Fetal and Pediatric Pathology, 33:119–122, 2014Copyright C© Informa Healthcare USA, Inc.ISSN: 1551-3815 print / 1551-3823 onlineDOI: 10.3109/15513815.2013.850133

CASE REPORT

Perforated Meckel’s Diverticulum in a Very PretermBaby Revealed at Birth

Aida Borgi,1 Asma Bouziri,1 Nedia Boujelbene,2 Nedia Sghairoun,3

Serra Belhadj,1 and Najla Benjeballah1

1PICU-Children’s Hospital of Tunis, Tunis, Tunisia; 2 Salah Azaiez Institute, Tunis, Tunisia;3Department of Surgery A, Children’s Hospital of Tunis, Tunis, Tunisia

Perforated Meckel’s diverticulum (MD) in a preterm baby is very rare. We report a case of a verypreterm baby, born at 29-week gestation, with a birth weight of 1400 g, admitted in the thirdhour of life to our intensive care unit (ICU) for respiratory distress syndrome with abdominal dis-tention. An abdominal radiograph showed a pneumoperitoneum. Laparotomy revealed Meckel’sperforation. The baby was discharged healthy at the age of 16 days. MD should be kept in mindas one cause of an acute abdomen in preterm neonates mimicking necrotizing enterocolitis. Toour knowledge, our patient is the third reported case described in the literature and the first onerevealed at birth.

Keywords: Meckel’s diverticulum perforation, pneumoperitoneum, prematurity

INTRODUCTION

Meckel’s diverticulum (MD) is the most common congenital gastrointestinal anomalyand is present in about 2% of the general population [1]. Two to six percent of the pa-tients develop complications of MD [2, 3]. MD perforation is rare in newborn and veryrare in preterm babies [4]. We report a case of MD perforation in a very preterm infantrevealed at birth.

CASE REPORT

An out born, 29-week gestation boy, weighing 1400 g was born by urgent cesarean sec-tion for worsening twin pregnancy. He was born to a 38-year-old multigravida mother.During the delivery, the first twin was dead and the second twin had APGAR scoresof 9 at 5 min and 10 at 10 min. Severe respiratory distress was noted immediately af-ter birth necessitating his rapid transfer to intensive care unit (ICU) at 3 h of age. Onadmission, he had cyanosis and severe respiratory distress. His abdomen was muchdistended. The chest radiograph was normal but the abdomen radiograph showed apneumoperitoneum (Figure 1). The baby’s condition improved after mechanical ven-tilation and continuous gastric aspiration without surfactant administration. Oxygenrequirements were 21%. An emergency laparotomy was performed at 5 h of age on

Received 10 June 2013; Revised xx Xxxx; accepted 26 September 2013.Address correspondence to Dr Aida Borgi, PICU-Children’s Hospital of Tunis, Tunis, 1007 Tunisia.E-mail: aidabdoc@yahoo.fr

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Figure 1. The abdomen radiograph showing a pneumoperitoneum.

suspicion of a gut perforation. At laparotomy, a perforated MD measuring up to 1 cmwithin about 30 cm of the ileocecal valve on the antimesenteric border was found. Theappearance of the surrounding bowel was healthy without any inflammatory reaction.A segmental resection (1.5 cm) of the intestine with end-to-end anastomosis was per-formed. Pathological examination of MD showed that the lining of the diverticulumwas found to be ileal mucosa (Figure 2). A discrete inflammatory reaction without ec-topic mucosa was observed within the diverticulum. A nearly intact muscular layerwas found, but a focal defect of the muscular layer was found in the wall with a perfo-rated area.

Figure 2. Meckel’s diverticulum lined by all three layers of the bowel wall (star in the lumen).

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Perforated Meckel’s Diverticulum Revealed at Birth

Our patient recovered well from surgery. He was weaned from ventilatory supporton day 4 of life. He required a prolonged total parenteral nutrition via a central ve-nous catheter with continuous gastric aspiration. He received 10 days of cefotaximeand metronidazole. Culture of the peritoneal effusion showed no bacterial growth. En-teral feeding was introduced successfully 12 days after surgery. He was discharged onday 16 of life with a regular outpatient follow up.

DISCUSSION

Our patient was a very preterm baby born at 29-week gestation. He developed res-piratory distress immediately after birth without abnormalities on X-ray chest ex-cluding hyaline membrane disease. Respiratory distress was secondary to abdominaldistention. The baby’s condition improved after mechanical ventilation and contin-uous gastric aspiration. Abdominal distention occurred without any history of ven-tilation by valve mask. Abdominal radiograph revealed a pneumoperitoneum. Wesuspected iatrogenic gastric perforation or idiopathic intestinal perforation. Pneu-moperitoneum refers to radiological evidence of rupture of an air-containing vis-cus with resultant gross soiling of the peritoneal cavity [4]. In the newborn, it is anacute surgical emergency with serious implications requiring immediate surgical in-tervention to ensure survival. Laporotomy was performed and revealed perforatedMD. Pneumoperitoneum in neonates can occur in several disease processes includ-ing necrotizing enterocolitis (NEC), perforated appendicitis, or idiopathic intestinalperforation. The pathological examination confirmed the diagnosis of MD perforationwithout any ectopic mucosa. Very few cases of MD perforation were described in theliterature. These cases mimic necrotizing enterocolitis [5, 6]. Our patient did not re-ceive enteral feeds and it was so soon to suspect necrotic enterocolitis.

Symptomatic MD in neonates is rare. The most common presenting symptom inneonates is bowel obstruction [4]. Bleeding of rectum was reported in one case [7].Perforated MD in newborn is very rare with only 11 cases described in the literatureduring the last 25 years [4, 8–10]. The median age at presentation was 4.5 days [4]. Onlytwo perforated MD occurred in very preterm baby [4, 8]. They were symptomatic withpneumoperitoneum on day 3 of life [4] for the first and day 6 of life for the second[8]. Both of them had a significant number of factors that may have been predispos-ing them to intestinal perforation, including antenatal and postnatal steroid therapy,hypoxia and poor intrauterine blood flow [4]. Our patient had not any factor and hewas symptomatic at birth. To our knowledge, he is the first case of perforated MD inpreterm revealed at birth.

There were no deaths reported for neonates with isolated perforated MD. Our pa-tient was discharged after 16 days.

CONCLUSION

Meckel’s diverticulum (MD) should be kept in mind as one cause of an acute abdomenin preterm neonates mimicking NEC or idiopathic intestinal perforation. Prompt sur-gical intervention confers a good prognosis. The age at presentation in our patient isthe originality of this reported case.

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for thecontent and writing of the paper.

Copyright C© Informa Healthcare USA, Inc.

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[7] Sinha CK, Fishman J, Clarke SA. Neonatal Meckel’s diverticulum: spectrum of presentation. PediatrEmerg Care 2009;25:348–349.

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[9] Lee do S. Perforated Meckel’s diverticulum in a 1-day-old neonate. Am Surg 2012;78:E26–E27.[10] Skelly BL, Ervine E, Bisharat M, et al. Small bowel skip segment Hirschprung’s disease presenting

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