Diala, Diana Ray Margarita S.

Group D

Written Case Report

General Data
This is the case of T.R.E., 9 years old, male, Roman Catholic, who resides in
Nantangalan, Pozirrubio, Pangasinan and was admitted for the first time at Region 1
Medical Center on June 28, 2018 at 12:00PM.

Chief Complaint: Epigastric pain

History of Present Illness:

Two days prior to admission, the patient presented with crampy epigastric pain,
with no radiation, with a pain scale of 8 out of 10, which was accompanied by vomiting
and 4 days of no bowel movement, no associated fever, anorexia, dysuria, hence, sought
consult at other institution where he was admitted for 2days. During his first hospital day,
urinalysis, CBC and ultrasound were done. Urinalysis revealed increase Red blood cell
count of 75-80/hpf and White blood cells of 6-10/hpf. CBC revealed increased White blood
cells of 25.6x103U/L and Neutrophils, 0.87. His ultrasound showed free-fluid collection in
the hepatorenal space, pelvic, and paracolic gutters, and there was dilated fecal-filled
bowel noted. He was given antacids and suppository, which offered little relief of
symptoms.
One day prior to admission, the patient claimed that the abdominal pain has
lessened, which prompted his parents to transfer the patient at our institution, hence,
admitted.
Past Medical History:
The patient has a history of confinement to another institution due to loose bowel
movement. He has no comorbidities and no past history of past transfusion. No known
allergy to food and medications,

Family History:
No known heredo-familial diseases.
Personal, Social, Educational History:
 The patient is currently in Grade 3. He used to study in a private school but recently
was transferred to a public school, the patient claimed that due to the comfort rooms being
unhygienic, he refuses to urinate or defecate there, instead he waits until he arrives home.
He is fond of eating junk foods and drinking softdrinks.

Review of Systems:
Constitutional: (-) fatigue; (-) weakness; (-) weight loss

Neurologic: (-) headache, (-) syncope, (-) seizures, (-) areas of focal weakness, (-)
sensory problems / numbness “tingling” or “pins and needles”, (-) history of seizures, (-)
dizziness, (-) scotoma, (-) vertigo, (-) tremors or other involuntary movements .

Eyes: (-) significant visual difficulties, (-) blurred vision, (-) diplopia, (-) eye pain

ENT: (-) problems in hearing; (-) sore throat (-) sinus drainage (-) epistaxis
(-) tinnitus

Cardiovascular / PVS: (-) chest pain or discomfort (-) PND (-) orthopnea
(-) palpitation (-) Rheumatic fever (-) claudication ; (-) bipedal edema (-) leg cramps

Respiratory: (-) cough (-) difficulty of breathing (-) no hemoptysis

Gastroenterology: (-) Dysphagia (-) odynophagia (-) change in appetite (-) belching or
bloatedness(-) flatulence (-) nausea (-) vomiting (+) abdominal pain
(-) diarrhea (+) constipation (+) change in bowel movement (-) melena (-) hematochezia

GUT: (-) dysuria or burning pain on urination (-) incontinence (-) hematuria (-) nocturia (-
) frequency (-) polyuria (-) urgency (-) hesitation (-) dribbling (-) loss of parabolic curve

Musculoskeletal: (-) joint pain (-) swelling or redness (-) decreased range of motion (-)
myalgia

Endocrine: (-) diabetes (-) thyroid disease or hormone replacement (-) night sweats

Immunologic /Hematologic: (-) easy bruising or bleeding (-) urticarial/allergy

Psychiatric: (-) insomnia, depression, mania or mood swings (-) psychotropic drugs

Physical Examination:
General survey: conscious, coherent, afebrile, ambulatory with the following vital signs:
BP=100/70 mm Hg CR = 100bmp RR=24bmp Temp = 36.7oC

Skin: warm to touch, no scars/lesions, intact

HEENT: pinkish palpebral conjunctivae ; anicteric sclerae ; (-) circus senilis ;
(-) xanthelasma ; (-) alopecia, (-) tonsillopharyngeal congestion

Chest/ Lungs: symmetrical ; (-) retractions ;(-) lag; (-) spider angiomas; equal
vocal and tactile fremiti ; equally resonant on both lung fields; equal breath
sounds ; (-) rales ; (-) wheezes

Heart: Adynamic precordium ; Apex beat at the 4th or 5th intercostal space left
midclavicular line ; (-) thrills/ heaves ,normal rate regular rhythm ; (-) murmurs

Abdomen: slightly globular, distended, (+) epigastric pain; (-) caput medusae;
normoactive bowel sounds; tymphanitic ; (-) splenomegaly

Rectal examination: good sphincteric tone, no mass or lumps palpated, no blood on

tactating finger

Genitalia: Grossly normal external genitalia

Impression: Acute Appendicitis probably Ruptured

Course in the ward:

1st day of hospital stay: the patient was maintained on NPO, and hooked in PLRS
1L 30-35gtts/min x 6hrs. Laboratory tests were requested, such as CBC, blood typing,
urinalysis, chest x-ray AP/L, serum electrolytes, abdominal x-ray supine and upright.
Medications given were Metronidazole 450mg IV q8, Cefuroxime 700mg IV q8, and
Omeprazole 20mg IV OD. NGT was inserted. He then undergone emergency exploratory
laparotomy.
 Intra-Operative findings:
- GETA
- Patient in supine position
- Asepsis/antisepsis
- Sterile drapings
- Midline excision carried down to the
peritoneum
- Exploration #1/Identification of
Pathology:

Diverticulum adherent to
peritoneum
Loop obstruction (ileum-viable)
- Adhesiolysis
- Wedge resection
- Anastomosis
- Hemostasis
- Exploration #2
- Instrument and sponge count complete
- Exploration #3
- Layer by layer closure with vicryl 2-0
- Sterile dressing

2nd day of hospital stay: the patient is still on NPO and was advised to ambulate.
The patient claimed that he already had passed flatus and defecated twice. On his first
defecation, his stool was tarry and semi-formed but on his second defecation, his stool
was brown in color and semi-formed. He had no fever, no cough, no chest pain, no
abdominal pain, no difficulty of breathing. Vital signs were: BP 110/70, CR 96, RR 21,
temp. 36.8°C.
3rd day of hospital stay: Patient still maintained on NPO.
4-5th- day of hospital stay: general liquid diet to soft to DAT diet
6th day of hospital stay: patient has improved and discharged.
Pertinent Laboratory and Radiologic Findings:
- CBC: WBC: 17.09, Neutro: 84.8, Hgb: 159, Hct: 47.8, Plt: 671
- Serum electrolytes: Na: 131.1, K: 4.16, Cl: 96.1; iCa: 1.24
- Plain abdomen AP upright and supine: gas-distended bowel loops are seen in the
central and left hemiabdomen with no significant air fluid level
- UTZ: free-fluid collection in the hepatorenal space, pelvic and paracolic gutters,
dilated fecal filled bowels noted
- CXR: Normal findings
Differential Diagnosis:
I. Appendicitis
II. Gastroenteritis
III. Colitis

Final Diagnosis: Closed Loop Obstruction secondary to Meckel’s Diverticulum S/P

Wedge Resection, end-to-end Anastomosis (June 28, 2018)
Case Discussion:
Meckel’s diverticulum
Meckel's diverticulum is the most common congenital anomaly of the
gastrointestinal tract. It results from incomplete obliteration of the vitelline duct leading to
the formation of a true diverticulum of the small intestine. Meckel's diverticula are
uncommon and often clinically silent, particularly in the adult. Asymptomatic Meckel's
diverticulum may be discovered during abdominal exploration for the evaluation of
unrelated pathology. Less commonly, they are found incidentally on diagnostic imaging.
When symptomatic, Meckel's diverticulum may present with abdominal pain or symptoms
of gastrointestinal bleeding or bowel obstruction. The most common presentations
associated with symptomatic Meckel’s diverticula are bleeding, intestinal obstruction and
diverticulitis. Bleeding is the most common presentation in children with Meckel’s
diverticula, representing over 50% of Meckel’s devierticulum-related complications
among patients less than 18 years of age.
3. Omphalomesentric duct anomalies • Vitelline duct or omphalomesenteric duct
anomalies are secondary to the persistence of the embryonic vitelline duct, which
normallyobliterates by weeks 5–9 of intrauterine life • Meckel’s diverticulum is the most
common vitelline duct anomaly
Embryology During week 3 of gestation, the midgut is open into the yolk sac, which
does not grow as rapidly as the rest of the embryo. Subsequently, by week 5, the
connection with the yolk sac becomes narrowed and is then termed a yolk stalk, vitelline
duct, or omphalomesenteric duct. Normally, the vitelline duct disappears by gestational
week 9, just before the midgut returns to the abdomen
Rule of 2’s:
- its incidence is 2%
- it is located 2 feet (60 cm) from the ileocecal valve
- it is 2 inches long (5 cm)
- it has 2 cm in diameter
- turns symptomatic before 2 years of age
- commonly contains 2 types of heterotopic tissue (gastric and pancreatic)
- 2 times more common in males than in females

Pathophyisology
Most complications of these abnormalities are related to ectopic tissue (gastric,
pancreatic, colonic, endometriosis, or hepatobiliary). Ectopic gastric tissue usually causes
bleeding from ulceration of the adjacent ileal mucosa. The ileal mucosa is not equipped
to buffer the acid produced by the ectopic gastric mucosa and thus is prone to ulceration.
ulceration. The site of the ulceration is most often at the junction of the normal ileal
mucosa and the ectopic gastric mucosa.
• Intestinal obstruction may be caused by a Meckel’s diverticulum attached to the
umbilicus by a fibrous cord or by a fibrous cord between the ileum and the umbilicus and
can also occur by intussusception with the diverticulum
Complications of Meckel Diverticulum
 - Ulceration
- Hemorrhage
- Small bowel obstruction
- Diverticulitis
- Perforation

Clinical Presentation
The classic presentation is an older infant or young child with painless rectal
bleeding (This usually consists of a large volume of bright red bleeding but can
occasionally also present as dark, tarry stools). Melena may be episodic and usually
ceases without treatment; sometimes the melena is insidious and not appreciated by the
family. In a young child with hemoglobin positive stools and a chronic iron deficiency
anemia, the diagnosis of Meckel’s diverticulum should be considered. Intestinal
obstruction, usually due to intussusception, is the most typical presentation in newborns
and infants. The symptoms include crampy abdominal pain, bilious vomiting, currant-jelly
stools, and abdominal distention. Patients with Meckel’s diverticulitis often have
symptoms that resemble appendicitis. They are usually older children. Periumbilical pain
is the first symptom. They usually do not have the same amount or intensity of vomiting
and nausea.
Diagnosis
Diagnosis of a symptomatic vitelline duct malformation is dependent on the
anatomic configuration and its presentation, signs, and symptoms. History and physical
examination are important for the diagnosis A complete description of the quality and
frequency of the bloody stools is necessary in patients with rectal bleeding. Rectal
examination and lower endoscopy is useful to identify other causes of lower bleeding.
The test of choice for a bleeding Meckel’s diverticulum is a (Meckel scan), which
concentrates the isotope in ectopic gastric mucosa
Treatment
Symptomatic children with omphalomesenteric duct remnants should be
resuscitated before intervention. Those with significant haemorrhage should be
transfused. The incision chosen varies with the symptoms and the age of the patient.
Surgical treatment — Children with Meckel’s diverticulitis or a bleeding Meckel’s
diverticulum are operated on by using a transverse appendectomy incision with medial
extension if necessary. Patients with suspected intestinal obstruction should be explored
through a generous laparotomy incision.