A Rare Case of Massive GI Bleeding due to Jejunal Diverticulosis: A Diagnostic Dilemma and the Importance of Endoscopic Timing and a Multidisciplinary Treatment Approach

Abstract

Purpose: A 77-year-old man with no significant past medical history presented to an outside institution with worsening shortness of breath and melena. Hemoglobin 7.6 g/dL on admit. Transfused 3 units pRBC. Incremented to 9.2 g/dL but then fell to 7.2 g/dL the following day. EGD was normal. Colonoscopy with TI intubation showed pan-colonic diverticulosis without active bleeding. He continued to pass melena and require pRBC transfusions. Second EGD and small bowel (SB) enteroscopy performed showing diverticulum in proximal and mid-jejunum without bleeding. Abdominal CT angiography showed no active hemorrhage. He was transferred to our institution. Capsule endoscopy showed large jejunal diverticula with old blood. Balloon-assisted enteroscopy showed multiple large-sized diverticula in distal duodenum, proximal/mid-jejunum. Diverticula contained old blood/clots, but no actively bleeding lesion or recent stigmata seen. Surgical consultation obtained andopined since diverticula involved proximal duodenum and no active bleeding seen, any surgical intervention involving resection of this area would be technically difficult. Mesenteric angiogram showed no active bleeding. Patient required daily pRBC transfusion (total of 12 units since admission). Then began to pass maroon colored stools. Urgent SB enteroscopy with cap-fitted pediatric colonoscope performed. Fresh blood found in proximal jejunum. Large diverticulum with fresh clot/oozing blood identified (Fig 1) but no definitive target seen for endoscopic therapy. Tattoo marking applied. Patient taken for urgent surgery. Laparotomy showed jejunal tattoo with multiple surrounding large diverticuli. 40 cm segment containing tattooed jejunum resected (Fig 1) and fresh blood found inside. Pathology confirmed tattooed region of the diverticuli to be source of bleeding. No further episodes of rebleeding post-surgery or at 60 days. This case illustrates the importance of endoscopic timing in reaching the appropriate diagnosis and the multidisciplinary approach used in successful management. Evaluation of the SB during an episode of active bleeding, particularly in cases when EGD/Colonoscopy are non-diagnostic, can be the key to finding the correct diagnosis. In cases where the etiology of intestinal bleeding is unclear or other diagnostic testing is inconclusive, more urgent endoscopy at the time of active bleeding may have a role in establishing the diagnosis and providing treatment.Figure 1