Massive GI Bleeding Due to Jejunal Diverticulosis: A Rare Diagnostic Dilemma Highlighting the Importance of Endoscopic Timing and Multidisciplinary Care

Abstract

SymbolIntroduction: Jejunal diverticula form as a result of increased intraluminal pressure at the weakest points of the jejunum, usually near the site of entry of blood vessels into the bowel wall, leading to herniation of mucosa/submucosa through the muscle layer. Patients present with melena and obscure GI bleeding. Once the diagnosis is established, the treatment of choice is surgical resection of the jejunal segment and primary anastomosis. A 77-year-old man presented to an outside institution with 3 days of shortness of breath and melena. Hemoglobin was 7.6 g/dL on admission. Transfused 3 units of pRBC and incremented to 9.2 g/dL, but fell to 7.2 g/dL the following day. EGD was normal. Colonoscopy with TI intubation showed pan-colonic diverticulosis without active bleeding. Melena continued and small bowel enteroscopy performed showing diverticula in the duodenum and proximal jejunum without any blood or clots. Melena continued and an abdominal CT angiography was performed. No bleeding seen. Patient transferred to our institution and capsule endoscopy was performed. Findings suggested a jejunal source of bleeding and a double balloon-assisted enteroscopy was performed. Surgical consultation obtained and stated that since multiple diverticula were found in the duodenum/jejunum but no active bleeding was seen, any surgical intervention in this area would be technically difficult and a targeted resection could not be performed; UGI series with small bowel follow-through performed to assess number and extent of diverticula. Multiple diverticula noted in the second/third portions of the duodenum, proximal/mid-jejunal loops and distal ileum. On hospital day 7, the patient began to have maroon-stools. Taken for urgent enteroscopy with a cap-fitted pediatric colonoscope. Cap used to carefully examine small bowel mucosa and interrogate diverticula. Actively bleeding jejunal diverticula located but no targets for endoscopic treatment identified. Area tattooed and patient sent for surgical resection. Patient did well following surgical resection of jejunal segment. No additional episodes of melena/hematochezia occurred. He was discharged from the hospital and no further GI hemorrhage at 6 months of follow-up.In summary, massive gastrointestinal hemorrhage from jejunal diverticulosis is extremely rare and preoperative localization of the bleeding intestinal segment is challenging. This case illustrates the importance of endoscopic timing in reaching the appropriate diagnosis and the multidisciplinary approach used in its successful management. Urgent endoscopy at the time of active bleeding may be the key to establishing the diagnosis and allow for targeted surgical resection and definitive hemostasis.Symbol