Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Introduction Diverticulosis in the colon is a common cause of lower gastrointestinal (GI) bleeding. Non-Meckel diverticula in the small bowel have been reported in the literature; however, they rarely cause significant bleeding. We present a case of an 88-year-old woman with a bleeding jejunal diverticulum that was diagnosed and treated with a push enteroscopy. Case Description An 88-year-old African-American female with a past medical history of colonic diverticulosis and atrial fibrillation on rivaroxaban presented with a 4-day history of melena. She reported having soft, black stools 2–3 times a day, associated with persistent epigastric discomfort and nausea. Her last dose of rivaroxaban was a day prior to arrival. She denied alcohol use, smoking, or use of non-steroidal anti-inflammatory drugs (NSAIDs). Her most recent esophagogastroduodenoscopy (EGD), performed 15 years earlier, had shown mild erosive gastritis and a duodenal polyp, which was identified as a benign Brunner's gland polyp on biopsy. She had a colonoscopy 9 years earlier, which was unremarkable except for colonic diverticulosis. On arrival at the hospital, her blood pressure was 110/50 mmHg, and her heart rate was 60 beats per minute. She had a soft abdomen without tenderness. Her hemoglobin was 9.9 g/dL. Rivaroxaban was held, and she was given intravenous fluids and pantoprazole. She underwent EGD the next day, which showed no obvious bleeding source but revealed two large nonbleeding duodenal diverticula. She subsequently underwent colonoscopy, which showed old blood and multiple pan-colonic diverticula without any active bleeding. She continued to have hematochezia and blood loss anemia requiring transfusion, but remanded stable hemodynamically. A radionuclide bleeding scan was performed, which showed active bleeding from a source in the left upper quadrant. Additionally, a computed tomography angiography (CTA) scan of the abdomen localized the bleeding to the jejunum. She underwent push enteroscopy 9 days from initial presentation, which showed extensive diverticulosis in the second part of the duodenum and the proximal jejunum. One of the jejunal diverticula was noted to have active oozing, which was managed with an endoscopic hemoclip to achieve hemostasis. Over the next few days, she did not have further bleeding, and her hemoglobin stabilized. Rivaroxaban was reintroduced and was well-tolerated prior to discharge. Discussion Non-Meckel small bowel diverticula are a rare cause of GI bleeding. Most of these are in the duodenum, with only 0.3–1.3% of the population having jejunal or ileal diverticula based on autopsy studies. Jejunal diverticula are mostly asymptomatic, with only 2% associated with bleeding. However, they may lead to life-threatening bleeding requiring embolization by interventional radiology (IR) and, rarely, surgery. Our case highlights the importance of considering small bowel diverticular bleeding in a patient with overt GI bleeding without an obvious source on EGD and colonoscopy. In such cases, advanced imaging like radionuclide scans and CTA can help identify the source. Our case was also unique in that the patient’s jejunal diverticular bleeding was successfully managed endoscopically rather than requiring more invasive intervention, underscoring the role of hemostasis by push enteroscopy when the patient is hemodynamically stable.

Comments

American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter Resident and Medical Student Day, May 2, 2025, Troy, MI

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