An Unusual Cause of Gastrointestinal Bleeding: There Is More Than Meets the Eye

Abstract

Question: A 39-year-old man was admitted to the hospital with a 3-week history of intermittent episodes of melena and normocytic anemia with a hemoglobin of 7.0 and mean corpuscular volume of 86. His pre-endoscopic Rockall score was 0 and a Glasgow Blatchford of 10. His past medical history included diagnoses of schizophrenia and hypothyroidism. His medications included levothyroxine and risperidone and there was no history of nonsteroidal anti-inflammatory drug use use. He was transfused to a target hemoglobin of 9 and underwent gastroscopy with duodenal biopsies and colonoscopy with no stigmata of recent hemorrhage to explain his presentation. An urgent capsule endoscopy (SBCE) was performed in view of negative investigations. Figure A and the Supplementary Video show the capsule (SBCE) image and video clip of the abnormality. Magnetic resonance imaging (MRI) of the small bowel was performed following his SBCE findings (Figure B). Figure C reveals the histopathology specimen of the abnormality. What is the likely diagnosis? Look on page 915 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The images reveal the presence of an inverted Meckel's diverticulum, although this diagnosis was not recognized preoperatively in this case. Although rare, inverted Meckel’s diverticulum has been reported in the literature.1Rashid O.M. Ku J.K. Nagahashi M. et al.Inverted Meckel’s diverticulum as a cause of occult lower gastrointestinal haemorrhage.World J Gastroenterol. 2012; 18: 6155-6159Crossref PubMed Scopus (20) Google Scholar It can present as bleeding because of the presence of either ectopic gastric mucosa, trauma, or inversion-induced ischaemia.1Rashid O.M. Ku J.K. Nagahashi M. et al.Inverted Meckel’s diverticulum as a cause of occult lower gastrointestinal haemorrhage.World J Gastroenterol. 2012; 18: 6155-6159Crossref PubMed Scopus (20) Google Scholar Abdominal radiographic imaging including computed tomography is usually nonspecific unless the patient has intestinal obstruction or intussusception; however, 1 case reported a positive preoperative diagnosis using MRI.2Dujardin M. Op de Beek B. Osteaux M. Inverted Meckel’s diverticulum as a leading point ileoileal intussusception in an adult: case report.Abdominal Imaging. 2002; 27: 563-565Crossref PubMed Scopus (31) Google Scholar It can appear as a smooth intraluminal mass or a pedunculated polyp.3Levy A.D. Hobbs C.M. Meckel diverticulum: radiologic features with pathologic correlation.Radiographs. 2004; 24: 565-587Crossref PubMed Scopus (211) Google Scholar Treatment is surgical excision and is curative. It was initially felt that the findings at MRI (Figure B, arrow) and SBCE (Figure A) were consistent with a small bowel tumor and he underwent a laparoscopic small bowel resection of the lesion (midileum). The histology, however, confirmed the presence of an inverted Meckel’s diverticulum. Figure C shows a transverse cross-section through the Meckel’s diverticulum demonstrating peri-intestinal fat and covering inverted bowel wall. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjMjMwMGY1ZWNkYjEzYWUyNzFkZTIwYzZjMzQ0ZjA5OCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgwNjU5NTMyfQ.EFQ_UMkZSyU_Qgct6T2FNPXIiKhzroL7et6zvesAcBMbqMxeRIwYZtiktjvCfvHRyX66uE5S4beCyVkzcBFiPxp7QtBVWEPncVZBb6wS18Lsyb_3Y5vrCHN9cP6vMObvtIgOf9N8D-x1K-PR19FLr5X5sYl8Kckp97bH837Sw49kFnitVW-0pi9O4BsUQCjehLMqQkHkFyZ_7-KZY9mjcbzWEFXY9kyvGD07F1-Xlp_4oKrHCFD1FOX_uV5MrKvwGFLwz27pCfVoRmdyc-0Ns58P89Mxi9IQRIrOujbTAvHHY9cT0xKlJ4XQqvP5wSoMyO56OxF-Mi0630A5YYz5Eg Download .mp4 (5.01 MB) Help with .mp4 files Supplementary Video