Unusual sources of gastrointestinal bleeding.

Abstract

A 51-year-old lady was initially evaluated with severe hematochezia of one-day duration. Her medical history included hepatitis C infection, alcoholism complicated with compensated hepatic cirrhosis, and a previously resected colon cancer. The patient reported that 12 h prior to her initial hospital visit she developed abdominal bloating and passed an extensive amount of bright red blood mixed with her stool filling the toilet bowl. Prior to this, she had been drinking up to 12 beers per day. After the initial episode, continued bloody bowel movements were accompanied by severe weakness, dizziness, and feeling faint, prompting her to visit the emergency department, where on initial evaluation she was notably anxious. A nasogastric lavage revealed no blood or material resembling coffee grounds in the aspirate. Heart rate was 94 beats/min, and blood pressure was 86/51 mmHg. Her abdomen was soft, non-tender, and non-distended; bowel sounds were present and slightly increased in volume and frequency; and a scar following a previous surgical incision was noted in the left lower quadrant. Rectal examination revealed frank red blood in the vault but without palpable masses or hemorrhoids. Hgb was 7.8 g/ dL, lower than a baseline value of 11.8 g/dL recorded a month previously. The platelet count was 107 9 10/mm. Prothrombin time was elevated international normalized ratio (INR) of 1.49. Her blood urea nitrogen level was 15 mg/dL, with serum concentrations of creatinine 0.59 mg/dL, albumin 2.4 g/dL, total bilirubin 0.6 mg/dL, aspartate aminotransferase (AST) 131 unit/L, and alanine aminotransferase (ALT) 82 unit/L. Admission Mayo EndStage Liver Disease (MELD) score was 11. The patient was resuscitated and admitted to the medical intensive care unit where ongoing gastrointestinal hemorrhage was evaluated with urgent upper gastrointestinal endoscopy which revealed no site of recent bleeding, although moderate portal hypertensive gastropathy was present. Colonoscopy then demonstrated a normally healed site of surgical anastomosis, but throughout the colon there was fresh blood that appeared to be oozing from a site caudad to the ileocecal valve (Fig. 1). An isotopic In-tagged red blood cell scan identified a focus of active bleeding in left lower quadrant, possibly in the small bowel. After the scan, the patient had repeated episodes of rectal bleeding complicated by hemorrhagic shock with a blood pressure 65/35 mmHg, prompting emergent exploratory laparotomy. At operation, the source of bleeding was identified as an ectopic varix in the small bowel approximately 65 cm proximal to the ileocecal valve which was resected surgically and confirmed pathologically. By postoperative day 10, the patient had recovered well without recurrence of bleeding but left against medical advice, although she was reported to have recovered well 1 week following discharge. D. Castresana A. Kaza Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM, USA