Stepwise diagnosis and minimally invasive management of obscure gastrointestinal bleeding secondary to a Meckel’s diverticulum: a case report

Abstract

Background

Obscure gastrointestinal bleeding (OGIB) presents a significant diagnostic challenge for clinicians due to the anatomical characteristics and inaccessibility of the small intestine. Preoperative diagnosis is particularly challenging, and optimal management relies heavily on precise lesion localization. We report the successful diagnosis and minimally invasive resection of a bleeding Meckel's diverticulum using a multidisciplinary stepwise approach.

Case presentation

A 25-year-old Chinese man presented to the emergency department with melena that rapidly progressed to recurrent hematochezia. Initial esophagogastroduodenoscopy and an urgent colonoscopy were non-diagnostic due to significant blood retention obscuring the visual field. To non-invasively locate the bleeding source, abdominal computed tomography angiography (CTA) was performed, which identified a diverticular structure with segmental enhancement in the distal ileum. Guided by this structural roadmap, retrograde double-balloon enteroscopy (DBE) was successfully performed, revealing a Meckel's diverticulum accompanied by multiple irregular large ulcers with stigmata of recent bleeding. Endoclips were deployed around the lesion during the DBE procedure for preoperative marking. This endoscopic intervention facilitated a targeted, tissue-sparing laparoscopic segmental small bowel resection in the present case. Postoperatively, an enhanced recovery after surgery (ERAS) protocol was implemented, enabling early enteral nutrition. The patient’s recovery was uneventful, and he was discharged on postoperative day 8 without recurrence.

Conclusions

For overt OGIB, a stepwise “CTA-DBE-Laparoscopy” pathway may be useful in selected patients. Non-invasive CTA provides an essential anatomical compass, while endoscopic marking prior to surgery facilitated targeted resection and reduced surgical trauma in the present case.

Introduction

Obscure gastrointestinal bleeding (OGIB) is defined as persistent or recurrent bleeding from the gastrointestinal (GI) tract with no identifiable source after standard esophagogastroduodenoscopy (EGD) and colonoscopy. The term “suspected small bowel bleeding” has been increasingly adopted in contemporary guidelines to describe this entity more precisely, though “OGIB” remains widely used in clinical practice. It accounts for approximately 5% of all GI bleeding cases, with up to 80% of these lesions originating in the small bowel [1]. In young adults, conditions such as Meckel's diverticulum or non-Meckel's small bowel diverticula are significant causes of lower GI hemorrhage, frequently complicated by ulceration from ectopic gastric or pancreatic tissue [2].

Locating these lesions is technically demanding for gastroenterologists due to the length, redundancy, and active peristalsis of the small intestine. Historically, unresolved overt OGIB often required surgical exploratory laparotomy, which is associated with greater tissue trauma, prolonged postoperative ileus, and potential over-resection of the bowel [3]. With advancements in medical technology, the diagnostic paradigm has shifted toward precise endoscopic and radiological localizations [4]. Here, we describe a case of severe OGIB in a young man where a stepwise diagnostic approach—utilizing computed tomography angiography (CTA) as a structural guide and double-balloon enteroscopy (DBE) for definitive diagnosis and endoscopic marking—led to a targeted, minimally invasive surgical intervention.

Case report

A 25-year-old previously healthy Chinese man presented to the emergency department with a 20-h history of passing melena, accompanied by generalized fatigue and dizziness. He denied hematemesis, abdominal pain, or a history of non-steroidal anti-inflammatory drug use. His surgical history was notable only for an appendectomy performed 20 years prior. On admission, his vital signs were stable (blood pressure: 122/70 mmHg, heart rate: 77 beats/min). Physical examination revealed a flat, soft abdomen with normal bowel sounds. Digital rectal examination confirmed the presence of melena. Initial laboratory investigations showed a hemoglobin level of 12.6 g/dL, which decreased to 11.6 g/dL over the next 24 h. Liver enzymes were mildly elevated, but coagulation profiles were normal.

Given the initial presentation of melena, an upper GI bleed was suspected. An urgent EGD revealed chronic non-atrophic gastritis with bile reflux but no evidence of recent hemorrhage or varices. Shortly after the EGD, the patient developed recurrent hematochezia (approximately 50–100 mL of dark and bright red blood per episode), indicating a rapid transit distal bleeding source. An urgent colonoscopy was attempted on hospital day 3. However, the procedure was aborted as the colonic lumen was entirely filled with solid stool, blood clots, and coffee-ground fluid, precluding safe advancement and mucosal visualization.

To non-invasively identify the bleeding source before further endoscopic attempts, an abdominal CTA was performed. Given the patient's recurrent hematochezia and the need for urgent evaluation, CTA was prioritized over a technetium-99 m pertechnetate scintigraphy (Meckel scan) due to its rapid acquisition and broad diagnostic capability. The imaging revealed a blind-ending diverticular structure with inflammatory wall thickening and segmental enhancement in the distal ileum (Fig. 1a). Notably, no active contrast extravasation was observed at the exact time of the scan, likely due to the intermittent nature of the hemorrhage. Mild stenosis at the origin of the celiac trunk was also noted. Based on the anatomical roadmap provided by the CTA, the patient was prepared for a targeted retrograde DBE. The enteroscope was advanced retrogradely to approximately 110 cm proximal to the ileocecal valve. At this location, it clearly revealed a Meckel's diverticulum associated with multiple irregular, large ulcers with stigmata of recent bleeding (Fig. 1b). To facilitate the subsequent surgical intervention, the lesion was marked with endoclips (Fig. 1c).

Fig. 1.

Preoperative imaging and endoscopic localization. A Abdominal computed tomography angiography (CTA) revealing a diverticulum with segmental bowel wall thickening and enhancement in the distal ileum (red arrow). B Retrograde double-balloon enteroscopy (DBE) showing multiple irregular large ulcers adjacent to the Meckel's diverticulum. C Deployment of endoclips around the lesion during DBE to provide precise preoperative marking

The endoclips were deployed strictly for preoperative localization, as no active spurting vessel was identified during the examination. Following the DBE procedure, the bleeding ceased spontaneously. Despite the earlier episodes of hematochezia, the patient's hemoglobin level decreased only mildly from 12.6 g/dL to 11.6 g/dL over 24 h. He maintained hemodynamic stability through intravenous fluid resuscitation alone, and no blood transfusion was required. This spontaneous cessation of hemorrhage and sustained clinical stability allowed the medical team to optimize the patient's condition and schedule an elective, targeted surgery on hospital day 9, which potentially avoided the need for an emergent laparotomy.

On hospital day 9, the patient underwent a laparoscopic segmental small bowel resection. During intraoperative exploration, the surgeon identified a 2 × 2 × 2 cm diverticulum at the anti-mesenteric border of the distal ileum, in the region indicated by the preoperative endoscopic clip markings (Fig. 2a). The clips were localized by gentle intraoperative palpation of the bowel wall with laparoscopic instruments. This localization facilitated a limited, tissue-sparing small bowel segment resection, and a primary side-to-side anastomosis was fashioned. Histopathological examination confirmed a Meckel's diverticulum containing ectopic gastric mucosa. This ectopic tissue was accompanied by adjacent mucosal ulceration and chronic inflammatory cell infiltration, confirming the pathophysiological mechanism of the bleeding (Fig. 2b).

Fig. 2.

Surgical and histopathological confirmation. A Laparoscopic view during targeted small bowel resection, identifying the Meckel's diverticulum corresponding to the preoperative endoscopic clip markings. B Hematoxylin and eosin (H&E) staining of the resected specimen demonstrating ectopic gastric mucosa, mucosal lceration, and chronic inflammatory cell infiltration (original magnification × 100)

Postoperatively, an enhanced recovery after surgery (ERAS) protocol was implemented. Specifically, this included early ambulation on postoperative day 1, early removal of the urinary catheter, an opioid-sparing multimodal analgesia regimen, and the early introduction of oral liquids. This minimally invasive approach and protocol allowed for a rapid return of bowel function, minimal opioid reliance, and a prompt transition to an oral diet. The patient was discharged uneventfully on postoperative day 8. At the 3-month follow-up, the patient reported complete resolution of symptoms without recurrence of GI bleeding (Table 1).

Table 1.

Timeline of key clinical events and interventions

Time	Key Events and Interventions
20 h prior to admission	The patient developed melena accompanied by generalized fatigue and dizziness
Day of admission (Day 1)	Presented to the Emergency Department; initial EGD revealed no active bleeding source; subsequent recurrent hematochezia occurred
Hospital Day 3	Urgent colonoscopy aborted due to significant retained blood and stool. Abdominal CTA performed, revealing a diverticular structure with inflammatory wall thickening and segmental enhancement in the distal ileum; no active contrast extravasation observed
Preoperative period	Targeted retrograde double-balloon enteroscopy (DBE) performed. Meckel's diverticulum with adjacent ulcers showing stigmata of recent bleeding, identified and marked with endoclips. Bleeding ceased spontaneously; patient remained hemodynamically stable without requiring blood transfusions
Hospital Day 9	Elective, tissue-sparing laparoscopic segmental small bowel resection performed under the guidance of preoperative endoscopic markings
Postoperative Day 8	Patient discharged uneventfully after successful implementation of the Enhanced Recovery After Surgery (ERAS) protocol
3-month follow-up	Complete resolution of symptoms with no recurrence of gastrointestinal bleeding

Discussion

The diagnosis of OGIB requires a systematic, escalating diagnostic algorithm. This case underscores the dynamic relationship between clinical presentation and the origin of GI bleeding. Initially, the patient presented with melena, a symptom traditionally associated with upper GI sources. However, bleeding from the right colon or small bowel can also present as melena if the intestinal transit time is prolonged [5]. The subsequent rapid transition to hematochezia appropriately shifted the clinical suspicion to the mid-to-lower GI tract.

When active lower GI bleeding precludes a clear colonoscopic evaluation, the diagnostic algorithm must be carefully tailored. In young patients, while a Meckel scan is a classic non-invasive tool for detecting ectopic gastric mucosa, its utility is limited during acute overt hemorrhage where time is of the essence. Similarly, capsule endoscopy is highly valuable for stable patients but is often non-diagnostic during active hematochezia due to blood obscuring the visual field. Therefore, non-invasive vascular imaging becomes an essential triage tool. CTA can detect extravasation rates as low as 0.3 mL/min and offers an excellent structural roadmap, even when showing only inflammatory changes or structural anomalies (as in our case) rather than active extravasation [6]. In our case, CTA accurately localized the abnormality to the distal ileum, which prevented a potentially negative or overly broad surgical exploration. Following regional identification by imaging, device-assisted enteroscopy serves as an effective diagnostic tool for evaluating small bowel pathologies [7]. In young patients, Meckel's diverticulum typically presents at the distal ileum and can harbor ectopic gastric mucosa, leading to adjacent mucosal ulceration and painless, severe hemorrhage [8].

This case highlights the practical value of multidisciplinary collaboration between gastroenterologists, radiologists, and surgeons in modern clinical practice. Extensive exploratory laparotomy for OGIB often leads to unnecessary bowel handling and occasionally excessive bowel resection leading to malabsorption. By utilizing DBE for definitive diagnosis and placing endoclips prior to surgery, we facilitated intraoperative lesion identification. This transition from the endoscopy suite to the operating room facilitated a minimally invasive laparoscopic resection and may have contributed to the patient's overall recovery.

Conclusions

In conclusion, for young patients presenting with recurrent overt obscure gastrointestinal bleeding, small bowel diverticular disease should remain high on the differential. A multidisciplinary stepwise algorithm—employing CTA for anatomical triage followed by targeted device-assisted enteroscopy and endoclip marking—may be a useful strategy in selected patients. In the present case, this approach facilitated lesion localization and enabled targeted, tissue-sparing laparoscopic resection.

Patient perspective

"I was extremely anxious when I experienced sudden and significant bleeding. The medical team explained every step of the diagnostic process clearly. I am very grateful for the advanced endoscopic techniques and the minimally invasive laparoscopic surgery, which resulted in a very small incision and allowed me to recover and eat normally much faster than I expected. Since my discharge, I have returned to my normal life without any further bleeding episodes."

Abbreviations

OGIB

Obscure gastrointestinal bleeding

GI

Gastrointestinal

EGD

Esophagogastroduodenoscopy

CTA

Computed tomography angiography

DBE

Double-balloon enteroscopy

ERAS

Enhanced recovery after surgery

Author contributions

J.H. and W.L. wrote the main manuscript text, L.T. collected the clinical data. H.Y. and G.L. prepared Figs. 1 and 2 and assisted with the interpretation of the endoscopic and radiological findings. L.C. contributed to the imaging analysis and critically revised the manuscript. Y.L. conceived the case report, supervised the clinical management, and finalized the manuscript. All authors reviewed the manuscript.

Funding

The authors declare that no financial support was received for the research, authorship, and/or publication of this article.

Availability of data and materials

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was approved by the Medical Ethics Committee of The Second Affiliated Hospital of Fujian University of Traditional Chinese Medicine. Written consent was obtained from the patient for the use of data.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.