom found . preoperative diagnosis of symptomatic meckel s diverticulum is difficult , especially in patients presenting with symptoms other than per - rectal bleeding . in a study of 776 patients , 88% of patients with meckel s diverticulum presenting with per - rectal bleeding had a correct preoperative diagnosis while only 11% of patients who presented with other symptoms were rightly diagnosed preoperatively . plain x - ray , ct scans and barium studies are rarely useful in pre - operative diagnosis of meckel s . in our patient , ct scan was done twice and it failed to recognize the presence of inflamed meckel s diverticulum on two occasions . hence pre - operative diagnosis is many times not possible and a high index of suspicion is essential in dealing with an undiagnosed abdominal pain . when the patient presents with gastrointestinal bleeding , technetium-99 m pertechnate scan is a useful non - invasive investigation . in children , it has a sensitivity of 8090% , specificity of 95% and accuracy of 90% but in the adults , it is less reliable with a sensitivity of 62.5% , specificity of 9% and accuracy of 46% . as the technetium-99 m pertechnate scan is specific to ectopic gastric mucosa and not specifically to meckel s diverticulum , it may be positive in gut duplication cysts with ectopic gastric mucosa . resection of incidentally found meckel s diverticulum has been justified due to a potential for morbidity and mortality throughout life . in 1976 , soltero et al . first opposed routine resection of incidentally found meckel s diverticulum , demonstrating that there was only a small chance of a truly asymptomatic meckel s diverticulum causing disease in later life . peoples et al . also discouraged the resection of incidentally found meckel s diverticulum as they found that the lifetime risk of developing symptoms from a meckel s diverticulum do not significantly outweigh the surgical morbidity and mortality of resection . incidentally found meckel s diverticulum with a broad base or of a short length should be left in situ while the palpability of mucosal heterotopia would steer a surgeon towards resection . park et al . also recommend a selective approach , advising resection of incidentally detected meckel s diverticulum in the following cases : ( i ) patients younger than 50 years of age ; ( ii ) male patients ; ( iii ) diverticulum longer than 2 cm ; ( iv ) detection of abnormal features inside the diverticulum . a recent meta - analysis does not support routine resection of incidentally detected meckel s diverticulum . the definitive treatment of symptomatic meckel s diverticulum is surgery , via laparotomy , laparoscopic or laparoscopic - assisted approaches . the extent of resection is guided by the type of complication encountered and the intra - operative findings . a narrow - base omphalomesenteric remnant without any palpable mass in the lumen may be treated with a simple wedge resection of the diverticulum and closure of the ileal defect . in cases where the diverticulum has a wide base or palpable ectopic tissue or where there is inflammatory or ischemia changes in adjacent ileum , it is preferable to resect the involved bowel with end - to - end bowel anatamosis . segmental ileal resection is also required for treatment of patients with gastrointestinal bleeding as the site of bleeding is usually in the adjacent ileum . involvement of the diverticulum by benign tumors can be dealt with a simple diverticulectomy , depending on the site and size of the lesion . where malignant tumors are involved , wide intestinal and mesenteric resection would be required . in conclusion , meckel s diverticulum is not uncommon and hence should be considered as a differential diagnosis in a patient with an unestablished cause of intestinal obstruction .
meckel s diverticulum occurs in 2% of the general population and majority of patients remain asymptomatic . 
 gastrointestinal bleeding is the most common presentation in the paediatric population . 
 while asymptomatic and incidentally found meckel s diverticulum may be left alone , surgery is essential for treating a symptomatic patient . despite advances in imaging and technology , 
 pre - operative diagnosis is often difficult . 
 we present a first report of an unusual mechanism of small bowel obstruction due to meckel s diverticulitis in a paediatric patient . 
 the diagnosis was only apparent at laparotomy .