A 48-Year-Old Man With Recurrent Gastrointestinal Bleeding

Anissa Aulia Adjani 03009024

Patient : Mr. X
Age : 48
Recurrent gastrointestinal bleeding

33 Months Earlier
Clinical History midepigastric pain and passed. Positive black stool. Have been taking low dose of Ibuprofen for months Anemic Vital signs were on normal range Other physical states was in normal range Abdomen was soft and nontender
The results of evaluation by esophagogastroduodenoscopy and colonoscopy, including examination of the terminal ileum, were normal. No source of bleeding was identified Two units of packed red cells were transfused, and the patient was discharged home with instructions to avoid further use of nonsteroidal antiinflammatory drugs.

Physical Examination

Laboratory / imaging studies/workup

Treatment and Medication

31 Months Earlier (2 months follow up)

Clinical History Physical Examination Patient reported that he had fatigue Vital Signs in normal range Physical state in normal range

Laboratory/imaging The hematocrit was 26.3 percent studies/workup Occult blood stool negative Air-contrast barium studies of the upper gastrointestinal tract with small-bowel follow-through were performed two months and eight months later; the results were normal. Treatment and Medication Ferrous sulfate (325 mg three times per day) was prescribed *One month later, the hematocrit had risen to 38.0 percent

2 Years Earlier
Clinical History Physical Examination the patient again had midepigastric pain Vital Sign in normal range Physical State in normal range *no abnormalities on abdomen examination

Laboratory/Ima The physical examination and an abdominal ging ultrasonographic evaluation revealed no Studies/Workup abnormalities. A stool specimen was positive for occult Blood serologic test for antibody to Helicobacter pylori was positive Treatment and Medication Ranitidine was administered, and the patient was discharged home with a prescription for 20 mg of omeprazole per day A 10-day course of metronidazole, tetracycline, and

1 Year Earlier
Clinical History Midepigastric pain recurrent and black stool

Physical Examination

All vital signs in normal range No abnormalities in physical state

(CT) scan of the abdomen and pelvis showed a normal bowel without obstruction or inflammation. There were no masses The pain and the symptoms resolved without treatment

Laboratory/Imaging Studies/Workup

Treatment and Medication

2 Months Earlier
A video-capsuleendoscopic study showed a small arteriovenous malformation in the midjejunum, which was not bleeding. There was a soft-tissue mucosal lesion in the distal ileum, which was not bleeding. The patient remained hemodynamically stable, and there was no further gastrointestinal bleeding. Esomeprazole, at a dose of 40 mg per day, was prescribed, and the patient was discharged home on the fifth hospital day.

VIDEO-CAPSULE ENDOSCOPE

1 Month Earlier
An enteroclysis procedure had shown a pedunculated intraluminal filling defect within the distal ileum, which had smooth margins and was mobile under direct fluoroscopy. CT scanning of the abdomen and pelvis with the use of intravenous contrast material showed a soft-tissue lesion, 2 cm in diameter, within the distal small bowel; its central area had the density of fat and was surrounded by a wall with the density of soft tissue. In retrospect, this lesion had been evident on the study performed one year before admission, and had become enlarged. The patient was readmitted to the hospital. Mesenteric angiography showed no abnormalities. A diagnostic procedure was performed.

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

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

The Mass from the Distal Ileum.

A palpable mass in the distal ileum with an ileoileal intussusception was identified. Examination of the open specimen revealed a large, polypoid lesion with a long stalk and reddening of the mucosa at the tip.

Inverted Meckels Diverticulum As shown, all layers of the bowel (Hematoxylin and Eosin).
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

DIAGNOSIS
CLINICAL DIAGNOSIS

Submucosal tumor or inverted Meckels diverticulum.

ANATOMICAL DIAGNOSIS

Inverted Meckels diverticulum with ulceration

THERAPY
The treatment for a bleeding Meckels diverticulum is segmental resection

RESUME
This patients intermittent abdominal pain can be attributed to a Meckels 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 Meckels diverticulum.