title: Unusual presentation of a Meckel's diverticulum: A case report.
abstract: BACKGROUND
  Meckel's diverticulum (MD) is the most common congenital malformation of the gastrointestinal tract. Intestinal obstruction is the lead presenting symptom in the adult population due to multiple causes (intussusception, incarceration, adhesions, strictures and torsion). Our patient had a complicated MD with an unique combination of risk factors and findings.
  
  
  METHODS
  We report an unusual case of an 18-year-old patient presenting with acute small bowel obstruction for several days, who developed focal peritoneal signs on right lower quadrant. On laparotomy, findings included a necrotic giant MD and a small bowel volvulus around a fibrous band that attached MD to the umbilicus. Segmental enterectomy with primary anastomosis was performed.
  
  
  CONCLUSIONS
  Axial torsion and gangrene of MD is the rarest complication. Its pre-operative diagnosis remains elusive as it can be clinically indistinguishable from other intra-abdominal inflammatory conditions. The correct diagnosis of complicated MD before surgery is often difficult because this condition can mimic other acute abdominal pathologies. There are several risk factors that can point to an accurate and early diagnosis, especially when combined with the appropriate imaging techniques, such as computed tomography with oral and intravenous contrast.
  
  
  CONCLUSIONS
  This complication remains underdiagnosed, often with delayed surgical intervention and sub-optimal treatment that leads to significant morbidity and mortality.
authors.affiliation: Department of General Surgery, Centro Hospitalar Trás-os-Montes e Alto Douro Avenida da Noruega, Lordelo, 5000-508 Vila Real, Portugal. Electronic address: ntalmeida@chmtad.min-saude.pt.
authors.forename: Nádia
authors.initials: N
authors.lastname: Tenreiro
authors.affiliation: Department of General Surgery, Centro Hospitalar Trás-os-Montes e Alto Douro Avenida da Noruega, Lordelo, 5000-508 Vila Real, Portugal.
authors.forename: Herculano
authors.initials: H
authors.lastname: Moreira
authors.affiliation: Department of General Surgery, Centro Hospitalar Trás-os-Montes e Alto Douro Avenida da Noruega, Lordelo, 5000-508 Vila Real, Portugal.
authors.forename: Silvia
authors.initials: S
authors.lastname: Silva
authors.affiliation: Department of General Surgery, Centro Hospitalar Trás-os-Montes e Alto Douro Avenida da Noruega, Lordelo, 5000-508 Vila Real, Portugal.
authors.forename: Luis
authors.initials: L
authors.lastname: Madureira
authors.affiliation: Department of General Surgery, Centro Hospitalar Trás-os-Montes e Alto Douro Avenida da Noruega, Lordelo, 5000-508 Vila Real, Portugal.
authors.forename: João
authors.initials: J
authors.lastname: Gaspar
authors.affiliation: Department of General Surgery, Centro Hospitalar Trás-os-Montes e Alto Douro Avenida da Noruega, Lordelo, 5000-508 Vila Real, Portugal.
authors.forename: António
authors.initials: A
authors.lastname: Oliveira
keywords: Axial torsion; Case report; Meckel’s diverticulitis; Meckel’s diverticulum; Small bowel obstruction