Obscure gastrointestinal bleeding for 10 years in a 31-year-old man.

Question: A 31-year-old man was referred to our hospital because of acute onset of hematochezia. He reported to have colicky abdominal pain 4 hours before the onset of hematochezia. He had similar attack for 4 times in the previous 10 years. Repeated upper endoscopy, colonoscopy, computed tomography (CT), and angiography all failed to identify the bleeder. Like this attack, he recalled the previous bleeding episodes were precipitated with lower abdominal colicky abdominal pain and were self-limited after conservative treatment.Two episodes of hematochezia with hypovolemic shock occurred within 2 hours after admission. He was then transferred to the intensive care unit with fluid resuscitation. Emergent CT angiography disclosed only blood clots in the colon. A double-balloon enteroscopy found the presence of a lesion during anal route examination (Figure A; Video A). A tattoo was done for subsequent laparoscopic resection of the lesion (Figure B; Video B).What is the endoscopic and laparoscopic diagnosis of the lesion?See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.Answer to the Clinical Challenges and Images in GI Question: Image 2: Meckel's DiverticulumThe enteroscopy disclosed a diverticulum at 60 cm from the ileocecal valve (Figure A). Subsequent laparoscopy disclosed a 2-cm-long, inflamed diverticulum in the anti-mesenteric side of the terminal ileum (Figure B). Pathologic examination confirmed the clinical diagnosis of Meckel's diverticulum by showing ectopic gastric mucosa in the distal third of the diverticulum (Figure C).View Large Image Figure ViewerDownload Hi-res image Download (PPT)The most common congenital anomaly of the gastrointestinal tract is Meckel's diverticulum occurring in 2%–3% of the general population.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar Bleeding is the most common complication of Meckel's diverticulum. Although its pathologic and clinical features are well known, a preoperative diagnosis remains difficult to make.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar The Tc-99m pertechnetate scintigraphy is the most commonly used diagnostic tool. It has a high accuracy (90%) in the pediatric patients but a low accuracy (46%) in the adult population.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar Angiography could be useful in the setting of active bleeding but the diagnosis of Meckel's diverticulum is usually unsuspected.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar Both capsule endoscopy2Zeisler B. Moyer S.M. Farrell M. et al.Electronic clinical challenges and images in GI Meckel's diverticulum.Gastroenterology. 2008; 134: e3-e4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and double-balloon enteroscopy3Hol L. Kuipers E.J. Clinical challenges and images in GI Meckel's diverticulum.Gastroenterology. 2007; 133: 392Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar are useful to investigate obscure gastrointestinal bleeding caused by Meckel's diverticulum. Compared with capsule endoscopy, double-balloon enteroscopy is more invasive, but is more useful for precise localization of the lesion found, as shown in this case. This allows the surgeon to locate the lesion easily, especially during laparoscopic surgery. Question: A 31-year-old man was referred to our hospital because of acute onset of hematochezia. He reported to have colicky abdominal pain 4 hours before the onset of hematochezia. He had similar attack for 4 times in the previous 10 years. Repeated upper endoscopy, colonoscopy, computed tomography (CT), and angiography all failed to identify the bleeder. Like this attack, he recalled the previous bleeding episodes were precipitated with lower abdominal colicky abdominal pain and were self-limited after conservative treatment. Two episodes of hematochezia with hypovolemic shock occurred within 2 hours after admission. He was then transferred to the intensive care unit with fluid resuscitation. Emergent CT angiography disclosed only blood clots in the colon. A double-balloon enteroscopy found the presence of a lesion during anal route examination (Figure A; Video A). A tattoo was done for subsequent laparoscopic resection of the lesion (Figure B; Video B). What is the endoscopic and laparoscopic diagnosis of the lesion? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Answer to the Clinical Challenges and Images in GI Question: Image 2: Meckel's DiverticulumThe enteroscopy disclosed a diverticulum at 60 cm from the ileocecal valve (Figure A). Subsequent laparoscopy disclosed a 2-cm-long, inflamed diverticulum in the anti-mesenteric side of the terminal ileum (Figure B). Pathologic examination confirmed the clinical diagnosis of Meckel's diverticulum by showing ectopic gastric mucosa in the distal third of the diverticulum (Figure C).The most common congenital anomaly of the gastrointestinal tract is Meckel's diverticulum occurring in 2%–3% of the general population.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar Bleeding is the most common complication of Meckel's diverticulum. Although its pathologic and clinical features are well known, a preoperative diagnosis remains difficult to make.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar The Tc-99m pertechnetate scintigraphy is the most commonly used diagnostic tool. It has a high accuracy (90%) in the pediatric patients but a low accuracy (46%) in the adult population.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar Angiography could be useful in the setting of active bleeding but the diagnosis of Meckel's diverticulum is usually unsuspected.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar Both capsule endoscopy2Zeisler B. Moyer S.M. Farrell M. et al.Electronic clinical challenges and images in GI Meckel's diverticulum.Gastroenterology. 2008; 134: e3-e4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and double-balloon enteroscopy3Hol L. Kuipers E.J. Clinical challenges and images in GI Meckel's diverticulum.Gastroenterology. 2007; 133: 392Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar are useful to investigate obscure gastrointestinal bleeding caused by Meckel's diverticulum. Compared with capsule endoscopy, double-balloon enteroscopy is more invasive, but is more useful for precise localization of the lesion found, as shown in this case. This allows the surgeon to locate the lesion easily, especially during laparoscopic surgery. The enteroscopy disclosed a diverticulum at 60 cm from the ileocecal valve (Figure A). Subsequent laparoscopy disclosed a 2-cm-long, inflamed diverticulum in the anti-mesenteric side of the terminal ileum (Figure B). Pathologic examination confirmed the clinical diagnosis of Meckel's diverticulum by showing ectopic gastric mucosa in the distal third of the diverticulum (Figure C). The most common congenital anomaly of the gastrointestinal tract is Meckel's diverticulum occurring in 2%–3% of the general population.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar Bleeding is the most common complication of Meckel's diverticulum. Although its pathologic and clinical features are well known, a preoperative diagnosis remains difficult to make.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar The Tc-99m pertechnetate scintigraphy is the most commonly used diagnostic tool. It has a high accuracy (90%) in the pediatric patients but a low accuracy (46%) in the adult population.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar Angiography could be useful in the setting of active bleeding but the diagnosis of Meckel's diverticulum is usually unsuspected.1Levy A.D. Hobbs C.M. From the archives of the AFIP Meckel diverticulum: radiologic features with pathologic correlation.Radiographics. 2004; 24: 565-587Crossref PubMed Scopus (208) Google Scholar Both capsule endoscopy2Zeisler B. Moyer S.M. Farrell M. et al.Electronic clinical challenges and images in GI Meckel's diverticulum.Gastroenterology. 2008; 134: e3-e4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and double-balloon enteroscopy3Hol L. Kuipers E.J. Clinical challenges and images in GI Meckel's diverticulum.Gastroenterology. 2007; 133: 392Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar are useful to investigate obscure gastrointestinal bleeding caused by Meckel's diverticulum. Compared with capsule endoscopy, double-balloon enteroscopy is more invasive, but is more useful for precise localization of the lesion found, as shown in this case. This allows the surgeon to locate the lesion easily, especially during laparoscopic surgery. Supplementary material Download .mpg (5.52 MB) Help with mpg files Video 1 Download .mpg (6.33 MB) Help with mpg files Video 2 Download .mpg (5.52 MB) Help with mpg files Video 1 Download .mpg (6.33 MB) Help with mpg files Video 2