A 42-year-old man arrived at an emergency hospital in Iasi, Romania, with two days of cramping abdominal pain, a swollen belly, and vomiting that had turned bile-colored. The obstruction was obvious. The cause was not.
He had never had abdominal surgery. That single fact removes the explanation behind most bowel obstructions, because scar tissue from previous operations is by far the most common cause. Surgeons call an abdomen that has never been opened a virgin abdomen, and an obstruction in one is a genuine diagnostic problem.
The case was published on August 26 in Reports by a team at “Grigore T. Popa” University of Medicine and Pharmacy and St. Spiridon County Emergency Clinical Hospital.
Two Days of Pain and No Scars to Blame
He was afebrile and stable but visibly distressed, with a distended, drum-tight, diffusely tender abdomen. There was no palpable mass and no hernia in the groin or at the navel.
His history complicated the picture. The pain had started after drinking, and he had a history of alcohol use disorder, chronic liver disease, a previous bout of acute pancreatitis and gallstones. Recurrent pancreatitis and biliary disease were therefore listed alongside obstruction.
His white cell count was normal at 5.22 x 10³/μL and his C-reactive protein was only mildly raised. But his blood urea was 104 mg/dL with normal creatinine, and his hemoglobin was 16.8 g/dL, a pattern the authors read as dehydration from vomiting and fluid shifting out of circulation.
Ultrasound showed fluid-filled loops of small bowel measuring up to 49 millimeters in diameter, with walls thickened to 7 millimeters. Contrast CT confirmed mechanical obstruction with a transition point in the pelvis and collapsed bowel beyond it, but could not say what was causing it.
The differential was wide: a congenital or adhesive band, an internal hernia, a small bowel tumor, an inflammatory stricture, or an intussusception. Given two days of symptoms, a clear transition point, and no surgical history to explain it, the team chose to operate the same day.
The Mechanism Was Backward
During laparotomy, they found a Meckel diverticulum approximately 25 centimeters from the junction of the small intestine and colon. It is the most common congenital anomaly of the gastrointestinal tract, a leftover pouch from a duct that should have closed before birth, present in roughly 0.3 to 2.9 percent of people. Most never cause trouble.
What made the case publishable is which structure was doing the trapping. A fibrous band ran from the antimesenteric side of the ileum to the adjacent mesentery, forming a bridge with a gap beneath it. The diverticulum had passed under that bridge and become constricted near its base. The neighboring loop of ileum was kinked, obstructed, and ischemic, though there was no perforation, necrosis, or volvulus.
In the mechanisms usually described, the diverticulum is the constrictor: a band arising from it forms a ring, and a separate loop of bowel herniates through and is strangled. Here the relationship was inverted. The diverticulum was the trapped structure, and obstruction of the adjacent bowel was a knock-on effect.
The authors compared their case against eight previous reports and found none with the same configuration. The two nearest involved a diverticulum trapped by a Ladd’s band and a defect in the mesocolon. In both, volvulus developed, the bowel died, and a segment had to be cut out.
Saving the Bowel by Cutting One Band
The repair was almost anticlimactic. Surgeons divided the band, releasing the strangled diverticulum. After release and warm packing, the ileal segment regained its color, peristalsis returned, and mesenteric pulsation returned. They judged it viable and did not resect it. The diverticulum itself, six centimeters long and roughly twice the reported average length, was removed at its base using a linear stapler.
He went home on the seventh day and remained asymptomatic at reviews on day 21 and day 90. Pathology found gastric metaplasia in the diverticulum, stomach-type tissue growing where it does not belong, a known feature of symptomatic cases.
What the Report Cannot Tell You
The authors are direct about the gap in their own work. The fibrous band was divided but never sent separately for pathology, so nobody can say whether it was a congenital remnant or scar tissue from earlier subclinical inflammation. Vascular and nerve structures inside such a band would have pointed to a congenital vitelline origin. They recommend that future cases submit the band for examination.
CT deserves a note of its own. It established that there was an obstruction and where it was, but not why, which the authors say reflects its recognized limited sensitivity for this diagnosis. Preoperative identification succeeds in a minority of cases, and exploration remains both diagnostic and therapeutic.
For readers, the useful signal is not about anatomy. Meckel’s diverticulum is common and mostly asymptomatic, with a lifetime risk of complications estimated at 4 to 6 percent that decreases with age, and it is not routinely screened for. Cramping abdominal pain with distension and vomiting is an emergency regardless of cause, and obstruction in a patient who has never had surgery is where waiting carries the most risk. A Mayo Clinic series of 1,476 patients linked four features to symptomatic presentation: male sex, age under 50, diverticular length over 2 centimeters, and abnormal tissue inside the pouch. All four applied here.
Key Questions Answered
What is a Meckel diverticulum?
It is a pouch left over from a duct that normally closes before birth. It is the most common congenital anomaly of the digestive tract, present in roughly 0.3 to 2.9 percent of people.
Why was this case unusual?
Normally, the diverticulum, or a band arising from it, does the constricting. Here, the diverticulum was the structure that became trapped and strangled within a separate fibrous band.
Why did no prior surgery make diagnosis harder?
Scar tissue from previous operations causes most bowel obstructions. Without it, surgeons face a much wider list of causes, and CT often cannot identify which one.
Was any bowel removed?
No intestine was resected. Dividing the band restored blood flow, the affected segment recovered, and only the diverticulum was removed with a stapler.
What could the authors not determine?
Whether the fibrous band was congenital or formed later from inflammation. It was not submitted separately for pathology, which they list as the report’s main limitation.
When should abdominal pain be treated as urgent?
Cramping pain with distension and vomiting warrants prompt assessment. This report describes one rare cause among many and is not a guide to self-diagnosis.
