Meckel's diverticulum--too often forgotten in adults?

Meckel's diverticulum is the commonest congenital anomaly of the gastro-intestinal tract, being present at 2 % of autopsies.1 Approximately 4% cause symptoms and most present during the first decade of life.2 Hence, there is an awareness among clinicians of the possibility of the lesion presenting in infancy or childhood, but a clinical diagnosis of Meckel's diverticulum is rarely considered pre-operatively in adults. We describe three cases admitted to one surgical unit during a three-month period, which illustrate the varying presentation of the condition in adults. CASE 1 An 83-year-old lady was admitted with a two-day history of vomiting and abdominal distension. Examination revealed increased bowel sounds and X-rays showed distended loops of bowel with fluid levels, in keeping with small bowel obstruction. Laparotomy was performed and revealed several loops of distended small bowel, with one loop entrapped behind a mesodiverticular band, which extended from the apex of a Meckel's diverticulum to the base of the small bowel mesentery. The diverticulum and band were resected and her post-operative course was uneventful. Histology revealed ischaemic necrosis of the diverticulum, but no heterotopic mucosa. CASE 2 A 42-year-old man was admitted with a 10-hour history of severe lower abdominal pain. Abdominal examination revealed marked rebound tenderness in the left iliac fossa. However, on reassessment 30 minutes later, the point of maximal tenderness had surprisingly shifted to the right hypochondrium. Serum amylase and electrolytes were normal but the white cell count was elevated. Abdominal X-rays showed no free intraperitoneal gas. Laparotomy was under-taken and revealed a 5 cm long Meckel's diverticulum with a 6 x 4 cm gangrenous pouch at the apex. The diverticulum was resected and his post-operative course was uncomplicated. When the specimen was opened it was found to contain a 4 x 3cm enterolith. Histology revealed ischaemic necrosis and gangrene of the diverticulum but no heterotopic mucosa.