A Case of Obscure Gastrointestinal Bleeding: 547

A 20 yo M with no PMH presented to an outside hospital with dark stools and decreased exercise tolerance. His hemoglobin (Hb) was 7.8 g/dL. EGD, Colonoscopy, Meckel's Scan and Small Bowel Series were all unremarkable; the patient was stable during workup and was discharged. Two months later, he syncopized due to recurrent bleeding. His Hb level was 7.5 g/dL with MCV of 68. Workup including enteroscopy, Technetium-labeled RBC scan, and CT scan were unremarkable. Colonoscopy revealed blood throughout the colon; he was transferred to our ICU. Initial evaluation included a normal Meckel's Scan and RBC scan. Patient was given a heparin challenge while in the ICU. On heparin, the patient rebled, but was hemodynamically stable. A repeat bleeding scan was positive for activity in the ileum or right colon. Colonoscopy revealed blood throughout the colon but not in the terminal ileum. Video capsule endoscopy was performed while the patient remained on heparin. Distal small bowel images revealed a diverticular orifice with surrounding blood. [figure1]Exploratory laparoscopy revealed a Meckel's Diverticulum.[figure2] A diverticulectomy was performed and the specimen revealed atopic gastric mucosa within the diverticulum. The patient made an uneventful recovery.FigureFigure Capsule endoscopy is an effective method to diagnose Meckel's Diverticulum. A heparin challenge in a monitored setting can aid in the localization of obscure bleeding source. Meckel's Scan has an approximately 60% sensitivity in the diagnosis of Meckel's Diverticulum in the adult populationa; capsule endoscopy and exploratory laparoscopy should be pursued when clinical suspicion for Meckel's remains high. Lin S, et al. Gastrointestinal bleeding in adult patients with Meckel's diverticulum: the role of technetium 99m pertechnetate scan. South Med J 2002;95(11):1338–41.