Perforated Meckel’s A rare evolution from diverticulitis to sepsis

Authors: Manuela Montatore, Maria Grazia Capasso, Federica Masino, Marina Balbino, Giuseppe Guglielmi

Abstract

Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and affects ∼2% of the population. Although usually asymptomatic, MD may lead to complications including diverticulitis, bleeding, obstruction, and—rarely—perforation. Because perforated MD often mimics acute appendicitis, diagnosis before surgery is frequently missed. We describe a 58-year-old man who presented with right lower quadrant pain, fever, and nausea. Ultrasound excluded appendicitis and raised suspicion for MD. Contrast-enhanced CT confirmed an inflamed 3.5-cm MD with surrounding fat stranding, consistent with acute diverticulitis. The patient initially improved with conservative therapy but returned five days later with worsening pain and fever. A second CT revealed microperforation with peridiverticular extraluminal gas and fluid. Within 48 hours, clinical sepsis developed. A third CT demonstrated frank pneumoperitoneum and diffuse peritoneal free fluid. Exploratory laparotomy confirmed a perforated MD, which was resected, followed by ileostomy. Postoperative recovery was uneventful. Although rare, MD perforation is potentially life-threatening. This case uniquely illustrates the radiologic evolution from diverticulitis to microperforation and ultimately free perforation, documented across three consecutive CT examinations. Awareness of this progression may improve early recognition and timely surgical management of complicated MD.

Case description

A 58-year-old man with no relevant medical history presented with acute right lower quadrant abdominal pain, fever (38.2°C), and nausea. Symptoms had worsened over 24 hours. Physical examination revealed localized guarding, rigidity, and rebound tenderness, prompting suspicion of acute appendicitis.

Abdominal ultrasound demonstrated a blind-ending, thick-walled tubular structure with a preserved gut signature, consistent with a Meckel’s diverticulum, while the appendix appeared normal (Fig. 1). Based on these findings, contrast-enhanced CT was performed. CT confirmed a 3.5-cm diverticulum on the antimesenteric border of the distal ileum, with mural thickening and surrounding fat stranding, consistent with acute diverticulitis (Fig. 2). No extraluminal gas, perforation, or abscess was present.Fig. 1Abdominal ultrasound of the right lower quadrant demonstrating a blind-ending, thick-walled tubular structure with the characteristic "gut signature," consistent with Meckel’s diverticulum. No signs of appendiceal inflammation are observed.Fig Fig. 2Portal venous phase contrast-enhanced abdominal CT (axial A–A’, coronal B–B’, sagittal C–C’) demonstrating a blind-ending, thick-walled tubular structure consistent with a Meckel’s diverticulum, located approximately 3.5 cm proximal to the ileocecal valve. Mild mesenteric fat stranding is present. Although additional contrast-enhanced phases were acquired, image quality was suboptimal due to patient motion, and therefore the portal venous phase was selected as the most representative. Although multiphase contrast-enhanced CT was performed, several acquisitions were affected by patient respiratory and motion artifacts due to abdominal pain and discomfort. For this reason, only the portal venous phase—being the most diagnostically reliable—was selected for inclusion in the manuscript.Fig

The patient received intravenous ceftriaxone and metronidazole and improved clinically within 48 hours. He was discharged with oral antibiotics and advised to return if symptoms recurred [[1], [2], [3]].

Five days later, he returned with intensified abdominal pain, fever, and abdominal distension. Repeat CT demonstrated new small pockets of extraluminal gas adjacent to the diverticulum and mesenteric fluid, indicating microperforation and localized peritonitis (Fig. 3).Fig. 3Second contrast-enhanced CT scan (axial A, coronal B) demonstrating early microperforation of the Meckel’s diverticulum. Arrows indicate small foci of extraluminal gas adjacent to the diverticular wall, while arrowheads highlight subtle mesenteric fluid collections consistent with localized peritonitis. No free intraperitoneal air is present. These annotated images were selected to ensure precise correspondence with the findings described in the text.Fig

Within 48 hours, the patient developed hypotension, tachycardia, high fever, and diffuse abdominal rigidity, suggesting evolving sepsis. A third CT scan revealed extensive pneumoperitoneum and diffuse peritoneal free fluid, confirming free perforation (Fig. 4).Fig. 4Third CT scan (coronal, sagittal and axial) with lung-window, showing pneumoperitoneum (free intraperitoneal air) consistent with free perforation of the Meckel’s diverticulum and peritonitis.Fig

Emergency exploratory laparotomy identified a perforated Meckel’s diverticulum with purulent contamination. The diverticulum and adjacent ileal segment were resected, the abdomen was irrigated, and a protective ileostomy was created. The postoperative course was uneventful, and follow-up confirmed complete recovery.

Discussion

Meckel’s diverticulum is a congenital anomaly resulting from incomplete involution of the omphalomesenteric duct [4]. Although the classic “rule of twos” is often cited, only 4%-6% of individuals with MD develop symptoms [5], and perforation is highly uncommon (<0.5% of symptomatic cases) [6,7]. In adults, diverticulitis is the most frequent cause of perforation.

Because the clinical presentation overlaps with appendicitis, Crohn’s disease, or other causes of acute abdomen, imaging plays a decisive role. CT is the preferred diagnostic modality, capable of identifying mural thickening, hyperenhancement, peridiverticular fat stranding, and signs of early complications. Microperforation may manifest as small extraluminal gas pockets or mesenteric fluid, whereas free perforation presents with pneumoperitoneum and diffuse peritonitis.

The differential diagnosis includes acute appendicitis, non-Meckelian small bowel diverticulitis, Crohn’s disease, perforated neoplasms (including GIST, lymphoma, or adenocarcinoma), foreign body perforation, and ischemic or stercoral perforation [3,6]. Differentiating these entities requires careful assessment of the diverticulum’s origin, enhancement pattern, and associated mesenteric changes [[7], [8]].

The most remarkable aspect of this case is the sequential radiologic documentation of disease evolution across 3 CT from diverticulitis to microperforation and then to free perforation with sepsis. Such stepwise imaging is seldom reported in the literature and offers valuable insights into the progressive nature of complicated MD [[9], [10]]. This case reinforces the importance of repeat imaging when symptoms persist or worsen despite conservative treatment [[11], [12]].

Conclusion

Although rare, perforation of Meckel’s diverticulum is a potentially life-threatening condition. Contrast-enhanced CT plays a central role in diagnosis, monitoring for complications, and guiding surgical intervention. The sequential CT progression observed in this patient highlights how rapidly MD diverticulitis can evolve and underscores the need for prompt surgical evaluation when deterioration occurs. Clinicians should include MD in the differential diagnosis of right lower quadrant pain, particularly when appendicitis is excluded.

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