Red Blood Cell Scan Research Articles

Polypoid heterotopic gastric mucosa: in terminal ileum causing extensive lower gastrointestinal bleeding without Meckel’s diverticulum: a case report

BackgroundHeterotopic gastric mucosa (HGM) can be located in various parts of the gastrointestinal tract. As a rare anomaly in the small intestine, it can become complicated by intussusception, obstruction, gastrointestinal bleeding, and even peritonitis, leading to death.Case presentationThis case report focuses on a 12-year-old Middle Eastern boy who presented with hematochezia and abdominal pain for a couple of days. A tagged Red blood cell (RBC) scan and Technetium scan revealed gastrointestinal bleeding at the lower abdomen, highly suggestive of the diagnosis of Meckel’s diverticulum. Subsequently, exploratory laparotomy revealed contiguous and scattered mucosal lesions with multiple polyps of various sizes in the terminal ileum. Meckel’s diverticulum was absent, and the patient was treated with resection and primary anastomosis. The resected tissue revealed extensive ectopic gastric mucosa and polypoid tissues. The patient recovered uneventfully and was discharged four days after the surgery. The symptoms did not recur within six months after his surgery.ConclusionOur case demonstrated that despite the rarity of multiple polypoid gastric heterotopias in the terminal ileum, it should be considered as one of the differential diagnoses of gastrointestinal tract bleeding.

Long-Term Natural History of Presumptive Diverticular Hemorrhage.

The natural history of patients with well-documented presumptive diverticular hemorrhage (TICH) is unknown. Our aims are to report (i) rebleeding rates and clinical outcomes of presumptive TICH patients with and without rebleeding, (ii) conversion to definitive TICH during long-term follow-up (F/U), and (iii) risk factors of presumptive diverticular (TIC) rebleeding. This was a retrospective cohort study of prospectively collected results of presumptive TICH patients from 1994 to 2023. Presumptive TICH was diagnosed for patients with TICs without stigmata of recent hemorrhage and no other cause of bleeding found on anoscopy, enteroscopy, capsule endoscopy, computed tomography angiography, or tagged red blood cell scan. Patients with ≤6 months of F/U were excluded. Of 139 patients with presumptive TICH, 104 were male and 35 female. The median age was 76 years. There were no significant differences in baseline demographics of rebleeders and non-rebleeders. During long-term median F/U of 73 months, 24.5% (34/139) rebled. A total of 56% (19/34) of rebleeders were diagnosed as definitive TICH, and they had significantly higher rates of readmission ( P < 0.001), reintervention ( P < 0.001), and surgery ( P < 0.001). During F/U, there were significantly higher rates of newly diagnosed hypertension and/or atherosclerotic cardiovascular disease in rebleeders ( P = 0.033 from a logistic model). All-cause mortality was 42.8%, but none was from TICH. For presumptive TICH during long-term F/U, (i) 75.5% did not rebleed and 24.5% rebled. (ii) 56% of rebleeders were diagnosed as definitive TICH. (iii) New development of hypertension and atherosclerotic cardiovascular disease were risk factors of TIC rebleeding.

The Role of Imaging for GI Bleeding: ACG and SAR Consensus Recommendations.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high health care utilization and costs. Radiologic techniques including CT angiography, catheter angiography, CT enterography, MR enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist, which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided. © Radiological Society of North America and the American College of Gastroenterology, 2024. Supplemental material is available for this article. This article is being published concurrently in American Journal of Gastroenterology and Radiology. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Citations from either journal can be used when citing this article. See also the editorial by Lockhart in this issue.

“Tag - You're It!” Use of Tagged Red Blood Cell (RBC) Scan to Localize Gross Hematuria

“Tag - You're It!” Use of Tagged Red Blood Cell (RBC) Scan to Localize Gross Hematuria

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

S2611 It Is so Complicated: Pancreatico-Spleno-Colonic Fistula Presenting as Gastrointestinal Bleeding

Introduction: Gastrointestinal bleeding is common in clinical practice with variable etiology, we present a rare case of pancreatic pseudocyst complicated by spleno-colonic fistula manifesting with brisk hematochezia. Case Description/Methods: A 50-year-old male with no significant past medical history presented with fever and acute encephalopathy. He subsequently had a prolonged and complicated hospital course with a new diagnosis of Human immunodeficiency virus/Acquired immunodeficiency syndrome, disseminated tuberculosis, and chronic pancreatitis with a pancreatic pseudocyst. During hospitalization, the patient suddenly developed passage of bright red blood per rectum over 48 hours with down-trending hemoglobin. Hemoglobin initially dropped from 9.6 g/dL to 5.0 g/dl (Normal: 12-16 g/dL) and he required multiple units of packed red cell, platelets, and fresh frozen plasma transfusion. The patient underwent a tagged Red blood cell scan with radiolabelled 28.4 mCi of Tc-99 m. Red blood cell tagged Tc 99 m gastrointestinal bleeding scan showed large brisk pooling of the radiotracer in the splenic flexure consistent with significant active hemorrhage in the region of the splenic flexure. There was a retrograde flow of the tracer into the transverse colon and antegrade flow into the descending colon. Retrospective evaluation of the prior CT tomography scans of the abdomen demonstrated possible communication between the pancreatic tail cyst, the spleen as well as the splenic flexure which was the likely source of the GI bleed. The patient had a total of 35 units of packed red blood cells transfused, 8 units of platelets, and 7 units of fresh frozen plasma during his hospital course. The patient failed multiple attempts at Interventional radiology arterial embolization and due to multiple co-morbidities, he was not a candidate for surgical intervention. He later died after 6 months of hospitalization (Figure 1). Discussion: There have been reported cases of pancreatico-colonic fistula and spleno-colonic fistula, arising from pancreatic pseudocysts and pseudoaneurysms associated with trauma, pancreatitis, and Crohn’s disease. Pancreatico-spleno-colonic fistula is a rare and complex entity usually presenting with massive gastrointestinal bleeding. The findings of acute or chronic pancreatitis and pseudocyst with gastrointestinal bleeding should raise the suspicion of possible pancreatico-colonic fistula. Prompt imaging is key to accurate diagnosis and management.Figure 1.: Tc-99 m RBC tagged showing radiotracer in the splenic flexure, transverse colon and the descending colon. Non-contrast (A) and contrast enhanced axial (B, C) and coronal (D, E) computerized tomographic scan of the abdomen showing cystic mass at the tail of pancreas (blue arrow) communicating with the spleen and splenic flexure of the colon(red arrow).

Angiographic Diagnosis of a Meckel's Diverticulum in a 26-month-old Boy.

A 26-month-old boy presented with recurrent hematochezia. Abdominal examination was normal. Laboratory findings showed hemoglobin of 7.5 g/dL. Abdominal ultrasound (US) for intussusception revealed a short (0.3 cm) segment of wall thickening in the distal ileum and Meckel’s scan was negative. The patient underwent two additional Meckel’s scans, tagged red blood cell scan, CT-angiography, upper endoscopy and colonoscopy, and video capsule endoscopy, but had normal results. Superior mesenteric angiography was performed revealing an area of abnormal vasculature in the terminal ileum (Fig. 1). Subsequently, exploratory laparotomy showed an obvious Meckel’s diverticulum (MD), and Meckel’s diverticulectomy was performed (Fig. 2).FIGURE 1.: Meckel's Diverticulectomy.FIGURE 2.: Meckel’s Diverticulectomy. A) Gross specimen of MD removed from patient and (B) histological examination of MD with the presence of ectopic gastric mucosa.MD is the most common congenital malformation of the gastrointestinal tract, occurring in approximately 2% of the population (1). The gold standard in diagnosing a MD is a Meckel’s scan which detects the accumulation of a radioisotope, Technetium-99m. However, false negatives do occur and this is likely due to insufficient gastric mucosa in the MD (2). The literature on typical angiographic findings for diagnosis of MD are limited to a few individual cases (3–6). Our patient exhibited multiple abnormal corkscrew-like arteries of the ileocolic artery. Angiography can detect MD in the absence of acute bleeding through visualization of the vitelline artery (7). ACKNOWLEDGMENTS A.P. was involved in conception and design, acquisition of data, drafting the work, final approval of the version to be published. M.R.A., P.M., T.R.B., and C.M.S. were involved in conception and design, critical revision of work, final approval of version to be published. L.A. was involved in conception and design, acquisition of data, critical revision of work, final approval of version to be published.

Colo-enteric fistula associated with diffuse large B cell lymphoma that resulted in gastrointestinal bleeding: A case report and literature review

Introduction and importanceThe most common symptoms of primary gastrointestinal (GI) lymphoma are non-specific, such as nausea, vomiting, diarrhea, weight loss, and abdominal pain. The rare acute symptoms include bowel obstruction, intussusception, and perforation. Primary small bowel lymphoma accounts for the smallest proportion of all GI malignancies. We report a case of intestinal lymphoma presenting with bloody stools and anemia.Case presentationThe patient initially underwent both duodenoscopy and colonoscopy with negative findings. Isotopic red blood cell (RBC) scan was then performed due to persistent bleeding along with computed tomography angiography (CTA) because of suspected bleeding in the left abdomen. Successful embolization over the arcade of the sigmoid and left colic arteries was performed. However, the bleeding did not stop, and ischemic colitis was diagnosed by repeat colonoscopy. A coloenteric fistula was finally discovered during emergent laparotomy.Clinical discussionGI lymphomas are a rare disease entity among the all GI malignancies. Despite acute abdominal symptoms including obstruction, perforation, bleeding and intussusception, enteral fistula is also one of the complications. It was seen to be a long-term complication after treatment or disease process in most of cases, however it could occur as the initial manifestation. GI bleeding is a life-threatening condition and commonly needs prompt decision making. There were no standard managements for these patients, it depends on clinical judgements from physician individually.ConclusionThis is a rare condition that has not been previously described in Taiwan. Early diagnosis and timely management will decrease morbidity and mortality in the GI lymphoma population.

Gastrointestinal Bleeds.

Gastrointestinal Bleeds.

Lower Gastrointestinal Bleeding

Of patients who present with major gastrointestinal (GI) bleeding, 20 to 30% will ultimately be diagnosed with bleeding originating from a lower GI source. Lower GI bleeding has traditionally been defined as bleeding originating from a source distal to the ligament of Treitz; however, with the advent of capsule endoscopy and deep enteroscopy allowing for visualization of the entire small bowel, the definition has been updated to GI bleeding originating from a source distal to the ileocecal valve. Lower GI bleeding can range from occult blood loss to massive bleeding with hemodynamic instability and predominantly affects older individuals, with a mean age at presentation of 63 to 77 years. Comorbid illness, which is a risk factor for mortality from GI bleeding, is also more common with increasing age. Most deaths related to GI bleeding are not due to uncontrolled hemorrhage but exacerbation of underlying comorbidities or nosocomial complications. This review covers the following areas: evaluation of lower GI bleeding (including physical examination and diagnostic tests), initial management, and differential diagnosis. Disorders addressed in the differential diagnosis include diverticulosis, arteriovenous malformations (AVMs), ischemic colitis, anorectal disorders, radiation proctitis, postpolypectomy bleeding, and colorectal neoplasms. Figures show an algorithm for management of patients with suspected lower GI bleeding, tagged red blood cell scans, diverticular bleeding, colonic AVM, ischemic colitis, bleeding hemorrhoid, chronic radiation proctitis, and ileocolonic valve polyp. Tables list descriptive terms for rectal bleeding and suggested location of bleeding, imaging modalities and differential diagnosis for lower GI bleeding, endoscopic techniques for hemostasis, and an internal hemorrhoids grading system. This review contains 8 highly rendered figures, 5 tables, and 100 references.

Lower Gastrointestinal Bleeding

Of patients who present with major gastrointestinal (GI) bleeding, 20 to 30% will ultimately be diagnosed with bleeding originating from a lower GI source. Lower GI bleeding has traditionally been defined as bleeding originating from a source distal to the ligament of Treitz; however, with the advent of capsule endoscopy and deep enteroscopy allowing for visualization of the entire small bowel, the definition has been updated to GI bleeding originating from a source distal to the ileocecal valve. Lower GI bleeding can range from occult blood loss to massive bleeding with hemodynamic instability and predominantly affects older individuals, with a mean age at presentation of 63 to 77 years. Comorbid illness, which is a risk factor for mortality from GI bleeding, is also more common with increasing age. Most deaths related to GI bleeding are not due to uncontrolled hemorrhage but exacerbation of underlying comorbidities or nosocomial complications. This review covers the following areas: evaluation of lower GI bleeding (including physical examination and diagnostic tests), initial management, and differential diagnosis. Disorders addressed in the differential diagnosis include diverticulosis, arteriovenous malformations (AVMs), ischemic colitis, anorectal disorders, radiation proctitis, postpolypectomy bleeding, and colorectal neoplasms. Figures show an algorithm for management of patients with suspected lower GI bleeding, tagged red blood cell scans, diverticular bleeding, colonic AVM, ischemic colitis, bleeding hemorrhoid, chronic radiation proctitis, and ileocolonic valve polyp. Tables list descriptive terms for rectal bleeding and suggested location of bleeding, imaging modalities and differential diagnosis for lower GI bleeding, endoscopic techniques for hemostasis, and an internal hemorrhoids grading system. This review contains 9 figures, 8 tables, and 103 references.

Lower Gastrointestinal Bleeding

Of patients who present with major gastrointestinal (GI) bleeding, 20 to 30% will ultimately be diagnosed with bleeding originating from a lower GI source. Lower GI bleeding has traditionally been defined as bleeding originating from a source distal to the ligament of Treitz; however, with the advent of capsule endoscopy and deep enteroscopy allowing for visualization of the entire small bowel, the definition has been updated to GI bleeding originating from a source distal to the ileocecal valve. Lower GI bleeding can range from occult blood loss to massive bleeding with hemodynamic instability and predominantly affects older individuals, with a mean age at presentation of 63 to 77 years. Comorbid illness, which is a risk factor for mortality from GI bleeding, is also more common with increasing age. Most deaths related to GI bleeding are not due to uncontrolled hemorrhage but exacerbation of underlying comorbidities or nosocomial complications. This review covers the following areas: evaluation of lower GI bleeding (including physical examination and diagnostic tests), initial management, and differential diagnosis. Disorders addressed in the differential diagnosis include diverticulosis, arteriovenous malformations (AVMs), ischemic colitis, anorectal disorders, radiation proctitis, postpolypectomy bleeding, and colorectal neoplasms. Figures show an algorithm for management of patients with suspected lower GI bleeding, tagged red blood cell scans, diverticular bleeding, colonic AVM, ischemic colitis, bleeding hemorrhoid, chronic radiation proctitis, and ileocolonic valve polyp. Tables list descriptive terms for rectal bleeding and suggested location of bleeding, imaging modalities and differential diagnosis for lower GI bleeding, endoscopic techniques for hemostasis, and an internal hemorrhoids grading system. This review contains 9 figures, 8 tables, and 103 references.

Lower Gastrointestinal Bleeding

Of patients who present with major gastrointestinal (GI) bleeding, 20 to 30% will ultimately be diagnosed with bleeding originating from a lower GI source. Lower GI bleeding has traditionally been defined as bleeding originating from a source distal to the ligament of Treitz; however, with the advent of capsule endoscopy and deep enteroscopy allowing for visualization of the entire small bowel, the definition has been updated to GI bleeding originating from a source distal to the ileocecal valve. Lower GI bleeding can range from occult blood loss to massive bleeding with hemodynamic instability and predominantly affects older individuals, with a mean age at presentation of 63 to 77 years. Comorbid illness, which is a risk factor for mortality from GI bleeding, is also more common with increasing age. Most deaths related to GI bleeding are not due to uncontrolled hemorrhage but exacerbation of underlying comorbidities or nosocomial complications. This review covers the following areas: evaluation of lower GI bleeding (including physical examination and diagnostic tests), initial management, and differential diagnosis. Disorders addressed in the differential diagnosis include diverticulosis, arteriovenous malformations (AVMs), ischemic colitis, anorectal disorders, radiation proctitis, postpolypectomy bleeding, and colorectal neoplasms. Figures show an algorithm for management of patients with suspected lower GI bleeding, tagged red blood cell scans, diverticular bleeding, colonic AVM, ischemic colitis, bleeding hemorrhoid, chronic radiation proctitis, and ileocolonic valve polyp. Tables list descriptive terms for rectal bleeding and suggested location of bleeding, imaging modalities and differential diagnosis for lower GI bleeding, endoscopic techniques for hemostasis, and an internal hemorrhoids grading system. This review contains 9 figures, 8 tables, and 103 references.

Perforation of a Giant jejunal duplication in a child - A rare cause of acute abdomen in paediatrics

Small intestinal duplications are rare in pediatrics. Usually, they are asymptomatic but when symptoms arise, it can be nonspecific abdominal pain, melena, abdominal bloating, constipation or chronic blood loss leading to iron deficiency anemia. Rarely life-threatening complications are seen like intestinal obstruction, mucosal ulcerations, intestinal perforation and peritonitis. Diagnosis is at laparotomy in acute abdomen or during imaging. Imaging methods are ultrasound scan abdomen, Computed tomography scan of abdomen, Magnetic resonance scan of abdomen, capsule enteroscopy or technetium 99 labeled red blood cell scan. Chronic iron deficiency anemia in combination with abdominal symptoms with melena or positive stool occult blood and having negative upper and lower gastrointestinal endoscopy, must prompt further imaging as have described above. We present a pediatric jejunal duplication, which presented with chronic abdominal symptoms including melena and chronic anemia for 2 years, which was not diagnosed. Patient presented with acute abdomen due to small bowel perforation and peritonitis.

S2118 Angiographic Diagnosis and Treatment of Adult GI Bleeding from Meckel’s Diverticulum

INTRODUCTION: Meckel's diverticulum is the most common gastrointestinal anomaly resulting from a persistent omphalomesenteric duct. It is usually discovered in children when gastrointestinal (GI) bleeding occurs. This case demonstrates the use of provocative angiography for both the diagnosis and treatment of a bleeding Meckel's diverticulum in an adult. CASE DESCRIPTION/METHODS: A 22-year-old woman with no known past medical history presented to the emergency department with a chief complaint of black stool, lightheadedness and weakness. On exam, her abdomen was soft and non-tender. Rectal exam showed black stool with bloody mucus. Labs were significant for a Hgb of 6.1 (MCV 90.1) from 12.1 one week prior. During her hospitalization she underwent several studies to determine the location of her bleed. Esophagogastroduodenoscopy, colonoscopy, tagged red blood cell scan, and Meckel’s Scan were all normal. Video capsule endoscopy visualized blood in the terminal ileum and cecum mixed with stool, however no lesions were identified in these areas on colonoscopy. Magnetic resonance enterography was without evidence of small bowel inflammation. A visceral arteriogram was performed by interventional radiology, which was negative for bleeding until provocation was done using direct intra-arterial thrombolytic infusion (tissue plasminogen activator) that demonstrated active bleeding in an superior mesenteric artery branch which appeared to be serving a Meckel's diverticulum. Successful embolization was performed with a 3 mm coil and no further bleeding episodes occurred during her hospital stay. One month later she returned for surgical resection. Pathology confirmed Meckel's diverticulum with focal ulceration, underlying granulation tissue, and gastric heterotopia. DISCUSSION: Tc-99m pertechnetate scintigraphy (Meckel's Scan) is helpful in diagnosis of a Meckel’s diverticulum as pertechnetate is taken up by mucin-secreting cells of ectopic gastric tissue. This scan has high sensitivity and specificity in children but is drastically lower in adults as hemorrhage due to ectopic gastric mucosa is primarily a pediatric disease. For adults with suspected bleeding from a Meckel's diverticulum with multiple negative imaging modalities including a Meckel's scan, it is important to continue pursuit of the diagnosis using all means available. This case demonstrates the vital importance of provocation angiography in diagnosis of a Meckel's diverticulum that would have otherwise been missed and therefore left untreated.Figure 1.: Negative Meckel’s Scan. No heterotopic gastric mucosa visualized.Figure 2.: Angiogram before tPA administration. Red arrow indicates suspected Meckel diverticulum served by superior mesenteric artery branch.Figure 3.: Angiogram after tPA administration. Red arrow indicates area of extravasation and active bleeding.

S2151 A Cautionary Tale: Hemosuccus Pancreaticus in a Patient With a History of Chronic Pancreatitis

INTRODUCTION: Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding from the pancreatic duct and is usually secondary to chronic pancreatitis, pancreatic pseudocysts, or tumors. We present a diagnostically challenging case of upper gastrointestinal bleeding (UGIB) from the pancreatic duct in a relatively young patient with a history of recurrent pancreatic injuries and alcohol use. CASE DESCRIPTION/METHODS: A 35-year-old man with recurrent acute and chronic alcohol-induced pancreatitis presented with acute melena and general fatigue. In the emergency department, complete blood count showed a hemoglobin of 6.4 compared to 13 earlier in the year. He received one unit of packed red blood cells, intravenous (IV) fluids, and IV pantoprazole. During his hospital course, he experienced an episode of hematemesis, and he continued to have melena. Subsequently, esophagogastroduodenoscopy (EGD) was performed and revealed blood in the second portion of the duodenum but no other remarkable sources of bleeding. The patient's hemoglobin continued to trend downwards. Tagged red blood cell scan showed blood accumulation in the proximal small bowel of the right hemiabdomen. A repeat EGD was performed, showing blood in the ampulla of Vater. Contrast-enhanced computed tomography angiography and magnetic resonance cholangiopancreatography revealed a likely thrombosed pseudoaneurysm in the gastroduodenal artery with mass effect on the pancreatic neck, severely narrowing the splenoportal vein confluence. Imaging also confirmed evidence of chronic pancreatitis as well as hepatic steatosis. An arteriogram with successful coil embolization of the gastroduodenal artery was performed. The patient’s clinical status improved, and he was discharged home in stable condition. DISCUSSION: Our case represents how hemosuccus pancreaticus can be difficult to diagnose in an acutely anemic patient with risk factors for typical etiologies of UGIB. The delay in diagnosis and treatment can be attributed to repeated endoscopies unable to visualize the source of bleeding as well as the intermittent bleeding itself that can often resolve without intervention.Figure 1.: Esophagogastroduodenoscopy reveals bleeding in the second portion of the duodenum.Figure 2.: Magnetic resonance cholangiopancreatography demonstrates a hematoma in the pancreatic neck, markedly narrowing the pancreatic duct and splenoportal confluence.Figure 3.: Post embolization angiogram at the level of the common hepatic artery shows successful coil embolization of the gastroduodenal artery.

Delayed Massive Lower Gastrointestinal Bleeding Secondary to Suprapubic Cystostomy, A Case Report of Very Rare Complication

Introduction: Suprapubic cystostomy is a common procedure in urology. Bowel perforation is the most serious and rare complication. This report highlights the first published case of massive lower gastrointestinal bleeding as a complication secondary to suprapubic cystostomy. Case presentation: A sixty-seven-year-old patient with benign prostate hyperplasia had a suprapubic catheter inserted under spinal anesthesia, during concurrent cystoscopy. It was functioning well after insertion. Twelve days later, he developed massive hematochezia. On examination, he was hemodynamically stable. There was a demonstrable right lower abdominal tenderness and the digital rectal examination revealed dark red blood. The suprapubic cystostomy was draining clear urine without leakage. Investigations revealed a hemoglobin 6 g/dL and normal INR. Two units of packed red blood cells were given. A colonoscopy showed a normal colon with blood coming from above the ileocecal valve area. Upper endoscopy was normal. A red blood cell scan revealed active bleeding at the terminal ileum. A computerized tomography scan of the abdomen with IV contrast showed that the suprapubic catheter had passed into terminal ileum causing active bleeding. Exploratory laparotomy confirmed the presence of suprapubic catheter passing to the terminal ileum. The suprapubic catheter was removed, the unhealthy bowel resected, and anastomosis performed with no immediate post-operative complications. Conclusion: This case determines the importance of keeping careful watch for possible bowel injury after cystostomy and should be considered a rare complication and cause of lower gastrointestinal bleeding.

Delayed Massive Lower Gastrointestinal Bleeding Secondary to Suprapubic Cystostomy, A Case Report of Very Rare Complication

Introduction: Suprapubic cystostomy is a common procedure in urology. Bowel perforation is the most serious and rare complication. This report highlights the first published case of massive lower gastrointestinal bleeding as a complication secondary to suprapubic cystostomy. Case presentation: A sixty-seven-year-old patient with benign prostate hyperplasia had a suprapubic catheter inserted under spinal anesthesia, during concurrent cystoscopy. It was functioning well after insertion. Twelve days later, he developed massive hematochezia. On examination, he was hemodynamically stable. There was a demonstrable right lower abdominal tenderness and the digital rectal examination revealed dark red blood. The suprapubic cystostomy was draining clear urine without leakage. Investigations revealed a hemoglobin 6 g/dL and normal INR. Two units of packed red blood cells were given. A colonoscopy showed a normal colon with blood coming from above the ileocecal valve area. Upper endoscopy was normal. A red blood cell scan revealed active bleeding at the terminal ileum. A computerized tomography scan of the abdomen with IV contrast showed that the suprapubic catheter had passed into terminal ileum causing active bleeding. Exploratory laparotomy confirmed the presence of suprapubic catheter passing to the terminal ileum. The suprapubic catheter was removed, the unhealthy bowel resected, and anastomosis performed with no immediate post-operative complications. Conclusion: This case determines the importance of keeping careful watch for possible bowel injury after cystostomy and should be considered a rare complication and cause of lower gastrointestinal bleeding.

Time to Catheter Angiography for Gastrointestinal Bleeding after Prior Positive Investigation Does Not Affect Bleed Identification.

Objective:To determine, time to angiography for patients with positive gastrointestinal bleeding (GIB) on prior investigation (endoscopy [ES], nuclear medicine [NM] Tc99m red blood cells (RBC) scan, or computed tomography angiography), affects angiographic bleed identification.Materials and Methods:Visceral Angiograms performed from January 2012 to August 2017 were evaluated. Initial angiograms performed for GIB were included in the study. Exclusion criteria included recent abdominal surgery or procedure (30 days), empiric embolization (embolization without visualized active bleeding), and use of vasodilators, or subsequent angiogram. Timing and results of ES, NM Tc99m RBC scan, or computed tomography angiogram and catheter angiogram were recorded. In addition, age, gender, angiogram time, anti- platelet therapy, anti-coagulation therapy, bleed location, international normalized ratio, and units of packed RBCs received in the 24 h before catheter angiography were included in the study.Results:One hundred and seventy angiograms were included in the final analysis. Forty-three angiograms resulted in the identification of an active bleed (68.9 years, and 67.4% male). All of these patients were embolized successfully. One hundred and twenty-seven angiograms failed to identify an active bleed (70.4 years, and 49.6% male). No significance was found across the two groups with respect to time from prior positive investigation. Receiver operating characteristic analysis demonstrated that units of packed RBCs received in the preceding 24 h were correlated with positive bleed identification on catheter angiography.Conclusion:Time to angiography from prior positive investigation, including ES, NM Tc99m RBC scan, or computed tomography angiogram does not correlate with positive angiographic outcomes. Increasing units of packed RBCs administered in the 24 h before angiogram do correlate with positive angiographic findings.

2587 Never Too Old for Meckel's: A Unique Presentation of an Uncommon Source of Gastrointestinal Bleeding in Adults

INTRODUCTION: Meckel's diverticulum is a common gastrointestinal congenital malformation, affecting approximately 2% of the population. Related complications such as bleeding commonly occurs in the pediatric age group; although, in adults it is often missed. We present a case of recurrent obscure-overt gastrointestinal (GI) bleeding secondary to a Meckel's diverticulum which remained elusive after multiple diagnostic studies. CASE DESCRIPTION/METHODS: 30-year-old male with history of recurrent GI bleeding, presents to the outpatient GI clinic for further evaluation after being admitted to the intensive care unit (ICU) 3 weeks prior with massive hematochezia requiring several blood transfusions for a drop-in hemoglobin from 14 gm/dL to &lt;7 gm/dL. The patient had undergone endoscopy, colonoscopy, and video capsule endoscopy (VCE) three years prior for similar symptoms without an identifiable source. A nuclear tagged red blood cell scan was performed showing bleeding in the proximal colon. CT angiography following showed contrast extravasation in the distal jejunum and ileum which was treated with gel foam. The patient had no further episodes of hematochezia and was discharged. After the clinic visit, the patient underwent a Meckel's scan which did not show ectopic gastric mucosa but revealed colonic bleeding proximal to the hepatic flexure. Ileocolonoscopy was normal. Subsequent VCE showed abnormal mucosa in the distal small bowel. He finally underwent a retrograde balloon enteroscopy which revealed a distal small bowel diverticulum with a single adjacent, nonbleeding ulcer (Figure 1). Biopsies of the ulcer showed gastric foveolar metaplasia. Based on the findings, he was referred for a small bowel resection which revealed a jejunal Meckel's diverticulum with gastric oxyntic heterotopia on histology (Figures 2 and 3). DISCUSSION: This case highlights the potential morbidity and possible mortality of Meckel's diverticulum as a source of lower GI bleeding. Recent studies have recommended against prophylactic surgical resection in the absence of certain risk factors including age less than 40, male gender, and macroscopic mucosal alteration. Given this patient's significant hematochezia, transfusion requirements, and gross peri-diverticular ulceration, we opted for small bowel resection. Meckel's diverticulum should always be included in the differential for occult or overt GI bleeding, especially in young patients when no other sources of bleeding are readily identifiable.