Bleeding from Jejunal Diverticula

Abstract

Abstract Title:Bleeding from Jejunal Diverticula Background: Small intestinal hemorrhage is a common location of obscure GI bleeding and can be difficult to diagnose and treat given the limitations of traditional gastroscopes and colonoscopes. Jejunal diverticulosis is very rare with the prevalence of 0.3-1.9% in studies of the small bowel and 0.3-1.3% in autopsy studies. The presentation varies from being asymptomatic to causing massive gastrointestinal hemorrhage. We present a case of massive obscure GI bleeding from jejunal diverticulosis that was able to be successfully treated by deep enteroscopy with a pediatric colonoscope. Case Presentation: 68-year-old female with PMH of internal hemorrhoids, osteoporosis admitted with 3-day history of dark tarry stool, mild epigastric pain, and associated dizziness. She had no significant GI history. On admission, she was hemodynamically stable. Exam showed melena. Her Hg was 6.5 gm/dL. She was started on IV PPI and received 2 units of PRBCs. Esophagogastroduodenoscopy was performed that showed a 2mm non-bleeding ulcer in the gastric antrum, thought to be the source of bleeding, but no longer active. She was discharged home on oral PPI as Hb was stable Three days later, she returned to the ED with continued evidence of ongoing blood loss with multiple episodes of melena. Admission Hg was 6.0mg/dL. After initial PRBC transfusion and preparation, colonoscopy was performed that showed pan-diverticulosis, but no active bleeding. Deep intubation of the terminal ileum showed fresh blood, but no active source could be identified, indicating the source was in the proximal small bowel. Enteroscopy was then performed with a pediatric colonoscope that showed multiple jejunal diverticula. A visible vessel with active bleeding was seen within a jejunal diverticulum. Hemostasis was successful with clips and hemostatic powder Discussion: Jejunal diverticulosis is rare and can be congenital or acquired. Prevalence increases with age and most commonly presents in the 6th and 7th decade. The etiology is unclear, but possibly due to small bowel dysmotility with increased intraluminal pressure. It is often asymptomatic but can cause severe complications including hemorrhage, perforation, enterolith formation, small bowel diverticulitis and intestinal obstruction. Deep enteroscopy should be considered in patients with suspected small bowel bleeding.