S2131 Massive Hematochezia From a Large Bleeding Duodenal Diverticulum

Abstract

INTRODUCTION: Duodenal diverticula are a rare cause of GI bleeding despite being a common finding in the GI tract. We present a case of a patient who had massive hematochezia due to a complex duodenal diverticulum. CASE DESCRIPTION/METHODS: A 74 year old Hispanic female with past medical history of type 2 diabetes mellitus presented with weakness. She denied any aspirin or NSAID use. On admission, vital signs were normal and she had pale conjunctiva. Labs were significant for Hgb 6.7 g/dL and blood glucose of 494 mg/dL. She was admitted for transfusion and glucose management. After admission, she had an episode of large amount of red blood per rectum. She became hypotensive and Hgb dropped to 3.7 g/dL. She was intubated, transferred to the ICU and started on pantoprazole drip. Repeat Hgb was 10.5 g/dL after 4 units of packed RBC. EGD using a forward-viewing endoscope was done which showed a 30 mm diverticulum in the area of the major papilla with multiple smaller diverticula within the main diverticulum. There were several angiodysplasias within the diverticulum that were oozing blood (Figure 1). The lesions were injected with epinephrine and four hemostatic clips were placed (Figure 2). There was no further bleeding after intervention and Hgb remained stable. DISCUSSION: Duodenal diverticula are common findings in the GI tract and the vast majority are asymptomatic. The most common location is the descending part of the duodenum. Duodenal diverticula are a rare cause of GI bleeding. Diverticular bleeding can be due to an inflamed diverticulum, erosion into a major vessel, Dieulafoy lesion, aortoenteric fistula formation or angiodysplasia. EGD is a useful tool in diagnosing bleeding duodenal diverticula, but a side-viewing endoscope may be needed if no bleeding source is identified on forward-viewing endoscopes. Various endoscopic therapeutic strategies such as injection with epinephrine, bipolar coagulation, APC and hemostatic clips have been used for treatment of bleeding duodenal diverticula. In our case, successful hemostasis was achieved with epinephrine injection followed by placement of hemostatic clips. Duodenal diverticula should be included in the consideration of rare causes of hematochezia. Prompt diagnosis and treatment is necessary to avoid life-threatening complications.Figure 1.: Actively oozing angiodysplasias within the diverticulum.Figure 2.: Angiodysplasias after injection and hemostatic clip placement. No bleeding seen post intervention.