False Positive Meckleʼs Scan Leads to Exploratory Laparotomy and Finding of an Endoscopic Dieulafoyʼs Lesion

Abstract

Obscure gastrointestinal bleeding (OGIB) is challenging in both diagnosis and treatment. Multiple avenues exist to diagnose OGIB. Included are radiological tests such as bleeding scans, a Meckle's scan, and angiography. Surgery is a last resort after exhaustive workups. In patients less than 40 years of age, Meckle's diverticulum is a common etiology of OGIB. A Meckle's scan is only 9% specific in the adult population. The following case is of a false positive Meckle's scan leading to a negative exploratory laparotomy only to find a Dieulafoy's lesion via intraoperative repeated endoscopy. A previously healthy 31 year old white male presented with syncope, hematemesis, and a one week history of dark stools. Two days prior to presentation while drinking a few beers the patient had one pint volume of hematemesis associated with a loss of consciousness. On the day of presentation the patient reported a second episode of one pint hematemesis and a syncopal episode prompting evaluation in an emergency room. Admission labs included a hemoglobin of 5.4, hematocrit of 15.0 and a normal coagulation profile. The patient was monitored in a surgical step down unit with gastroenterology consulted. Two esophagastroduodenoscopies, a colonoscopy, a capsule endoscopy, and bleeding scans were all found to be negative. The patient required a total of 32 units of packed red blood cells over his hospital course. A Meckle's diverticulum scan was read as positive which prompted an exploratory laparotomy. Intraoperative inspection was negative although active bleeding continued through the nasogastric tube. Intraoperative endoscopy with push enteroscopy by gastroenterology was performed. A large clot was present in the gastric fundus which was unroofed revealing a nipple-like structure. This was identified as a Dieulafoy's lesion and treated with band ligation. Postoperatively, no further bleeding or transfusions occurred. He was later discharged home in stable condition. In 5% of cases the cause of GI bleeding is unknown. The case describes a false positive Meckle's scan leading to an exploratory laparotomy. Surgical results were negative, but the risks of surgery may have been avoided if continued endoscopy was performed. False positive Meckle's scans have also lead to the diagnosis of carcinoid tumor and leiomyosarcoma. In lieu of this case, the causes of false positive Meckle's scans should be investigated prior to exploratory laparotomy when diagnosing OGIB.