2.1. Patient information: A 16-month old previously healthy female infant, wt-10 kg presented to the emergency department.

2.2. Clinical History: The parents reported a 7 days history of increasing abdominal distension, associated with irritability and poor feeding and intermittent crying. This progressed to bilious vomiting for the last 4 days. There was no passage of stool for 4 days only few blood stained mucous like material came out. There was no history of fever, trauma, diarrhoea or similar episodes in the past.

2.3. Clinical findings: On examination: The child was irritable, tachycardiac and mildly dehydrated. The abdomen was markedly distended later, tense and tender on palpation, with no palpable mass. Bowel sounds were hyperactive initially but become sluggish later. Digital Rectal Examination: Revealed an empty rectal ampulla with the examining finger stained with mucous mixed blood.

2.4. Diagnostic Assessment: Based on the clinical triad of abdominal distension, bilious vomiting and constipation, a diagnosis of acute intestinal obstruction was made. The finding of blood on DRE, along with the age of the patient, made intussusception the leading preoperative diagnosis. An abdominal ultrasound was performed which shows no target sign but revealed dilated small bowel loops with fluid level. Given the clinical picture of complete obstruction, the decision was made for an emergency exploratory laparotomy.

2.5. Therapeutic Intervention: A Transverse supraumbilical (Rt) incision was given. Intraoperative findings revealed a grossly dilated proximal small bowel and collapsed distal bowel. A fibrous band (Meckel’s band) was identified, extending from the tip of a Meckel’s diverticulum to the mesentery. A loop of distal ileum was entrapped under this band, causing a tight, closed loop obstruction. There was no evidence of intussusception but bowel was necrosed at the part where fibrous band compressed the gut which is about 5 cm proximal to the ileo-cecal valve. The band was lysed. A wedge resection of the Meckel’s diverticulum at its base on the antimesenteric border was performed, followed by resection of the gangrenous part upto ascending colon and end to end anastomosis was done. A drain was placed in the pelvis.

This case illustrates a classic presentation of small bowel obstruction with an unusual etiology for the age group. The presence of blood on DRE is a hallmark of intussusception, seen in 50-60%of cases, which heavily biased the initial diagnostic impression. However, Meckel’s diverticulum with a persistent band is a well documented but less common cause of obstruction, particularly in older children and adults.

The pathophysiology involves the persistence of the omphalomesenteric duct as a fibrous cord, creating a fixed point around which small bowel loops can twist or become directly entrapped, as seen in this case. This can lead to rapid progression to strangulation and necrosis, making early intervention critical. The management is always surgical. The standard procedure involves laparotomy, lysis of band and resection of diverticulum. The choice of anastomosis depends upon the local condition of bowel and surgeon preference. An ileo-transverse anastomosis ,as performed here, is a safe option to avoid tension and narrowing at the resection site.

The key learning points are:
· Differential diagnosis: In any child with intestinal obstruction, congenital bands, including those from Meckel’s diverticulum, should be considered even when presentation suggests a more common condition like intussusception.
· Importance of exploration: When clinical and simple radiographic evidence points to complete obstruction, timely laparotomy remains both diagnostic and therapeutic.
· Surgical strategy: Simple band division with diverticulectomy and careful anastomosis provides an excellent outcome, as demonstrated by the patient’s uneventful recovery.

Although intussusception is the foremost concern in a toddler with intestinal obstruction and rectal bleeding, this case highlights Meckel’s diverticulum and its associated band as an important surgical differential. A high clinical index of suspicion, prompt surgical intervention, and appropriate resection are paramount for successful management and prevention of catastrophic complications like bowel necrosis. This case reinforces the principle that congenital anomalies must be considered in the spectrum of pediatric acute abdomen.