Abstract:
Ba?kgr?und: A?ute abd?men in ?hildren with severe pneum?nia p?ses a signifi?ant diagn?sti? ?hallenge. Abd?minal pain may initially be attributed t? l?wer l?be pneum?nia, delaying re??gniti?n ?f an underlying surgi?al path?l?gy. Me?kel's diverti?ulitis is an un??mm?n ?ause ?f intestinal ?bstru?ti?n, while v?lvulus se??ndary t? inflamed Me?kel's diverti?ulum ass??iated with a ruptured mesenteri? ?yst is ex?epti?nally rare.
Intr?du?ti?n: A?ute abd?men devel?ping during treatment ?f severe pneum?nia is un??mm?n but ?lini?ally imp?rtant. L?wer l?be pneum?nia may pr?du?e referred abd?minal pain, p?tentially masking life-threatening intra-abd?minal ??nditi?ns. Me?kel's diverti?ulum is the m?st ??mm?n ??ngenital an?maly ?f the gastr?intestinal tra?t, ???urring in appr?ximately 2% ?f the p?pulati?n. Sympt?mati? ?ases are un??mm?n, with intestinal ?bstru?ti?n representing ?ne ?f the maj?r surgi?al emergen?ies. Me?hanisms in?lude v?lvulus, intussus?epti?n, internal herniati?n, inflammat?ry adhesi?ns, and bands. Mesenteri? ?ysts are rare benign intra- abd?minal lesi?ns in ?hildren. Their ??existen?e with inflamed Me?kel's diverti?ulum ?ausing v?lvulus has rarely been rep?rted. We rep?rt an unusual ?ase ?f Me?kel's diverti?ulitis pr?du?ing distal ileal v?lvulus ass??iated with rupture ?f a mesenteri? ?yst in a ?hild with severe bilateral pneum?nia.
Case Rep?rt: A s-year-?ld male ?hild presented with fever f?r three days and respirat?ry distress. He was admitted t? a peripheral h?spital where ?hest radi?graphy dem?nstrated bilateral multil?bar pneum?nia with pleural effusi?n. He was managed with ?xygen supplementati?n and intraven?us br?ad-spe?trum antibi?ti?s. On the third day ?f h?spitalizati?n, he devel?ped diffuse abd?minal pain and pr?gressive abd?minal distensi?n. The abd?minal distensi?n rapidly w?rsened ?ver the f?ll?wing 12 h?urs, pr?mpting referral t? ?ur instituti?n. On arrival, the ?hild was t?xi?-l??king, febrile, ta?hypnei?, and re?eiving ?xygen supplementati?n. Clini?al examinati?n revealed pall?r with?ut i?terus. Respirat?ry examinati?n dem?nstrated bilateral ??arse ?repitati?ns. Abd?minal examinati?n sh?wed marked distensi?n with generalized tenderness, guarding, rigidity, and absent b?wel s?unds, ??nsistent with generalized perit?nitis. Lab?rat?ry investigati?ns revealed inflammat?ry ?hanges Abd?minal ultras?n?graphy dem?nstrated dilated small b?wel l??ps with distal ileal ?bstru?ti?n and free intraperit?neal fluid. Plain abd?minal radi?graph sh?wed multiple dilated small b?wel l??ps with numer?us air-fluid levels.
C?ntrast-enhan?ed CT abd?men dem?nstrated:
- Dilated pr?ximal small b?wel l??ps
- Distal ileal ?bstru?ti?n
- Whirlp??l sign suggestive ?f v?lvulus
- Signifi?ant free intraperit?neal fluid
CT ?hest ??nfirmed bilateral multil?bar ??ns?lidati?n with pleural effusi?n. C?nsidering the ?lini?al deteri?rati?n, generalized perit?nitis, intestinal ?bstru?ti?n, and severe pneum?nia, emergen?y expl?rat?ry lapar?t?my under general anesthesia was perf?rmed.
Operative Findings: The ?perative findings in?luded:
- Dilated pr?ximal small b?wel
- V?lvulus inv?lving the distal ileum
- Inflamed Me?kel's diverti?ulum a?ting as the lead p?int f?r v?lvulus
- Ruptured mesenteri? ?yst with appr?ximately s00 mL ?f amber-??l?red fluid
- Rea?tive intraperit?neal ??ntaminati?n with?ut gr?ss fe?al ??ntaminati?n
The v?lvulus was ?arefully det?rsed. Segmental ileal rese?ti?n in?luding the Me?kel's diverti?ulum was perf?rmed, f?ll?wed by primary ile?-ileal anast?m?sis. The ruptured mesenteri? ?yst was ex?ised, and th?r?ugh perit?neal lavage was perf?rmed.
P?st?perative C?urse: The ?hild remained ventilated in the pediatri? intensive ?are unit be?ause ?f underlying severe pneum?nia.
- POD 2: Su??essfully extubated
- POD 4: Passed flatus and st??ls
- POD 5: Oral sips initiated
- POD 7: Advan?ed t? s?ft diet
- POD 10: Dis?harged in stable ??nditi?n
At f?ll?w-up, the ?hild remained asympt?mati? with n?rmal b?wel fun?ti?n.
Dis?ussi?n: Me?kel's diverti?ulum a???unts f?r nearly half ?f ??ngenital gastr?intestinal an?malies but be??mes sympt?mati? in ?nly a min?rity ?f patients. Obstru?ti?n remains the m?st frequent indi?ati?n f?r surgery in ?hildren. V?lvulus se??ndary t? inflamed Me?kel's diverti?ulum is un??mm?n and may result fr?m inflammat?ry adhesi?ns, persistent vitelline remnants, ?r t?rsi?n ar?und the diverti?ulum. Mesenteri? ?ysts are rare lesi?ns with an in?iden?e estimated between 1 in 20,000 and 1 in 250,000 pediatri? admissi?ns. They may remain asympt?mati? ?r present with ?bstru?ti?n, v?lvulus, infe?ti?n, hem?rrhage, ?r rupture. Sp?ntane?us rupture ass??iated with Me?kel's diverti?ulitis has rarely been des?ribed. This patient presented an additi?nal diagn?sti? ?hallenge be?ause severe bilateral pneum?nia initially d?minated the ?lini?al pi?ture. Abd?minal pain in l?wer respirat?ry infe?ti?ns is frequently attributed t? diaphragmati? irritati?n, p?tentially delaying re??gniti?n ?f surgi?al emergen?ies. The rapid pr?gressi?n t? generalized perit?nitis pr?mpted ?r?ss-se?ti?nal imaging, where the whirlp??l sign str?ngly suggested v?lvulus. Early surgi?al expl?rati?n prevented b?wel is?hemia and all?wed definitive treatment ?f all underlying path?l?gies in a single pr??edure.
C?n?lusi?n: This ?ase highlights an extremely rare ??existen?e ?f Me?kel's diverti?ulitis ?ausing distal ileal v?lvulus with rupture ?f a mesenteri? ?yst in a ?hild underg?ing treatment f?r severe bilateral pneum?nia. Children with pneum?nia wh? devel?p pr?gressive abd?minal distensi?n, tenderness, guarding, ?r intestinal ?bstru?ti?n sh?uld be evaluated pr?mptly f?r an intra-abd?minal surgi?al emergen?y. Early CT imaging and timely expl?rat?ry lapar?t?my remain ?ru?ial f?r preventing b?wel l?ss and impr?ving ?ut??mes.
