2018 Occam’s Diverticula: Multiple Causes of Significant Lower GI Bleeding in a Young Man

Abstract

INTRODUCTION: Meckel’s Diverticulum (MD) is the most common congenital malformation of the gastrointestinal tract. MD is difficult to diagnose as it presents with intermittent symptoms or none at all. Lower gastrointestinal bleeding (LGIB) is the most common presentation. The diagnosis is made even more difficult when there are other plausible causes of bleeding on endoscopy. We present a case of severe LGIB in a young man with right sided diverticulosis found to have symptomatic MD after a prolonged work-up. CASE DESCRIPTION/METHODS: A healthy 23-year-old male presented with several episodes of bright red blood per rectum and crampy abdominal pain relieved by defecation. He denied taking any NSAIDs. He was hemodynamically stable with mild, lower abdominal tenderness. During admission, his hemoglobin decreased from 14.4 to 8.6 and he became hypotensive, pale and diaphoretic requiring two units of packed red blood cells. CT of abdomen and pelvis was unremarkable. EGD did not reveal a cause of bleeding. Colonoscopy showed scattered, small-mouthed diverticula in the ascending colon with no active bleeding and he was discharged with a presumptive diagnosis of diverticular bleeding. Video capsule endoscopy (VCE) performed for a second admission for hematochezia found blood clots throughout the distal small bowel without active bleeding. After much delay, a 99mTc pertechnate scan showed MD. He underwent surgery and had an ectopic gastric mucosa-containing diverticulum resected. He sustained no additional bleeding following surgery. DISCUSSION: Gastrointestinal bleeding is a major cause for hospitalization in adults. Less than 5% of cases are attributed to small-bowel sources. Diagnosis is more difficult when there are more common explanations for bleeding available. Diverticula located in the right colon are more likely to bleed despite being less common than left-sided ones, making them a plausible explanation for our patient’s symptoms. Even with the advent of non-invasive techniques to visualize the small bowel, diagnosing a small bowel bleed can prove to be a challenging feat. Diagnosis is affected by the features associated with a MD to include active bleeding, inversion or presence of heterotopic mucosa. Sensitivities for 99mTc pertechnate scan, CT and VCE are low at approximately 60, 48 and 8%, respectively, leaving much room for undiagnosed MD. High index of suspicion and multiple imaging modalities are required for diagnosis of MD, especially when more common explanations are present.