S6008 Perforated Meckel’s Diverticulum in a Young Adult: A Diagnostic Challenge in Acute Abdomen

Introduction: Meckel’s diverticulum (MD), the most common congenital gastrointestinal tract anomaly, is a true diverticulum typically located near the ileocecal valve. It affects about 2% of the population, but complications are rare, occurring in only 4%–7% of cases. Perforation is especially uncommon. We present a case of perforated MD in a young adult initially misdiagnosed due to nonspecific symptoms and unremarkable early imaging. Case Description/Methods: A 22-year-old woman with a history of irritable bowel syndrome presented with 4 days of sharp, constant right lower quadrant abdominal pain, nausea, vomiting, and decreased appetite. She denied fever, bowel or urinary changes, and was not sexually active. A computed tomography abdomen/pelvis (A/P) with intravenous contrast done 2 days earlier was unremarkable. On arrival, she had sinus tachycardia (HR 120s) and right lower quadrant tenderness with guarding. Labs showed hypokalemia (2.8 mEq/L) and non-anion gap metabolic acidosis. Serum Beta HCG and sexually transmitted disease testing (HIV, syphilis, chlamydia and gonorrhea) were negative. Complete blood count was unremarkable. Pelvic ultrasound showed pelvic free fluid with hemorrhagic/proteinaceous debris. Obstetrics and gynecology evaluation favored a ruptured hemorrhagic ovarian cyst. Her pain persisted, prompting repeat computed tomography A/P with intravenous contrast, which showed a pelvic fluid and gas collection (3.4 × 2.9 cm) abutting multiple bowel loops, concerning for perforated viscus. Same day repeat computed tomography A/P with intravenous and oral contrast showed contrast along a small bowel loop diverticulum, contiguous with the lower pelvic collection, suspicious for perforated Meckel's diverticulitis with abscess formation. She underwent urgent laparoscopy with removal of a gangrenous, perforated MD and intra-abdominal abscess drainage. Intra operative pathology showed no ectopic tissue or malignancy and cultures grew Alpha Streptococcus and Bacteroides ovatus. Blood cultures remained negative. She was discharged on ciprofloxacin and metronidazole for 5 days with symptom resolution. Discussion: MD is often misdiagnosed due to its rarity and vague symptoms. Even contrast-enhanced computed tomography may miss the diagnosis. This case highlights the diagnostic challenge of complicated MD and the value of maintaining clinical suspicion despite negative imaging. Repeat computed tomography with oral contrast proved critical in localizing the leak and guiding surgical management. Exploratory laparoscopy remains key in unclear acute abdominal presentations.