Case report of an acute abdomen due to perforated viscous. Laparotomy found the perforation at a Meckel's Diverticulum and was by a jujube pit. Photos of the operative findings in addition to the abdominal xray and CT scan are presented. Case discussion with review of literature. Dr Mohamad Al-Gailani MBChB, MS, FRCS Chief of Surgery Al Hammadi Hospital Nuzha Riyadh, KSA

1. DR. MOHAMAD AL-GAILANI FRCS ‫الكيالني‬ ‫محمد‬ ‫الدكتور‬
CONSULTANT SURGEON ‫الجراحة‬ ‫استشاري‬
CHIEF OF SURGERY ‫الجراحة‬ ‫قسم‬ ‫رئيس‬
RIYADH ‫الرياض‬
KSA ‫السعودية‬ ‫العربية‬ ‫المملكة‬
‫النبق‬ ‫فاكهة‬ ‫نواة‬ ‫عن‬ ‫الناجم‬ ‫ميكل‬ ‫رتج‬ ‫ثقب‬
(
‫العبري‬
:)
‫حالة‬ ‫تقرير‬
MECKEL’S DIVERTICULUM PERFORATION
CAUSED BY A JUJUBE PIT: A CASE REPORT

2. CLINICAL PRESENTATION:
EMERGENCY DEPARTMENT
 35 YEAR OLD MALE
 4 DAY HISTORY CENTRAL ABDOMINAL PAIN AND DIARRHEA
 SHIFTED TO RIGHT ILIAC FOSSA
 CHRONIC RENAL FAILURE ON HAEMODIALYSIS THREE TIMES A WEEK
 RIGHT NEPHRECTOMY AS A CHILD
 ON EXAM: TRANSVERSE SCAR RIGHT SIDE ABDOMEN, BOARD-LIKE RIGIDITY, ABSENT BOWEL
SOUNDS. ACUTE ABDOMEN!
 WORKING DIAGNOSIS: ACUTE APPENDICITIS (POSSIBLY PERFORATED) WITH GENERALIZED
PERITONITIS.
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS 2

3. INVESTIGATIONS
 HB 12% WCC 9.46 PLAT 230,000
 CRP 23
 UREA 31 CREAT 13.31
 ERECT CHEST AND PLAIN ABDOMEN XRAYS: PROMINENT SMALL BOWEL LOOPS. NO AIR
UNDER DIAPHRAGM.
 US ABDOMEN: NON VISUALIZED RIGHT KIDNEY (PREVIOUS NEPHRECTOMY), SMALL AMOUNT
OF SUB HEPATIC AND PELVIC FREE FUID COLLECTION.
 CT (DOUBLE CONTRAST): FREE FLUID SUB-HEPATIC, RIGHT ABDOMINAL SMALL BOWEL
OBSTRUCTIVE PROCESS (ILEAL LEVEL). INTRA-PERITONEAL GAS (PNEUMOPERITONEUM).
CONCLUSION: PERFORAED VISCOUS
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS 3

4. MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT
DR. MOHAMAD AL-GAILANI FRCS
4
PLAIN ABDOMEN XRAY
Prominent small bowel loops

5. MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT
DR. MOHAMAD AL-GAILANI FRCS
5
CT SCAN SHOWING INTRA-PERITONEAL GAS INDICATING
PERFORATED VISCOUS. NOTE THE ABSENT RIGHT KIGNEY

6. MANAGEMENT:
PERFORATED VISCOUS
 ADMIT TO ICU FROM ER.
 COMMENCE CEFTRIAXONE + METRONIDAZOLE IV
 DEXTROSE SALINE 100 ML/HOUR IV
 NG TUBE
 FOLEYS CATHETER
 TED STOCKINGS
 CLEXANE 40 MG SC
 PREPARE FOR EMERGENCY LAPAROTOMY
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS 6

7. EMERGENCY LAPAROTOMY:
FINDINGS
 INCISION: LOWER MIDLINE
 EXTENSIVE SMALL BOWEL ADHESIONS
 LOCALIZED PERITONITIS MAINLY RIGHT SIDED
 PERFORATION BY A JUJUBE PIT AT SITE OF A 3CM MECKEL’S DIVERTICULUM BUT WITH
MINIMAL SPILLAGE
 AN ILEAL NARROWING/STRICTURE (2 CM WIDE) DISTAL TO THE MECKEL’S DIVERTICULUM
WITH PROXIMAL DILATED BOWEL.
 NORMAL APPENDIX
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS 7

8. EMERGENCY LAPAROTOMY:
PROCEDURE
 METICULOUS SMALL BOWEL ADHESOLYSIS STARTING FROM THE DUODENO JEJUNAL
FLEXURE.
 THE MECKEL’S DIVERTICULUM (INCLUDING THE PERFORATION SITE) AND THE UNDERLYING
ILEAL STRICTURE WERE MOBILIZED, RESECTED WITH SIDE TO SIDE ANASTOMOSIS USING A
GIA STAPLER.
 COPIOUS 3 LITRE SALINE PERITONEAL WASHOUT.
 EXUDRAIN SIZE 18 LEFT AT SITE.
 OPERATION COMPLETED WITH LOOPED PDS MASS CLOSURE AND SKIN CLIPS.
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS 8

9. INTRA-OPERATIVE IMAGE:
JUJUBE SEED PENETRATING MECKEL’S DIVERTICULUM
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR.
MOHAMAD AL-GAILANI FRCS
9

10. INTRA-OPERATIVE IMAGE
CLOSE UP:
JUJUBE SEED PENETRATING MECKEL’S
10
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT
DR. MOHAMAD AL-GAILANI FRCS

11. HISTOPATHOLOGY:
14 CM ILEAL RESECTED LOOP
11
MECKEL’S
DIVERTICULUM (2.5 X 2
X 2 CM) DIAMETER
PERFORATION AND
OVERLYING SEROSAL
PURULANT MEMBRANE
AND THINNED OUT
WALL
ILEAL STRICTURE
2CM WIDE
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT
DR. MOHAMAD AL-GAILANI FRCS
DILATED PROXIMAL
ILEUM

12. POSTOPERATIVE COURSE
 RETURNED TO ICU FROM THEATRE
 CONTINUED ON ANTIBIOTIC, PANTOPRAZOLE 40MG IV DAILY, CLEXANE 40MG BID SC.
 HAEMODIALYSIS SCHEDULE CONTINUATION IN ICU
 PASSED FLATUS FOLLOWED BY BOWEL MOVEMENT ON 5TH POSTOPERATIVE DAY
 NG TUBE AND FOLEYS CATHETER BOTH REMOVED.
 READIVAC ABDOMINAL DRAIN FINALLY REMOVED ON 5TH POSTOPERATIVE DAY
 TRANSFERRED OUT OF ICU TO SURGICAL WARD.
 DISCHARGED FROM SURGICAL WARD ON 7th POSTOPERATIVE DAY.
 ROUTINE OUTPATIENTS FOLLOWUP IN 2 WEEKS, WELL. SKIN CLIPS REMOVED.
 DISCHARGED FROM OUR CARE.
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS 12

13. Meckel’s Diverticulum
 Meckel’s diverticulum occurs when the omphalomesenteric duct fails to obliterate completely
during fetal life.
 It is present in 2-3% of the population
 Meckel’s diverticulum is asymptomatic in most of the affected individuals, with a 4.2–16.9%
probability of symptomatic presentations
 They include Gastrointestinal bleeding, Abdominal pain and cramping, Obstruction of the bowels
and Diverticulitis.
 Meckel's Diverticulitis is similar to Acute Appendicitis in presentation and is one of its differential
diagnosis.
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS 13

14. JUJUBE PIT ‫النبق‬
(
‫العبري‬
)
BOWEL PERFORATION
 Gastrointestinal tract perforation and complications due to ingestion of a foreign body are
extremely rare.
 More than 90% of ingested foreign bodies pass through the intestine if they reach the stomach.
 Objects that cause perforation are usually sharp, pointed, or elongated such as
fish bones and needles. In our case it was the pointed tip of a jujube pit.
 The perforation can occur anywhere along the gastrointestinal tract, commonly in areas of
narrowing, in our case a stricture by Meckel's Diverticulum.
 Jujube pit bowel perforations are rare, it can occur both in children and adults.
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS 14

15.  The clinical presentation in our case pointed mostly to a diagnosis of perforated
appendicitis.
 The Meckel’s Diverticulum seems to have lead to narrowing of the bowel (as one
of its known rare potential complication)
 This 2 cm wide narrowing (on histology), must have contributed to the jujube pit
getting stuck with the sharp pointed tip eventually penetrating the wall leading
to peritonitis.
 A literature search confirmed the rarity jujube pit small bowel perforation
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS
15
DISCUSSION

16. CONCLUSION
 A case of perforated viscous secondary to foreign body ingestion.

‫غريب‬ ‫لجسم‬ ‫ابتالع‬ ‫نتيجة‬ ‫األمعاء‬ ‫ثقب‬ ‫حالة‬
 The perforation was found to be by a jujube pit of a Meckel’s
Diverticulum.

‫النبق‬ ‫نواة‬ ‫بواسطة‬ ‫ميكل‬ ‫رتج‬ ‫في‬ ‫الثقب‬ ‫على‬ ‫العثور‬ ‫تم‬
(
‫العبري‬
)
 In our view, this is a rare case and one of special interest.

‫خاص‬ ‫باهتمام‬ ‫تحظى‬ ‫لذلك‬ ‫و‬ ‫نادرة‬ ‫حالة‬ ‫هذه‬ ‫رأينا‬ ‫في‬
.
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS 16

17. REFERENCES
 Case Report Peritonitis with small bowel perforation caused by jujube pit in a 3-year-
old child: a case report. Int J Clin Exp Med 2018;11(1):384-387
 Intestinal Perforation Secondary to Pits of Jujube Ingestion: A Single-Center Experience
with 18 Cases. World J Surg. 2019 May;43(5):1198-1206
 Meckel’s diverticulum perforation by a fish bone: A case report. Int J Surg Case Rep.
2016; 28: 237–240.
MECKEL’S DIVERTICULUM PERFORATION CAUSED BY A JUJUBE PIT: A CASE REPORT DR. MOHAMAD AL-GAILANI FRCS
17

18. Dr. Mohamad Al-Gailani MBChB, MS, FRCS
‫الكيالني‬ ‫محمد‬ ‫الدكتور‬
Chief of Surgery ‫الجراحة‬ ‫قسم‬ ‫رئيس‬
Al Hammadi Hospital, Nuzha ‫الحمادي‬ ‫مستشفى‬
,
‫النزهة‬
Riyadh KSA ‫السعودية‬ ‫العربية‬ ‫المملكة‬ ‫الرياض‬
www.slideshare.net/MohamadAlGailani1