A 48-Year-Old Man With Recurrent Gastrointestinal Bleeding

Anissa Aulia Adjani03009024

Patient : Mr. X

Age : 48 Recurrent gastrointestinal

bleeding

Clinical History

midepigastric pain and passed. Positive black stool.Have been taking low dose of Ibuprofen for months

Physical Examination

AnemicVital signs were on normal rangeOther physical states was in normal rangeAbdomen was soft and nontender

Laboratory / imaging studies/workup

The results of evaluation byesophagogastroduodenoscopy and colonoscopy, including examination of the terminalileum, were normal. No source of bleeding was identified

Treatment and Medication

Two units of packed redcells were transfused, and the patient was discharged home with instructions to avoidfurther use of nonsteroidal antiinflammatory drugs.

33 Months Earlier

31 Months Earlier (2 months follow up)Clinical History Patient reported that he had fatigue

Physical Examination

Vital Signs in normal rangePhysical state in normal range

Laboratory/imaging studies/workup

The hematocrit was 26.3 percentOccult blood stool negativeAir-contrast barium studies of the upper gastrointestinal tract withsmall-bowel follow-through were performed two months and eight months later; theresults were normal.

Treatment and Medication

Ferrous sulfate(325 mg three times per day) was prescribed*One month later, the hematocrit had risento 38.0 percent

2 Years Earlier

Clinical History

the patient again had midepigastric pain

Physical Examination

Vital Sign in normal rangePhysical State in normal range*no abnormalities on abdomen examination

Laboratory/Imaging Studies/Workup

The physical examination and an abdominal ultrasonographic evaluation revealed no abnormalities. A stool specimen was positive for occult Bloodserologic test for antibody to Helicobacter pylori was positive

Treatment and Medication

Ranitidine was administered, and the patientwas discharged home with a prescription for 20 mg of omeprazole per dayA 10-day course of metronidazole, tetracycline, and pantoprazole was prescribed. *After serologic test result achieved

1 Year Earlier

Clinical History Midepigastric pain recurrent and black stool

Physical Examination All vital signs in normal rangeNo abnormalities in physical state

Laboratory/Imaging Studies/Workup

(CT) scan of the abdomen and pelvis showed a normal bowel without obstructionor inflammation. There were no masses

Treatment and Medication The pain and the symptoms resolved without treatment

2 Months EarlierA video-capsule–endoscopic study showed asmall arteriovenous malformation in the midjejunum,which was not bleeding. There was asoft-tissue mucosal lesion in the distal ileum, whichwas not bleeding. The patient remained hemodynamicallystable, and there was no further gastrointestinalbleeding. Esomeprazole, at a dose of40 mg per day, was prescribed, and the patient wasdischarged home on the fifth hospital day.

VIDEO-CAPSULE ENDOSCOPE

An enteroclysis procedure had shown a pedunculatedintraluminal filling defect within the distal ileum,which had smooth margins and was mobile underdirect fluoroscopy. CT scanning of the abdomenand pelvis with the use of intravenous contrast materialshowed a soft-tissue lesion, 2 cm in diameter,within the distal small bowel; its central area hadthe density of fat and was surrounded by a wall withthe density of soft tissue. In retrospect, this lesionhad been evident on the study performed one yearbefore admission, and had become enlarged.The patient was readmitted to the hospital. Mesentericangiography showed no abnormalities. A diagnosticprocedure was performed.

1 Month Earlier

Axial CT Image Obtained with the Use of Oraland Intravenous Contrast Material.

The mass extends from the terminal ileum distally intothe cecum. The mass has low attenuation, equal to thatof fat, except for a smooth, uniform, circumferential wallof soft-tissue attenuation (arrows).

The Mass from the Distal Ileum.A palpable mass in the distal ileum with an ileoileal intussusceptionwas identified. Examination of the openspecimen revealed a large, polypoid lesion with a longstalk and reddening of the mucosa at the tip.

Inverted Meckel’s Diverticulum(Hematoxylin and Eosin).

As shown, all layers of the bowel wall are present, including the muscularis propria, indicating that this is a true diverticulum. The center of the inverted diverticulum contains adipose tissue (black arrow), representing mesenteric fat. Inflamed and distorted intestinal mucosa is present (arrowhead), with mucosal ulceration (white arrows). There is mucosal hyperplasia and smooth muscle interdigitating between intestinal glands and crypts (inset; arrows), which are characteristic of a mucosal prolapse effect. Gastric pyloric glands are visible in the deep lamina propria (inset; arrowheads)

HISTOLOGICAL EXAMINATION

•On histologic examination,the inverted diverticulum contained all layers of the bowel wall, and therefore is a true diverticulum

•Much of the overlying mucosa was normal, but toward the tip of the diverticulum, it was ulcerated

•In the absence of gastric mucosa, the ulceration in this case can be explained by local ischemia or mechanical factors related to prolapse and intussusception

The treatment for a bleeding Meckel’s diverticulumis segmental resection

DIAGNOSIS

CLINICAL DIAGNOSIS

• Submucosal tumor or inverted Meckel’s diverticulum.

ANATOMICAL DIAGNOSIS

• Inverted Meckel’s diverticulum with ulcerationTHERAPY

RESUME

•This patient’s intermittent abdominal pain can be attributed to a Meckel’s diverticulum with recurrent episodes of intussusception. •In the patient under discussion, capsule endoscopy was performed, and the video showed a lesion protruding into the lumen of the distal ileum, with overlying mucosa that appeared normal (Fig. 2). A mucosal tumor would have differed in appearance from the surrounding mucosa. Therefore, the most likely diagnoses would be either a submucosal tumor, such as a leiomyoma or lipoma, or an inverted Meckel’s diverticulum.