Double-Balloon Enteroscopy for the Diagnosis of Meckel's Diverticulum in a 50-Year-Old Man With Obscure Gastrointestinal Bleeding

Abstract

50-year-old man presented to an outside facility with a 5-day history of intermittent hematochezia. This was associated with symptoms of fatigue, dyspnea on exertion, and headache. Blood work revealed hemoglobin of 7.9 gm/dL, and he was transfused 4 units of packed red blood cells. Esophagogastroduodenoscopy and colonoscopy were nonrevealing, and the patient was transferred to our facility for further care. Repeat esophagogastroduodenoscopy and colonoscopy with intubation of the terminal ileum were nondiagnostic and without evidence of bleeding. Patient had recurrent hematochezia, and a red blood cell scan demonstrated a focal area of mild increased activity to the left of the midline just above the level of the aortic bifurcation. Subsequent mesenteric angiogram and capsule endoscopy (CE) were nondiagnostic. A retrograde doubleballoon enteroscopy (DBE) was performed and showed a Meckel’s diverticulum (MD) at 100 cm proximal to the ileocecal valve (Figure A, arrow). The patient subsequently underwent a laparoscopy with removal of an MD at approximately 60 cm proximal to the valve (Figure B). Pathology revealed a 2.3 1.5 cm MD (Figure C) with a focus of gastric mucosa without ulceration. The postoperative course was uneventful, and patient was discharged home 2 days later in good condition. He continues to do well without any evidence of recurrent gastrointestinal bleeding (GIB) 1 year after surgery. MD is the most common congenital anomaly of the GI tract and occurs in 2%–4% of the population. 1 Although GIB is its most common complication in the pediatric population, this occurs rarely in adults and more scarcely in older adults. 1 Preoperative diagnosis of obscure GIB (OGIB) caused by MD in older adults is a clinical challenge for a number of reasons. First, it is infrequent and, thus, often not considered in the differential diagnosis. Second, the yield of the technetium pertechnetate scan in patients older than 40 years of age is reduced, with reported sensitivity and positive predictive values of 62.5% and 60.0%, respectively. 2