A 69-year-old female who presented with a 1-day history of melena stools, presyncope and fatigue was found to have a hemoglobin of 69 g/L from a baseline of 113 g/L. Her background is significant for two previous obscure, overt gastrointestinal bleeds investigated with esophagogastroduodenoscopy, colonoscopy, computed tomography with angiography, video capsule endoscopy and Meckel’s diverticulum scintigraphy, all of which were negative; on those occasions, her bleeds stopped spontaneously. During this admission, repeat upper and lower endoscopies (including a deep push enteroscopy) were once again unfruitful at localizing the bleeding source. As she was requiring multiple packed red blood cell transfusions daily to maintain her hemoglobin and systolic blood pressure, the decision was made by gastroenterology and general surgery to perform an intra-operative enteroscopy, where a massive mid-jejunal diverticulum with a large feeding mesenteric artery was discovered actively oozing (Figures 1–4). A resection with five cm margins was performed; the patient subsequently stopped bleeding, was discharged shortly thereafter, and had a normal hemoglobin on her 1-month follow-up.
Figure 1.
Laparotomy view.
Figure 2.
Trans-illuminated view showing mesenteric artery.
Figure 3.
Endoscopic view-1.
Figure 4.
Endoscopic view-2.