Atlas of pathology for medical students

The patient presents at 5 a.m. in the emergency room with complaints of diffuse abdominal pain, bloating and vomiting.
Vital parameters are stable, i. e. well compensated.
The patient is kept for observation, i. v. glucose and saline is administered together with pain therapy 5 mg Ketogan + 2.5 mg Stesolid.
At 00:40 next day the patient is evaluated to have worsening abdominal pain and palpatory tenderness: nausea, vomiting and abdominal pain fluctuating from VAS 1 to VAS 3. Complaints of reflux symptoms with vomiting.
The VAS-scale is an instrument which makes it possible to translate the patients subjective pain perception into an objective estimate. VAS stands for Visual Analogue Scale, and will assist in monitoring the change in pain perception by the patient on a scale 1 – 10, 10=worse possible pain known. A rule of thumb mentions that the patient should maximally indicate VAS level 3 if adequate pain therapy is administered.
Palpatory tenderness in the right and left lower abdominal quadrants.
No passage of stool for 48h.
Decreased ileal sounds.
Afebrile
CT scan reveals distended intestines and a dense point in the right lower quadrant. Vena mesenterica superior cannot be followed to the ileocaecal region. Ileum appears to be rotated upon itself.

Laboratory values:

Therapy:

Explorative laparoscopy.
Abdomen filled with transudate, reveals twisting of bowel segment around a strangulating adhesion caused by a long extruded bowel pocket in the ileocecal region believed to be a Meckel's diverticulum.
Much oedema in region extending from ileocecal valve and 40 cm proximal to the ileal tortion.
The strangulating tissue is cut, releasing the bowel which is untwisted. The strangulated segment shows congestive hyperemia.
The suspected Meckel's diverticulum is extirpated and the bowel is sutured using absorbable PDS.
A partial ileal bypass procedure is not performed as the strangulated ileum shows spontaneus reflexive peristaltic movement when stimulated externaly on its surface. Also the hyperemia is resolving, superior mesenteric pulse is felt and the bowel segment physiologic color and appearance is returning slowly.

Pictures

The Meckel's diverticulum causing strangulating adhesion seen as darker lump of tissue inferior to the hyperemic bowel segment, twisted around the Meckel adhesion:
Meckel's diverticulum, ileus, CLINIC (74469)
Meckel's diverticulum, ileus, CLINIC (74470)
Meckel's diverticulum, ileus, CLINIC (74471)

Histology:

Tissue sample measuring 15×10×35 mm. Light microscopy reveals tissue with widespread necrotic lesions. A villous mucosa is preserved and blood is found in all the bowel wall.
Surrounding muscularis is also present with islands of extravasated red blood cells with little amount of inflammatory cells.
No ectopic tissue could be identified with certainty.
In the section from the diverticulum resection edge more well kept mucosa is seen.
No atypia or signs of malignancy.

Pictures

Conclusion:

Necrotic Meckel's diverticulum, ileus.