eP492 - Massive Lower Gastrointestinal Bleeding Due to Small Bowel Diverticula: A Case Report

Purpose/Background: Diverticular disease affecting the small bowel, is rare with an incidence of 1–2% in the general population. During diagnostic work up for lower gastrointestinal bleeding, small bowel diverticulosis is not often considered as a cause of major bleeding. The location of the diverticula and lack of specific diagnostic modalities often leads to a diagnostic and therapeutic dilemma among providers. We present a case of a massive lower GI bleeding caused by numerous, large, small bowel diverticula.Methods/Interventions: A 68-year-old male with past medical history of coronary artery stents and colonic diverticulosis, presented to the ED with symptoms of bright red blood per rectum, pre-syncopal episodes, and symptomatic anemia. After resuscitation with blood products and admission to surgical intensive care unit, patient underwent CT angiogram, upper endoscopy, and colonoscopy. Upper endoscopy was negative for bleeding and colonoscopy demonstrated a large amount of blood and pan diverticulosis, but no active source of bleeding. The first two CT angiograms did not demonstrate any areas of active extravasation. Patient required additional blood transfusions with transient response, prompting for another CT angiogram with findings of acute arterial bleeding in the small bowel vasculature. Interventional radiology consultation was obtained, but during attempted super selective SMA angiography there was no active extravasation noted. Capsule endoscopy demonstrated bright red blood in proximal duodenum and distal small bowel, but no areas of active bleeding and tagged RBC scan was negative. Patient continued to have symptomatic, unlocalized lower GI bleeding progressing to massive hemorrhage and hemodynamic instability. He was taken for exploratory laparotomy and on-table push enteroscopy to localize and treat the presumed small bowel hemorrhage. In the operating room, patient was found to have numerous large jejunal and ileal diverticula. EGD and push enteroscopy (manually advanced) demonstrated hematin throughout the small bowel, but no active bleeding source. A 50 cm of small bowel resection was performed, including the segment that contained the large diverticula, and a side-to-side, functional end-to-end anastomosis was created. Patient was transferred back to the ICU and was extubated the following day, remained off vasopressor support and the rest of his hospital stay was uncomplicated. Pathology demonstrated small bowel diverticula.Results/Outcomes: Small intestinal diverticulosis is characterized by herniation of the mucosa and submucosa through the muscular layer of the bowel wall. Eighty per cent of diverticula occur in the jejunum, 15% in the ileum, and 5% in both. The specific diagnosis of small intestinal diverticulosis is possible by radiologic studies including CT angiogram, tagged RBC scans or push or double balloon enteroscopy, but the results vary based on the amount of bleeding, and location of the diverticula. This case demonstrates the difficulty in localizing a small bowel diverticular bleeding, and perplexity in decision making regarding the next step in treatment.Conclusion/

Discussion: Lower gastrointestinal bleeding is often difficult to adequately localize, especially when present in the small intestine. The importance of clinical vigilance often requiring repeated radiographic studies and endoscopic evaluations is of utmost importance, but in cases of unlocalized small bowel hemorrhage, a combination of open surgery and manual push enteroscopy can be attempted."Numerous, large small bowel diverticula

Massive small bowel diverticula causing lower gastrointestinal bleeding

Small bowel diverticula specimen
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