Perforated Meckel’s diverticulum mimicking appendicitis in a 64-year-old male: a case report and comparative analysis from a resource-limited setting

Abstract

Introduction and Importance:

Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract, typically asymptomatic but occasionally presenting with complications such as bleeding, obstruction, or rarely, perforation. Symptomatic MD is unusual in the elderly, often mimicking other acute abdominal conditions and posing diagnostic challenges, especially in low-resource settings.

Case Presentation:

We report a case of a 64-year-old male presenting with a 2-day history of right iliac fossa pain, fever, nausea, and vomiting. Clinical examination and laboratory findings were suggestive of perforated appendicitis. Due to the unavailability of CT imaging, an urgent exploratory laparotomy was performed, revealing a perforated MD located 40 cm from the ileocecal valve. A wedge resection was conducted. Histopathological examination confirmed ischemic necrosis and ectopic gastric mucosa. The patient recovered smoothly and was discharged on postoperative Day 5.

Clinical Discussion:

Perforation of MD is rare, particularly in elderly patients, and often leads to diagnostic confusion with more common causes of acute abdomen. In the absence of reliable imaging modalities, clinical acumen and timely surgical exploration are crucial. The presence of ectopic gastric mucosa within MD increases the risk of perforation. Surgical resection, tailored to intraoperative findings, remains the definitive treatment.

Conclusion:

This case underscores the need to consider MD in the differential diagnosis of acute abdomen, even in older adults. In resource-limited settings, prompt surgical intervention guided by clinical evaluation can be lifesaving and highlights the importance of maintaining a broad differential to avoid missed or delayed diagnoses.

Introduction

Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract^[1]. It arises from the incomplete obliteration of the vitelline (omphalomesenteric) duct during embryonic development and is classified as a true diverticulum, typically located on the antimesenteric border of the ileum within 100 cm of the ileocecal valve^[2]. Although MD is usually asymptomatic, it can present with complications such as bleeding, obstruction, diverticulitis, and rarely, perforation^[3]. While symptomatic MD is more commonly reported in children and young adults, its occurrence in the elderly is uncommon and poses significant diagnostic challenges^[4]. We present a unique case of perforated MD in a 64-year-old male, initially misdiagnosed as perforated appendicitis due to overlapping clinical features. Beyond its clinical rarity in the elderly, this case provides insights into decision-making and surgical practices in settings lacking imaging facilities – a perspective seldom discussed in current literature. This work has been reported in line with the SCARE 2025 criteria^[5].

HIGHLIGHTS

• Rare presentation of perforated Meckel’s diverticulum (MD) in a 64-year-old male, initially mimicking perforated appendicitis.

• Diagnosis was made intraoperatively due to the absence of advanced imaging in a resource-limited setting.

• Histopathology confirmed ischemic necrosis with ectopic gastric mucosa, a known risk factor for perforation.

• Clinical decision-making and timely surgical intervention led to successful management and recovery.

• This is the first documented case from Sudan highlighting spontaneous MD perforation in an elderly patient.

Case presentation

A 64-year-old male with no significant comorbidities presented to the emergency department with a 2-day history of progressively worsening right iliac fossa pain, fever, nausea, and vomiting. His vital signs included a temperature of 38.2°C, blood pressure of 90/70 mmHg, and a pulse rate of 108 bpm. Abdominal examination revealed generalized tenderness and guarding, particularly in the lower abdomen. There were no surgical scars, and the hernial orifices were intact. Laboratory findings showed leukocytosis, neutrophilia, and elevated CRP, indicating acute inflammation. Liver and renal function tests were within normal limits (Table 1). Abdominal ultrasound revealed mild pelvic free fluid but was otherwise inconclusive. A clinical diagnosis of perforated appendicitis was made, as CT imaging was unavailable. An urgent exploratory laparotomy via a lower midline incision was undertaken. Intraoperatively, a perforated MD was identified approximately 40 cm proximal to the ileocecal junction on the antimesenteric border of the ileum (Fig. 1). The surrounding bowel appeared viable, and there was no evidence of appendicitis, obstruction, or herniation. A wedge resection of the diverticulum was performed, followed by peritoneal lavage and closure. Histopathology revealed ischemic necrosis and ectopic gastric mucosa within the diverticulum (Fig. 2). The patient was discharged in good condition on postoperative Day 5 and reported no gastrointestinal symptoms or limitations in daily activities during follow-up at the referral clinic. At the 3-month follow-up visit, he remained asymptomatic with well-healed surgical scars and no evidence of delayed complications or functional impairment.

Table 1.

Summary of laboratory investigations on admission

Test	Result	Reference range
White blood cell count (WBC)	13.2 × 103/μL	4.0–10.0 × 103/μL
Neutrophils, %	86%	40–70%
C-reactive protein (CRP), mg/L	85 mg/L	<5 mg/L
Alanine aminotransferase (ALT), U/L	28 U/L	7–56 U/L
Aspartate aminotransferase (AST), U/L	24 U/L	10–40 U/L
Alkaline phosphatase (ALP), U/L	95 U/L	44–147 U/L
Total bilirubin, mg/dL	0.8 mg/dL	0.2–1.2 mg/dL
Direct bilirubin, mg/dL	0.2 mg/dL	0.0–0.3 mg/dL
Albumin, g/dL	4.2 g/dL	3.5–5.0 g/dL
Total protein, g/dL	6.8 g/dL	6.0–8.3 g/dL
Serum creatinine, mg/dL	0.9 mg/dL	0.6–1.3 mg/dL
Blood Urea Nitrogen (BUN), mg/dL	12 mg/dL	7–20 mg/dL

Figure 1.

Intraoperative identification of perforated MD (white arrow: MD with visible perforation at the tip; yellow arrows: adjacent small bowel loops; blue arrow: originating ileum).

Figure 2.

Histopathological section of MD demonstrating ectopic gastric mucosa (H&E Stain, × 100). The yellow arrow highlights an area of dense inflammatory infiltrate, the blue arrow indicates well-formed gastric glands within the ectopic mucosa, and the red arrow points to the surface epithelium lined by gastric-type cells.

Discussion

MD arises from the failed obliteration of the vitelline duct and occurs in approximately 2% of the population^[1,2]. Although frequently asymptomatic, complications such as hemorrhage, obstruction, inflammation, and, less commonly, perforation can occur^[3,4]. In adults, obstruction is the most common complication, while in children, bleeding predominates^[3]. Perforation is rare, occurring in less than 1% of cases, typically due to inflammation, foreign bodies, or ulceration associated with ectopic gastric mucosa^[4,6]. Symptomatic MD in elderly patients is particularly uncommon, accounting for less than 5% of complicated cases^[7]. Its clinical presentation often resembles more prevalent intra-abdominal conditions such as appendicitis or diverticulitis, which can delay diagnosis and lead to mismanagement^[7,8]. The differential diagnosis includes common causes of right lower quadrant or periumbilical pain such as acute appendicitis, Crohn’s disease, small bowel diverticulitis, perforated peptic ulcer, infectious enteritis, and less commonly, neoplasms such as lymphoma or GISTs. In children, intussusception and mesenteric adenitis are additional considerations. When granulomatous inflammation is identified intraoperatively or histologically, tuberculosis, Yersinia, sarcoidosis, Crohn’s disease, vasculitis, or lymphoma should be considered. Clinical judgment, imaging, intraoperative findings, and histopathology are essential in narrowing the diagnosis^[1-4,9]. In our case, the presentation with generalized peritonitis and right lower quadrant tenderness initially suggested perforated appendicitis. Previous reports document similar diagnostic challenges in elderly patients. Ioannidis et al. described a 75-year-old woman with an MD abscess misdiagnosed due to inconclusive imaging, eventually diagnosed via laparoscopy^[7]. Malcom et al. reported a case of a 71-year-old woman with a 29 cm perforated Meckel’s diverticulum containing ectopic tissue, without any evidence of obstruction^[10]. Hidalgo et al. noted a case of small bowel obstruction in a 79-year-old male with ulcerative colitis and MD, in whom the appendix appeared normal^[11]. Sarkardeh and Davari Sani presented a 92-year-old woman with a perforated MD causing obstruction despite lacking ectopic mucosa^[12]. De la Cruz Garcia et al. uniquely identified a perforated MD caused by a corn kernel in a 77-year-old man, exemplifying a rare foreign body-induced etiology^[6]. To contextualize this case, we reviewed similar reports of perforated MD in elderly patients. (Table 2) summarizes published cases in individuals aged 25 years and above, highlighting common misdiagnoses, imaging access, surgical approaches, and outcomes.^[13–17]

Table 2.

Reported cases of complicated MD in elderly and adult patients

Age/Sex	Country	Year	Diagnosis	Imaging findings	Surgical approach	Cause of perforation	Ectopic tissue	Outcome	Reference
77 M	Australia	2021	Meckel’s Diverticulitis	CT: 5 cm blind-ending structure with fecalized tip	Lap→Laparotomy: local perforation and inflamed MD; corn kernel obstructing lumen	Foreign body (corn kernel)	Not identified	Not reported	Cruz Garcia et al[6]
75 F	Greece	2022	Acute Abdomen	CT: Gallstones, possible MD, normal appendix	Laparoscopy: Abscessed MD found 50 cm from valve; resection of MD, gallbladder, and appendix	Meckel’s Diverticulitis	Not identified	Uneventful	Aristeidis et al[7]
54 F	USA	2018	Appendiceal stump dehiscence	Not performed	Laparotomy: Enteric spillage; perforated ileal diverticulum 55 cm from ileocecal valve; wedge resection	Pressure necrosis	Not identified	Anastomotic dehiscence	Fraser et al[8]
71 F	USA	2018	Meckel’s Diverticulitis	CT: Inflammatory mass with intramural air	Laparotomy: Suppurative mass with surface perforation; small bowel resection and appendectomy	Giant Meckel’s Diverticulitis	Gastric & Pancreatic	Uneventful	Malcom et al[10]
79 M	USA	2018	Bowel Obstruction	CT: High-grade obstruction	Laparoscopy: Small bowel diverticulum consistent with MD	Not reported	Not reported	Improved	Hidalgo et al[11]
92 F	Iran	2020	Intestinal Obstruction	X-ray: Dilated small bowel, air-fluid levels	Laparotomy: Internal hernia and 5 cm perforated MD 60 cm from valve	Not reported	Not identified	Not reported	Davari Sani et al[12]
34 M	UK	2022	Ileocolic Intussusception	CT: Intussusception; no obstruction or free air MRI: 6 cm pedunculated lesion	Laparotomy: Small bowel resection and site-to-site anastomosis	None	Gastric mucosa	Uneventful	Igwe et al[13]
39 M	UK	2024	Acute Appendicitis	CT: Intussuscepted small bowel segment in terminal ileum	Laparotomy: Ileo-ileal intussusception with inverted MD as lead point; resection performed	Inverted MD	None	Uneventful	Craine et al[14]
26 F	Brazil	2022	Bowel Obstruction	CT: Dilated loops, mesenteric torsion	Laparotomy: 20 cm MD adhered to anterior abdominal wall, causing internal hernia; adhesiolysis and segmental resection	Not reported	Not reported	Not reported	Villalaz et al[15]
71 F	USA	2020	Acute Appendicitis	CT: 2 cm MD with fat stranding and mucosal thickening	Laparoscopy: Contained perforation 2 ft from ileocecal valve, walled off by adjacent bowel; small bowel resection performed	Diverticulitis	Not identified	Uneventful	Yi DO et al[16]
65 M	India	2007	Small bowel tumor	CT: Pelvic mass compressing colon	Laparotomy: Lobulated tumor from ileal diverticulum (50 cm from valve); resection performed	GIST	None	Uneventful	Chandramohan et al[17]

In high-income countries, the diagnosis and management of acute abdominal conditions such as perforated MD are supported by advanced imaging modalities (CT, MRI, nuclear scans), minimally invasive surgical options, and robust perioperative infrastructure. In contrast, low-resource or conflict-affected settings lack reliable access to imaging, laboratory support, and specialized surgical tools, often necessitating reliance on clinical judgment and open exploratory laparotomy as the primary diagnostic and therapeutic measure. This diagnostic uncertainty increases the risk of delayed or missed diagnoses, prolonged operative times, and potential complications. In such environments, surgeons must operate under extreme constraints, balancing urgency with limited information—highlighting the critical need for context-adapted surgical protocols. While imaging such as CT may reveal signs of obstruction, it often fails to identify the diverticulum itself; thus, exploratory laparotomy remains the mainstay of diagnosis and treatment in advanced cases, particularly when obstruction is caused by rare conditions like mesodiverticular bands^[18]. According to the Lancet Commission on Global Surgery, over 5 billion people worldwide lack access to safe, affordable surgical care, with conflict zones presenting some of the most acute gaps^[19]. Moreover, surgical systems in fragile states are often disrupted by infrastructure collapse, workforce displacement, and supply chain interruptions, further compounding these challenges^[20,21].

In contrast, our patient had no evident risk factors such as prior surgery, foreign bodies, or obstructive features. The perforation appeared spontaneous, likely driven by ischemic necrosis and the presence of ectopic gastric mucosa. Importantly, diagnosis relied entirely on clinical acumen and timely laparotomy in a resource-limited setting without access to cross-sectional imaging. This underscores the critical importance of surgical judgment and maintaining a broad differential diagnosis in low-resource environments. To our knowledge, this is the first documented case of perforated MD in an elderly patient from Sudan.

While Technetium-99 m pertechnetate scanning is effective in children, its sensitivity in adults is significantly lower, ranging from 54% to 62%^[22]. CT imaging can suggest MD or its complications but is often inconclusive without a high index of suspicion^[23]. In low-resource contexts, alternative tools such as plain abdominal radiography and ultrasonography, although limited in specificity, may offer indirect clues – e.g., air-fluid levels, dilated bowel loops, or enteroliths^[24,25]. Ultrasonography may visualize a blind-ending tubular structure or surrounding inflammation, guiding surgical decisions in the absence of definitive imaging. Surgical resection remains the treatment of choice, with options including diverticulectomy or segmental ileal resection. Wedge resection (diverticulectomy) is often preferred when the diverticular base and adjacent ileum are unaffected, as it is less invasive, preserves bowel length, reduces operative time, and carries similar or lower complication rates compared to segmental resection^[26]. The surgical approach depends on diverticular base width, surrounding inflammation, and the presence of ectopic tissue^[27]. In our case, a wedge resection was appropriate given the narrow base and viable adjacent ileum. Histopathology confirmed ectopic gastric mucosa – present in up to 50% of symptomatic MD cases – which can secrete hydrochloric acid, leading to peptic ulceration, inflammation, and potential perforation^[2,10,28]. This reinforces the value of histological evaluation in determining etiology and guiding management. What distinguishes this case is not only the rare presentation of perforated MD in an elderly male but also the setting in which it occurred. Unlike most published cases which benefit from CT confirmation or laparoscopic exploration, this case was managed entirely based on bedside clinical assessment and surgical judgment. In fragile or conflict-affected health systems such as in parts of Sudan, this scenario is common, yet underreported. Our case fills this gap, advocating for recognition of diagnostic limitations and adaptation of management strategies in such environments. Our case adds to the limited literature on MD in elderly patients, particularly those presenting with spontaneous perforation without classic risk factors^[6,8]. It highlights the diagnostic difficulty posed by such rare presentations and emphasizes the importance of considering MD in the differential diagnosis of acute abdomen – especially in older adults and resource-constrained settings where advanced imaging is unavailable.

Conclusions

This case highlights a rare instance of perforated MD in an elderly male, initially misdiagnosed as perforated appendicitis. The lack of imaging resources necessitated reliance on clinical judgment and intraoperative findings. It underscores the importance of clinical vigilance and the role of surgical exploration in diagnosing abdominal emergencies in fragile healthcare systems.

Ethical approval

This case report did not require ethics approval, as it involves a single patient and does not constitute research according to the institution’s guidelines.

Consent

Informed written consent for publication, including the use of images, was obtained from the patient.

Sources of funding

No extramural funds were used to support this case report.

Author contributions

A.S.: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. H.E.: Conceptualization, Data curation. L.S.: Validation, Software, Writing – review & editing. E.T.: Data curation, Software. H.S.: Validation, Software.

Conflicts of interest disclosure

The authors declare no conflicts of interest. The authors confirm the accuracy of the data.

Guarantor

Dr. Alsadig Suliman accepts full responsibility for the integrity of the work, had full access to the data, and controlled the decision to publish.

Research registration unique identifying number (UIN)

This case report does not involve a clinical study and therefore was not registered. Registration was not required according to journal and institutional guidelines.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the preparation of this case report.

AI usage declaration

Generative AI (ChatGPT, OpenAI, accessed via web interface in May–June 2025) was used solely to assist with grammar correction and language refinement. No clinical data, patient identifiers, or statistical analyses were processed by the AI. All inputs were fully de-identified and compliant with GDPR. The corresponding author manually reviewed and verified all AI-assisted content to ensure accuracy and integrity. The AI’s role was limited to language support, and no figures or datasets were generated by AI.