Meckelʼs Diverticulum: Thinking Outside the Box with Acute Massive Small Bowel Hemorrhage in an Adult

Abstract

Introduction: Nonvariceal upper GI bleeding remains a common GI emergency with an incidence of 37-172 cases per 100,000 adults and a mortality rate of 3-14%.1 Meckel's diverticulum, while well described in the pediatric population, is a rare source of bleeding in adults that requires a different diagnostic and treatment approach. Case Report: We report a thirty year old woman with a history of IBS who presented to the emergency department two hours after having two episodes of melena and a subsequent episode of syncope. On arrival, she had stable vital signs but a hemoglobin level of 9.7 g/dl. Initial work-up included an EGD that was normal and a colonoscopy that showed clotted blood throughout the colon but fresh red blood in the terminal ileum. A radionuclide bleeding study the next day was negative. One day later, patient had recurrent bleeding. Repeat radionuclide study was positive in the right lower quadrant, thought to represent a small bowel source. At that point, despite having required 6 units of blood, patient remained hemodynamically stabile. Decision was to hold on angiography and instead pursue a Meckel's scan. Unfortunately, this scan was delayed one day due to interference between the radionuclide and technetium pertechnetate, but the next day the scan was done and was positive. The patient was then taken for surgery the same day and had an uncomplicated resection of the Meckel's diverticulum that was confirmed on pathology. Discussion: In up to 5% of cases of GI bleeding, the source is not found.2 Meckel's diverticulum, while commonly encountered in the pediatric population, remains a rare diagnosis for adults. Other diagnostic tests after negative endoscopies, including video capsule endoscopy, angiography, and radionuclide study are less sensitive and specific than a Meckel's scan and can interfere with making a timely diagnosis; indeed our use of the radionuclide study delayed the diagnosis by 1 day. This case illustrates the importance of keeping Meckel's in the differential diagnosis and the impact of appropriate testing in early diagnosis.