S2114 A Stitch in Time for Successful Management of Obscure Gastrointestinal Bleeding

INTRODUCTION: Gastrointestinal bleeding secondary to jejunal diverticulosis is rare. There is often a delay in diagnosis. Here we present a case of a patient presenting with an obscure gastrointestinal bleed who was later found to have jejunal diverticulum on push enteroscopy. CASE DESCRIPTION/METHODS: A previously healthy 54-year-old male presented in the early morning to the emergency room with massive hematochezia. Around midnight, he started having maroon-colored bowel movements. By morning he felt very lightheaded. He denied any abdominal pain, hematemesis, or melena. On admission, T 98.2 F, HR 96 bpm, RR 18/min, BP 114/68 mmHg. Abdomen was soft, nontender with normoactive bowel sounds. Initially, hemoglobin was 11.0 g/dL. However, the bloody bowel movements persisted. He became hemodynamically unstable. Hemoglobin dropped to 6.3 g/dL. Eight units of blood were transfused over a 24-hour period. Upper and lower endoscopy followed by tagged RBC scan showed no source of bleeding. CT angiography revealed possible bleeding in proximal jejunum. Angioembolization attempted however, no bleeding noted upon conventional angiography. Push enteroscopy showed multiple jejunal diverticula containing blood clots were noted. Upon irrigation an adherent clot was found in one of the larger diverticula that could not be dislodged. Due to multiple diverticula and the potential risk of recurrent bleeding, intraprocedural surgical consultant was obtained. Two marking clips were deployed to facilitate localization at laparoscopy. The patient then underwent laparoscopic small bowel resection with functional end to end anastomosis. Hemoglobin remained stable. Symptoms of gastrointestinal bleeding resolved. DISCUSSION: Obscure gastrointestinal bleeding (OGIB) is defined as recurrent or persistent bleeding after negative initial evaluation, including upper and lower endoscopy. It typically accounts for less than 5% of all gastrointestinal bleeds. The small bowel is the most common site of obscure GI bleeds. Majority of these cases are due to angiodysplasia, small bowel tumor and rarely, small bowel diverticulum. Delay in diagnosis is common due to inaccessibility of small bowel to endoscopy. Capsule endoscopy or deep enteroscopy are often necessary in diagnosis and localization of GI bleed. This case highlights the importance of considering jejunal diverticulum in patients with obscure gastrointestinal bleeding.Figure 1.: CT Angiography in coronal view showing suspected bleed in jejunum (arrow).Figure 2.: Push enteroscopy showing (a) multiple diverticula in jejunum with (b) blood clots present.